As Restrictions Came And Went, Ky. COVID Death Backlog Skyrocketed
When the Beshear administration eased life-saving restrictions in December, more than twice as many people were dying of COVID-19 as the public knew, and Gov. Andy Beshear focused his messaging on an optimistic and incomplete metric that’s been questioned by top health researchers.
From Nov. 20 to Dec. 13, the state closed indoor dining and further limited capacities at businesses and social gatherings. Beshear announced the targeted restrictions as a three-week effort to slow exponential growth in new infections following a steep rise in positive cases.
Despite protests and political pushback, the restrictions helped curb transmission in the short-term. After the restrictions were scaled back, however, the virus resurged reaching the highest case counts of the pandemic.
When the administration rolled back the targeted restrictions, Beshear’s public health officials had already exchanged emails about uncontrolled spread and a rising backlog of unreported COVID-19 deaths. Deaths were still surging and three of the state’s hospital regions reported intensive care units more than 80% full.
State epidemiologists received an avalanche of death reports faster than they could process them, but Beshear wouldn’t mention the backlog until months later.
A WFPL News and APM Reports analysis shows that nearly 1,200 people died of COVID-19 during the three weeks the targeted restrictions were in place, though the state only reported 465 deaths at the time. Nearly as many people died in those three weeks as died in the entire first six months of the pandemic, according to records.
Despite those warning signs, the administration chose to lift more intensive restrictions while centering its public messaging on the rate of positive COVID-19 tests, which Beshear claimed was declining.
But prominent public health researchers concluded that the rate was actually rising. Beshear’s public health commissioner even suggested months earlier that it wasn’t a good measure of the disease’s spread.
Experts say the continued winter surge could have been slowed if the restrictions were kept in place longer or were put in place earlier, though the political climate would have made that challenging: state Republicans were filing lawsuits and legislation to curtail Beshear’s powers, and restaurants were publicly threatening to reopen in defiance of the governor’s orders.
Cabinet for Health and Family Services spokesman Brice Mitchell said state leaders never relied solely on the positivity rate, but made decisions using a wide array of data in concert with public health experts and evolving guidance from the U.S. Centers for Disease Control and Prevention.
“Gov. Beshear has said repeatedly he is beyond politics and made decisions based on the advice of public health experts to save lives,” Mitchell said. “The Governor knows his actions were not always popular, but that inaction was deadly.”
Deaths ‘on the rise’
COVID-19 claimed the lives of at least 1,204 people in the first six months of the pandemic in Kentucky, but things would get much worse before they got better.
In late October, the number of deaths began to overwhelm state epidemiologists tasked with reviewing and confirming each case, according to a review of more than 700 emails from the Cabinet for Health and Family Services obtained through a public records request. The officials repeatedly mentioned the size of the backlog to colleagues and, in some instances, worried about keeping up.
“I just want everyone to be aware, deaths seem to be on the rise, although reported numbers do not always reflect them all due to documentation lacking,” according to an Oct. 20 email from State Public Health Veterinarian Kelly Giesbrecht. Giesbrecht is trained to handle human health hazards of animal origins, and helped to lead a team of epidemiologists reviewing COVID-19 deaths.
Two days later, the numbers were still increasing. On Halloween, the state’s top epidemiologist warned of an impending surge in an email to health officials across the state including the Office of the Secretary with the Cabinet for Health and Family Services.
“Happy Halloween Evening, All Public Health Fiends out there!” acting state epidemiologist Doug Thoroughman wrote. “What's really scary is that we had our highest natural case reporting day… This is a steeper increase in cases than the strong surge in June-July, indicating that we are in a critical situation.”
It was almost three weeks later when Beshear issued new restrictions: no indoor dining or bars, no gatherings bigger than two households and increased capacity restrictions at some businesses. The state also ceased in-person instruction in public and private schools until Dec. 7 for elementary schools and Jan. 4 for middle and high schools.
“I think people were waiting for something that is more than a recommendation, now they have it. I’ll take the slings and the arrows. I’ll take the blame, I’ll be the person that says no if that’s what it takes to protect our people,” Beshear said onNov. 18.
The restrictions were more expansive than most neighboring states had at the time, setting off protests and backlash. Dozens of restaurants joined a petition to rescind the closures even though federal health experts reported indoor dining as one of the highest-risk behaviors. Still, the restaurateurs vowed to defy Beshear if he didn’t re-open indoor dining by Dec. 14, when his order was set to expire.
At the same time, state Republicans were preparing to strip the governor of his emergency powers in the upcoming legislative session. Republican Attorney General Daniel Cameron filed a federal lawsuit seeking a restraining order against Beshear’s ban on in-person classes — one of many unsuccessful lawsuits filed over Beshear’s use of emergency powers.
Three days ahead of Thanksgiving, with families expected to gather across the country, Giesbrecht wrote to her colleagues burdened with the grim task of reviewing COVID-19 deaths:
"Don't be fooled by the 17 deaths. yesterday close to 70 deaths were reported!” she wrote.
“Also this morning, they are coming in fast as well. :("”
On Dec. 1, Giesbrecht wrote that she and her colleagues were still trying to get caught up on “back-logged cases” with the help of “several team members pitching in.”
“Hopefully we will not get more days of 40-70 cases, if we do, we may have trouble catching up.”
The following week, Kentucky joined most of the rest of the country in seeing its highest case count yet.
“Please note deaths are still coming in faster than we can review them, so we are behind,” Giesbrecht warned health officials in a Dec. 7 email.
In an emailed statement, Mitchell with the Cabinet for Health and Family Services said the governor relayed information to the public in regular briefings “minutes” after receiving an update from the Department of Public Health.
Despite the mounting delays in reporting deaths, the governor didn’t acknowledge the backlog on the day he told the public he planned to ease the restrictions.
“This is the last week of the executive order and we don’t foresee extending the executive order as it applies to the restaurants or bars or gyms,” Beshear said.
The governor’s messaging took an abrupt turn in the days before the announcement, shifting focus from dire warnings about the highest weekly cases to date: “Two reported dead from the virus Saturday were in their 30s and 40s”, to focusing on marginal declines in the state’s reported positivity rates.
A day after the restrictions ended, Thoroughman wrote, “it appears a reasonable possibility that we are beginning to see a downturn in case identification,” but he remained “cautiously optimistic” about short-term improvements.
He also highlighted the rising number of deaths.
“Unfortunately, deaths continue to surge,” he wrote.
Good news was on the horizon — that same day, the first coronavirus vaccines were administered in Kentucky. But it would be weeks or months before they reached everyone at high risk of death who wanted the shot.
The state was so backlogged by that point that most December deaths weren’t actually reported until after the first of the year. But the governor didn’t share that with the public.
On Dec. 18, as Kentuckians were deciding how to celebrate for the holidays, the state reported 2,344 COVID-19 deaths, but 4,095 Kentuckians had actually died by then.
The death numbers were crucial in communicating to the public the severity of the pandemic in 2020, said Beth Blauer, Johns Hopkins University associate vice provost over public sector innovation and leader in the Coronavirus Resource Center.
“In the absence of a vaccine, the only way we were going to be able to save lives was if we knew whether or not this disease was hitting our communities,” Blauer said. “I think that government had a responsibility to get as much information out to the public so that they could make the right decisions so they could protect themselves and their neighbors.”
On Dec. 19, Beshear told Kentuckianshis measures had successfully halted the growth of COVID-19 cases. “We have stopped the increase in cases, which we knew we had to do before we can start to decrease those numbers,” Beshear said.
But by early January, Thoroughman reported internally that COVID-19 trends had reversed. Daily case totals once again reached record highs, and hospital admissions were rising.
“Although we were experiencing declines on most measures over the past three weeks, many indications are that this trend has reversed,” Thoroughman wrote.
Counting the dead
Beshear previously acknowledged a backlog at a local health department, but he first revealed the backlog at the state level on Feb. 4, when WEKU reporter Stu Johnson asked why cases were declining but deaths were still high.
“Well, we’re certainly seeing deaths from the surge we had leading up to the holidays, from the holiday bump itself, but we are also having our committee get through more of the deaths where they are evaluating them to ensure that COVID-19 was a factor,” Beshear said.
A week later, a WFPL News investigation found hundreds of deaths reported by local health departments that had been left out of the publicly reported data. At the time, a state spokesperson said their backlog was lower than WFPL’s analysis found, and blamed other missing deaths on local health departments.
In March, Beshear revealed a different problem with the death numbers. He announced that additional COVID-19 deaths had been overlooked because a single, unnamed state official had stopped auditing death certificates as part of a review process during the holiday surge.
Giesbrecht began working on the review and asked “anyone available” on the state’s epidemiological team to assist in death certificate reviews, 100 cases at a time, according to an email.
“100 sounds like a lot, Brittany did them in about 2 hours. If you don’t finish all at once, that’s OK too, just stay in touch with how far you are getting,” she wrote.
When the review was completed earlier this month, the state added 1,273 deaths added to the toll from as far back as last March. The audit increased Kentucky’s total COVID-19 deaths by 18%.
The Cabinet For Health and Family Services declined a WFPL News interview request on the subject. The cabinet said it did not have any records of disciplinary actions for any employee regarding a failure to accurately count COVID-19 deaths.
The delays in reporting got longer from November to January.
WFPL obtained data through an open records request showing the dates that deaths occurred and when they were reported to the public. An analysis shows that 900 deaths were not yet reported at the time the restrictions went into effect — and that would have increased the overall death toll by a third.
By the time Beshear lifted restrictions on Dec. 13, the backlog of deaths had exploded, leaving 1,619 coronavirus deaths uncounted.
Shifting Emphasis On Positivity Rates
Beshear bolstered his decision to ease the additional restrictions by relying on an artificially low positivity rate that showed the state’s numbers declining, when in fact they were increasing, according to top coronavirus researchers.
Less than a week before Beshear eased the targeted restrictions, his communication’s office issued a press release touting “... the state’s sixth straight day with a declining positivity rate.”
On December 10, Beshear announced plans to end the more severe restrictions after three weeks; the same day, the state announced the highest number of newly reported cases since the start of the pandemic. Beshear chose to highlight the positivity rate.
“For the seventh straight day our positivity rate is decreasing. It’s now 9.13% and that’s what Dr. Stack would call a leading indicator,” Beshear said.
Dr. Steven Stack, the state’s public health commissioner, said back in October that test positivity should be used to understand if the state is testing enough people.
“Test positivity does not tell us how active the disease is, we cannot use this measurement to say there’s a lot of disease,” he said at the time.
Mitchell with the Cabinet for Health and Family Services wrote in an email response that neither the governor nor Dr. Stack “are aware of any substantive contradictions with them agreeing on measures to protect Kentuckians, reduce the spread of COVID and save lives.”
The positivity rate, on its face, is a simple metric. It’s the number of positive tests divided by the total number of tests, generally averaged over a seven-day period.
Using the state’s metrics, the positivity rate declined about .63% points to 8.52% in the time restrictions were in place, but the state had changed the way it reports those rates back in October.
Instead of dividing positive tests by total tests, the state began looking only at electronically submitted tests in a seven-day window — essentially a sample of tests that Stack said was representative of the entire state.
Stack responding to a question from WFPL News about the positivity rate during a December COVID-19 briefing:
“This is one thing I will look forward to when the job is over, trying to parse this data over and over as we have explained it repeatedly. The test positivity is a surrogate for adequacy of testing available to people, all of these are sample sizes. We never capture 100% of all the tests done,” he said.
Blauer, with the Coronavirus Resource Center at Johns Hopkins, studies coronavirus data trends across the country and creates data visualizations to inform the public and policymakers.
She analyzed Kentucky’s methodology for calculating positivity rates and concluded the state was removing positive tests more than seven days old while keeping the total number of tests in the denominator.
“That’s why we think they are not counting positives if they are older than seven days because of that infection rate but they are keeping them in the total test denominator,” Blauer said. “That’s the only way we could reverse engineer their number,” Blauer said.
So while Beshear said the positivity rate was going down, Johns Hopkins’ separate analysis of Kentucky’s test positivity showed the rate actually increased while restrictions were in place. WFPL’s own analysis found similar results.
With that in mind, Here’s Beshear on Dec. 10, three days before the restrictions ended:
“Certainly if we were over 10% of the positivity rate, it gets really concerning there,” he said.
That day, the state reported the day’s positivity rate at 9.13%. Leading coronavirus experts Johns Hopkins University reported Kentucky’s rate at 15% — and rising.
Restrictions Saved Lives
Once in place, Beshear’s targeted restrictions saved lives, public health experts agreed.
And there was scientific support for the restrictions. One CDC study from July found that people who had tested positive for COVID-19 were about twice as likely to have reported eating at a restaurant as those who tested negative.
Scientists from the University of Louisville in conjunction with the Cabinet for Health and Family Services conducted their own study projecting COVID-19 hospitalizations in 36 Kentucky counties, and concluded the restrictions had their intended effect.
“I think what this says is, you know, we saved a lot of people from going to the hospital, which obviously also saved a number of lives in Louisville, Kentucky,” said U of L Epidemiologist and co-author Dr. Natalie DuPre.
Her co-author Seyed Karimi said the trend lines from the actual data most closely aligned with low levels of compliance, meaning even if there weren’t that many people following the rules, it was still an effective strategy for managing infection.
Based on their estimates, low-compliance with targeted measures prevented about 1,500 hospitalizations by mid-January in the three hospital regions studied, according to the report.
Starting the restrictions sooner, or keeping them in place longer, would likely have saved even more lives, researchers said.
“I mean you can imagine that if you extend it, there would have been a greater effect,” Karimi said.
What Happened After Reopening
The vaccine rollout began in mid-Decemberwith health care workers receiving the first doses of vaccine the day after Beshear eased restrictions.
In line with CDC guidance, state officials prioritized health care workers and long-term care facilities, though it would be several weeks longer before the vaccines would begin to seriously affect case numbers.
That wasn’t soon enough for many Kentuckians. The weeks after Beshear lifted the targeted restrictions were some of the pandemic's most severe for Kentucky.
Case counts fell dramatically over Christmas, a drop state epidemiologists attributed to reduced reporting from labs and hospitals over the holiday as well as an internet outage affecting large portions of Eastern Kentucky.
The highest daily death toll in the pandemic occurred December 23, when COVID-19 claimed the lives of at least 73 people, according to state records. The state had reported just 26 deaths to the public on that day.
By January 2, electronically submitted tests — the only results that figure into the state’s positivity rate — had dropped 30% compared to before the holidays. That meant the results were weighted toward those submitted by health care facilities, according to an epidemiologist in an email.
The state’s reported positivity rate that day was at 10.79% — higher than the rate when Beshear put the restrictions in place.
The single-day peak for COVID-19 cases occurred January 6, when the state’s reported positivity rate stood at 12.29%. Cases began a steady decline near the end of January.
Projections of the actual number of hospital beds in use to treat COVID-19 patients peaked around mid-January before beginning to decline, according tothe University of Washington’s institute for Health Metrics and Evaluation.
At least 1,263 people died of COVID-19 in January, according to new state data.
Thoroughman described it as a “post-Christmas surge,” in a February 9 email. That was also the first date all of the state’s hospital regions had ICU, hospital bed and ventilator capacities under 80% since December.
On Friday, Beshear officially lifts the remaining COVID-19 restrictions. This phase of the pandemic is over, but it’s only just become clear how deadly a winter it was.
Additional reporting was by Geoff Hing of APM Reports, the investigative unit of American Public Media.
This story was produced as part of APM Reports’ public media accountability initiative, which supports investigative reporting at local media outlets around the country. Support also came from the Corporation for Public Broadcasting.