Critical Indicator Report

COVID-19 Critical Indicators September 15, 2021

Introduction

As Tennessee (TN) monitors reopening across the state, the Tennessee Department of Health (TDH) will maintain vigilance of cri cal COVID-19 indicators at the state and county levels to iden fy ‘problem areas’ across the state and provide early indica on of sustained increases in community transmission. These metrics were developed in line with the White House proposed State Ga ng Criteria and help oﬃcials monitor trends in four key areas: • Trends in COVID-19 Cases (see on page 2) • Trends in COVID-19 Symptoms (see on page 7) • Trends in COVID-19 Tes ng Capabili es (see on page 8) • Trends in Healthcare System Capacity (see on page 9)

Beginning June 12th, 2020, case trends (beginning on page 2) include both conﬁrmed and probable cases.

COVID-19 in TN at a Glance 1,171,722 4,432 73,435 14,289 Total Number of New COVID-19 Active COVID-19 Total Number of COVID-19 Cases Cases Today Cases Today COVID-19 Deaths

Key Deﬁnitions

Below are defini ons important to understanding this report. In addi on to these defini ons, each visuaiza on in this report will be explained in further detail in the technical notes (see page 11): • In TN, a COVID-19 case is counted in the daily case count, demographics, and outcomes, if it classified as a confirmed or probable case. Please see the COVID-19 case defini on found at h ps://www.tn.gov/content/dam/tn/health/documents/cedep/novel-coronavirus/COVID-Case-Defini on.pdf. • A confirmed case is someone who tested posi ve (via PCR test) for the virus that casues COVID-19 (SARS-Cov-2). • A probable case is someone who may have tested nega ve by PCR, tested posi ve by another type of test or may not have been tested at all, but has an illness consistent with COVID-19, and may have other risk factors. For example: • If a person is a close contact of a COVID-19 case and has a clinically-compa ble illness, this person meets the criteria to be a probable case • The specimen collec on date is the date someone's COVID-19 lab sample was collected. Due to lab turnaround me there may be delays between when a specimen is collected and a confirmed case is reported to the public. Unless otherwise stated, visualiza ons in this report use specimen collec on date as it more accurately indicates when a pa ent was sick (and not when their case was reported to the public).

This report was produced by the Tennessee Department of Health on September 17, 2021. Critical Indicators COVID-19 September 15, 2021 Trends in COVID-19 Cases in TN

The following sec on will visualize the COVID-19 case trends (both conﬁrmed and probable) in TN, including newly reported cases, the ac ve number of cases, and the number of COVID-19 conﬁrmed deaths.

Epidemic Curve of COVID-19 Cases by Specimen Collection Date1

The curve below visualizes the number of new cases each day since the beginning of the COVID-19 outbreak. The number of cases each day are visualized in the blue bars and the moving 7-day average is visualized with the red line. On August 30th, 2020, the moving 7-day average was the highest of the pandemic, averaging 8,338 new cases/day.

12K Illness that 12K began during this time may not yet be 10K reported. 10K s e s a C

8K 8K 1 - s D I e s V a O C C

9 f o 1

- 6K 6K e D I g a V r O e C v A

4K 4K g n i v o M

2K 2K

0K 0K Mar 1, 20 Jun 1, 20 Sep 1, 20 Dec 1, 20 Mar 1, 21 Jun 1, 21 Sep 1, 21 Specimen Collection Date The epidemic curve is based on the day the specimen was collected. Therefore, the most recent day’s data may not be complete as test results take an average of 2-5 days to be reﬂected in the visualiza on. To learn more about this visualiza on, please reference the technical notes.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 2| Critical Indicators COVID-19 September 15, 2021

Statewide Number and Rate of Active Cases2 The chart below visualizes the number and rate of ac ve COVID-19 cases in TN. On September 3rd, 2020 (orange line) TDH updated its defini on of an ac ve case significantly lowering the number of ac ve cases on that day and moving forward. Since TDH updated its defini on of an ac ve case, the number and rate of ac ve cases hit a peak on December 21st, 2020 with 85,406 cases. ) s

80K 1200 n o s

On September 15, 2021, there r e P were 73,435 active COVID-19 1000 0

cases in TN. The rate of active 0 0 60K , cases was 1,075.3 per 100,000 0 s 800 0 e 1

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i 600

40K e t s c a A C

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f o 200 e t a R 0K TDH updated its deﬁnition of an active case on 9/3/2020 0

Mar 1, 20 Jun 1, 20 Sep 1, 20 Dec 1, 20 Mar 1, 21 Jun 1, 21 Sep 1, 21 Date of Public Report

Daily Percent of Positive COVID-19 Tests3 The chart below visualizes the daily percent of posi ve COVID-19 tests. For today, September 15, 2021, the daily posi vity rate was 19.0% and the posi vity rate for the last 7 days was 18.9%.

25 19.0% 20 s o p

% 15 y l i a

D 10 Positivity Rate 10%

5 Positivity Rates 5%

Mar 1, 20 May 1, 20 Jul 1, 20 Sep 1, 20 Nov 1, 20 Jan 1, 21 Mar 1, 21 May 1, 21 Jul 1, 21 Sep 1, 21 Date

On 5/3/2021, TDH shi ed to a more reliable system-generated date, the date the COVID-19 case was added to the surveillance system. Because of this change, this visualiza on has had a minor shi in the number of new cases reported for each day and therefore, the daily percent of posi ve COVID-19 tests.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 3| Critical Indicators COVID-19 September 15, 2021

Positive Tests per 100,000 Person by Public Health Region (over last 7 days)4 The map below shows the number of new posi ve tests in the last 7 days per 100,000 persons. The arrow indicators represent the trend (up or down) as compared to the week prior. For the week of September 15, 2021, the highest rate of posi ve tests was seen in the Southeast Region. Addi onally, 12 of the 13 public health regions saw a decrease in the number of posi ve cases compared to the week prior.

646.7 619.5▲ 499.9 467.1 548.4 ▼ ▼ 621.7 ▼ ▼ 464.9 ▼ 404.5 ▼ ▼ 341.9 ▼ 527.5 696.2 450.3 ▼ ▼ 420.1 Positive Tests by Region ▼ ▼ 341.9 696.2

TN SARS-CoV-2 Variant Case Summary5

Below is a table summarizing COVID-19 variant cases reported to the Tennessee Department of Health. Because sequencing is not performed by all laboratories, these data are a convenience sample and not indica ve of the true prevalence of variants. To learn more about COVID-19 variants, please see the SARS-CoV-2 Variant Classiﬁca ons and Deﬁni ons published by the CDC: h ps://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html

Addi onal data on variant propor ons na onally and by state are avaiable from the CDC at: h ps://covid.cdc.gov/covid-data-tracker/#variant-propor ons

Variants of Concern B.1.617.2 TN Region B.1.1.7 -Alpha B.1.351 -Beta AY.1-Delta AY.2-Delta P.1 -Gamma -Delta Blountville-Sullivan Region 31 0 0 0 19 4 Chattanooga-Hamilton Region 83 0 0 0 71 0 East Tennessee Region 236 2 1 0 278 21 Jackson-Madison Region 16 0 0 0 72 1 Knoxville-Knox Region 49 1 0 0 68 4 Memphis-Shelby Region 1,663 4 0 5 2,157 39 Mid-Cumberland Region 600 1 0 2 387 15 Nashville-Davidson Region 355 1 0 2 264 11 Northeast Region 321 5 0 6 96 12 South-Central Region 129 1 0 1 110 0 Southeast Region 168 0 0 0 92 3 Upper-Cumberland Region 320 0 0 0 169 23 West Tennessee Region 344 7 1 0 521 11 Grand Total 4,315 22 2 16 4,304 144

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 4| Critical Indicators COVID-19 September 15, 2021

TN SARS-CoV-2 Variant Case Summary Continued5

Below is a table summarizing the COVID-19 variants of interest cases reported to the Tennessee Department of Health.

TN Region B.1.525 -Eta B.1.526 -Iota B.1.617.1 -Kappa

Chattanooga-Hamilton Region 0 1 2 East Tennessee Region 0 7 24 Jackson-Madison Region 1 1 8 Knoxville-Knox Region 0 1 6 Memphis-Shelby Region 0 25 86 Mid-Cumberland Region 5 24 29 Nashville-Davidson Region 0 20 32 Northeast Region 1 8 10 South-Central Region 0 4 8 Southeast Region 0 0 1 Upper-Cumberland Region 0 10 10 West Tennessee Region 0 10 63 Grand Total 7 111 279

Vaccine Breakthrough Cases in TN6 CDC deﬁnes COVID-19 Vaccine Breakthrough Cases as a U.S. resident with SARS-CoV-2 RNA or an gen detected on a respiratory specimen collected ≥14 days a er comple ng the primary series of an FDA-authorized COVID-19 vaccine. To learn more about breakthrough cases across the US and how they are being reported to the CDC: h ps://www.cdc.gov/vaccines/covid-19/health-departments/breakthrough-cases.html Overall Metrics: Symptoms: COVID-19 Outcome Breakthrough Cases Symptoms Breakthrough Cases Cases 35,938 Yes 6,255 Hospitalized Cases* 769 No 921 Deceased Cases** 296 Unknown 28,762

Summary of Recent Breakthrough Cases: % of COVID Hospitalizations % of COVID Deaths Month Dates Included % of Cases Unvaccinated Unvaccinated* Unvaccinated** May 5/2/2021 - 5/29/2021 96% (13,978/14,510) 95% (848/890) 97% (228/236) June 5/30/2021 - 7/3/2021 93% (6,005/6,486) 88% (389/443) 96% (152/159) July 7/4/2021 - 7/31/2021 86% (28,329/32,908) 87% (891/1021) 88% (184/208) August 8/1/2021 - 8/28/2021 87% (135,999/157,010) 86% (1933/2235) 83% (658/793) May- August 5/2/2021 - 8/28/2021 87% (184,230/210,914) 88% (4061/4589) 88% (1222/1396)

* Hospitaliza ons: Hospitaliza on data is reported from case interviews or via Tennessee Hospital Associa on data. Please note, TDH currently conducts more robust ac ve surveillance for hospitalized COVID-19 cases that are vaccinated than for those that are unvaccinated; therefore the data for hospitaliza ons among the unvaccinated may be more incomplete. We are working to improve the completeness of our hospitaliza on data. ** Deaths: Deaths where COVID-19 is a cause or contribu ng factor listed on the death cer ﬁcate. Other cases may s ll be under inves ga on.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 5| Critical Indicators COVID-19 September 15, 2021 7 Day Rolling Average of COVID-19 Cases by Vaccination Status The plot below shows the 7 day rolling average rate of COVID-19 cases (per 1,000,000 persons) by vaccina on status.

200

150

100 Not Fully Vaccinated 50

0 Fully Vaccinated

January February March April May June July August September

7 Day Rolling Average of COVID-19 Hospitalizations by Vaccination Status The plot below shows the 7 day rolling average rate of COVID-19 hospitaliza ons (per 1,000,000 persons) by vaccina on status.

10 Not Fully Vaccinated

0 Fully Vaccinated January February March April May June July August September

7 Day Rolling Average of COVID-19 Deaths by Vaccination Status

The plot below shows the 7 day rolling average rate of COVID-19 deaths (per 1,000,000 persons) by vaccina on status.

5 Not Fully Vaccinated

0 Fully Vaccinated

January February March April May June July August September

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 6| Critical Indicators COVID-19 September 15, 2021

7 Day Running Average of New Cases in Metropolitan Public Health Regions7

800 Blountville/Sullivan County s Chattanooga/Hamilton County e

s Jackson/Madison County a

C Knoxville/Knox County

w 600 Memphis/Shelby County e Nashville/Davidson County N

f o

g 400 a r e v A

y 200 a D

7 0

Mar 1, 20 Jun 1, 20 Sep 1, 20 Dec 1, 20 Mar 1, 21 Jun 1, 21 Sep 1, 21 The plot above illustrates the 7 day running average of new COVID-19 cases (based on the date of public report) for the six metropolitan public health regions. The Nashville/Davidson and Memphis/Shelby metropolitan areas have consistently reported higher counts of COVID-19 cases compared to the other four metropolitan areas since the outbreak began.

7 Day Running Average of New Cases in Rural Public Health Regions7

East Tennessee Region

s Mid-Cumberland Region e

s 1500 Northeast Region a

C South Central Region

w Southeast Region

e Upper Cumberland Region N

f West Region

o 1000

e g a r e v A

500 y a D

7 0

Mar 1, 20 Jun 1, 20 Sep 1, 20 Dec 1, 20 Mar 1, 21 Jun 1, 21 Sep 1, 21 The plot above illustrates the 7 day running average of new COVID-19 cases (based on the date of public report) for the seven rural public health regions.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 7| Critical Indicators COVID-19 September 15, 2021

Number of Deaths per Day (by date of death)8 On September 15, 2021, the total number of conﬁrmed COVID-19 deaths was 14,289 (11,458 conﬁrmed and 2,831 probable). Below are the number of COVID-19 deaths by the date of death. The red line represents the 4 day running average number of deaths. Deaths that occurred 120 during this 120 time may not yet be 110 reported to 110 TDH.

100 100

90 90 s h t a e D

80 80 f o

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70 70 u s N h e t g a a e r D e

60 60 v A

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y a D - 40 40 4

30 30

20 20

10 10

0 0 Mar 1, 20 Jun 1, 20 Sep 1, 20 Dec 1, 20 Mar 1, 21 Jun 1, 21 Sep 1, 21 Date of Death

Case Fatality Rate: 30-Day Case Fatality Rate: 1.2% 0.5% (14,289/1,171,722) (1,070/195,067)

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 8| Critical Indicators COVID-19 September 15, 2021

COVID-19 Active Cluster Monitoring Table9 The table below shows the number ac ve COVID-19 clusters that are currently being monitored by region and cluster type. To learn more cluster and cluster types, please reference the endnotes on page 14.

Facility Type CHR ETR JMR KKR MCR MSR NDR NER SCR SER SUL UCR WTR Total Assisted Care Living Facility 1 10 1 12 15 2 3 1 4 1 6 7 63

Bar 3 3

Community 20 5 9 81 6 24 30 5 3 9 4 196

Construction/Building 1 1 2

Correctional 1 4 1 1 3 1 6 2 5 1 2 10 37

Homeless Shelter 1 1 2

Industrial 2 4 2 1 1 4 9 23

Nursing Home 7 27 2 16 31 6 12 2 9 16 5 17 25 175

Other facility 6 10 5 16 7 8 6 1 3 5 67

Other Healthcare 1 3 4

Restaurant 1 1 1 1 4

Total 39 56 25 126 66 44 62 9 10 26 12 41 60 576

For more informa on on the metro and regional health departments, please click here or see page 15.

COVID-19 Conﬁrmed Clusters by Week10

The visualiza on below shows the number of new clusters iden ﬁed in Tennessee each week.

140

120 d e ﬁ i t 100 n e d I s r e t 80 s u l C 133 130 w e 60 122 120 119

N 113 114 110 111 f 101403 105 103 o 102 100 98 10096 96 r 91 e 88 8788 85 86 b 40 83 83 83 78 m 73 74

u 69 65 65 6367 N 6057 52 55 44 47 43 4447 20 4041 38 41 40 32 35 34 27 28 29 2926 25 22 2021 16 15 0 105 109 7

Jun 14, 20 Aug 9, 20 Oct 4, 20 Nov 29, 20 Jan 24, 21 Mar 21, 21 May 16, 21 Jul 11, 21 Sep 5, 21 Week

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 9| Critical Indicators COVID-19 September 15, 2021 Trends in COVID-19 Symptoms in TN The following sec on will visualize the trends in COVID-19 symptoms based on data collected through TN’s syndromic surveillance system, ESSENCE. ESSENCE tracks pa ent chief complaints and discharge diagnoses from 95 emergency departments across the state. The data are typically received from par cipa ng EDs within 24 hours of a pa ent encounter. These data are used to get pre-diagnos c es mates of health condi ons (like COVID-19) being reported from emergency departments.

Syndromic Surveillance (Emergency Room) Data11

25.00% Coronavirus-like Illness s

t Inﬂuenza-like Illness i s i V

t 20.00% n e m t r a p e D

15.00% y c n

e 14.0% g r e m E

l 10.00% l A

f o

e g a t

n 5.00% e c r e P 2.9% 0.00%

Nov 10, 19 Jan 26, 20 Apr 12, 20 Jun 28, 20 Sep 13, 20 Nov 29, 20 Feb 14, 21 May 2, 21 Jul 18, 21 Week Starting Date

Cornavirus like illness (CLI) is defined as symptom terms, free text, or discharge diagnoses specified by CDC that are likely to be related to illness caused by the 2019 novel Coronavirus. The visits counted within these criteria will contain a percentage illnesses caused by condi ons other than novel coronavirus infec on. The visits counted within these criteria will contain a percentage illnesses caused by condi ons other than novel corona virus infec on. These results should be considered preliminary in nature and are not all confirmed diagnoses of disease.

Influenza like illness (ILI) is defined by terms, free text, or discharge diagnoses that are likely to be related to illness caused by seasonal influenza. The visits counted within these criteria will contain a percentage illnesses caused by condi ons other than influenza infec on. These results should be considered preliminary in nature and are not all confirmed diagnoses of disease.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 10| Critical Indicators COVID-19 September 15, 2021 Trends in COVID-19 Testing Capabilities The following sec on will visualize the COVID-19 tes ng trends in TN, including laboratory tes ng turnaround me and the rates of tes ng across the state.

Laboratory Testing & Turnaround Time12

Below is the number of COVID-19 laboratory tests conducted in TN over the last year as well as the average laboratory turnaround me by month.

OCTOBER 2020 1.27 Days (859,090 Labs)

NOVEMBER 2020 1.82 Days (980,917 Labs)

DECEMBER 2020 1.37 Days (1,098,085 Labs)

JANUARY 2021 1.18 Days (831,128 Labs)

FEBRUARY 2021 1.02 Days (507,534 Labs)

MARCH 2021 0.89 Days (493,023 Labs)

APRIL 2021 0.83 Days (434,475 Labs)

MAY 2021 0.79 Days (309,983 Labs)

JUNE 2021 0.79 Days (203,261 Labs)

JULY 2021 0.76 Days (244,441 Labs)

AUGUST 2021 1.14 Days (827,268 Labs)

SEPTEMBER 2021 1.10 Days (439,071 Labs)

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 Average Turnaround Time in Days (# of Labs)

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 11| Critical Indicators COVID-19 September 15, 2021 Trends in COVID-19 Hospital Capacity The following sec on will visualize trends in hospital capacity, including the number of COVID-19 posi ve pa ents currently admi ed, hospital bed u liza on, and bed/ven lator availability. All of the visualiza ons below were created using data from the TN Healthcare Resource Tracking System (HRTS), a tool developed by TDH that manages healthcare facility bed, service and asset availability. These data are reported by hospitals across TN daily.

Number/Rate of COVID-19 Hospitalized Patients13 Below is the number of COVID-19 pa ents currently hospitalized (dark blue), and of those hospitalized who are in the ICU (green) and are using ven lators (light blue). The grey bar represents the number of pa ents per repor ng hospital, a rate that can help us be er interpret changes in COVID-19 hospitaliza ons (as not all hospitals report each day).

The total number of COVID-19 posi ve pa ents hospitalized across TN on September 16, 2021 was 3,658. There are 1,065 COVID-19 pa ents currently in the ICU and 779 u lizing ven lators. The number of admi ed pa ents per hospital repor ng was 28.80 (with 114 hospitals repor ng).

4000

30 3,658

3500 Inpa ent 25 l ICU

a 3000 t i p Ven lated s o h r e 20 2500 p s t s t n n e i e t i t a

2000 a p

P g 15 n i t r o p e 1500 r f o 10 # 1,065 1000

5 500

0 0 May 1, 20 Jul 1, 20 Sep 1, 20 Nov 1, 20 Jan 1, 21 Mar 1, 21 May 1, 21 Jul 1, 21 Sep 1, 21

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 12| Critical Indicators COVID-19 September 15, 2021

Hospital Utilization and Conﬁrmed COVID Hospitalizations in TN13

Total Bed Capacity: 12,344 12K

This visual illustrates the total number of 10K 9,439 hospital beds (adult ﬂoor beds) occupied by non-COVID-19 (light blue) and conﬁrmed COVID-19 pa ents (darker blue) since July 15th, 2020.

e 8K s

U Addi onally, please note the following: Non-COVID Hospitalizations n i • On December 18, 2020 this visualiza on was s d

e changed to compare the number of hospital B

r beds (adult ﬂoor beds) occupied by o

o 6K l non-COVID-19 pa ents and conﬁrmed COVID-19 F pa ents (excluding COVID-19 pa ents using ICU beds) across TN.

4K • On September 16, 2021, 27.5% (2,593/9,439) of ﬂoor bed hospitaliza ons in Tennessee were 2,593 COVID-19 pa ents.

2K COVID Hospitalizations

Jul 1, 20 Oct 1, 20 Jan 1, 21 Apr 1, 21 Jul 1, 21 Oct 1, 21

Quick Glance at Hospital Bed & Ventilator Availability13

Below is a brief snapshot of the currently available ﬂoor beds, ICU beds and ven lators across TN.

61% 10% 5% 1,195/1,968 1,238/12,198 121/2,237

Available Adult Ventilators Available Floor Beds Available ICU Beds

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 13| Critical Indicators COVID-19 September 15, 2021 Technical Notes

1. Epidemic Curve for COVID-19 Cases by Specimen Collec on Date (page 2)

The visualiza on on page 2 shows the daily new COVID-19 cases (blue bars) and 7-day moving average of new cases (red line). A seven day moving average is the average of one data point and the six preceding data points. Looking at the moving average helps to understand trends and account for ﬂuctua ons in the data.

Are probable cases included in the Epidemic Curve? Probable cases are included in the epidemic curve in this report. For the probable cases where specimen collec on date is not available, the date the pa ent's illness or symptoms began is used.

Can I recreate this with TDH publicly available data? Not exactly. The public downloadable datasets (Daily Case Informa on) present COVID-19 case counts based on the day they were publicly reported, not specimen collec on date. However, using the column New_Cases one can create a similar visualiza on. The primary diﬀerence between the visualiza on using the public dataset method and the one in this report would be that the trends seen in this report should align with trends seen roughly 2-5 days later in the public dataset visualiza on. Again, this would be because of the 2-5 day lag between specimen collec on date and public report date.

2. Statewide Number and Rate of Ac ve Cases (page 3)

The visualiza on on page 3 shows the number (light blue bars) and rate (dark blue line) of ac ve cases each day in TN.

How does TDH count recovered COVID-19 Cases? The number of ac ve COVID-19 cases are determined by: total number of cases - inac ve/recovered cases. TDH considers a case “inac ve/recovered” when: 1) they are at least 14 days beyond their symptom onset date, or are at least 14 days beyond the ﬁrst test conﬁrming illness if asymptoma c, and 2) are not deceased.

How is the rate of ac ve cases calculated? The ac ve rate is the total number of individuals who ac vely have COVID-19 in TN divided by the state popula on, see example calcula on and interpreta on below. The popula on of the state is from the 2018 projected popula on es mate for Tennessee.

Can I recreate this with TDH publicly available data? Yes. Using the public downloadable datasets (Daily Case Informa on) you can use the column Total_Ac ve to get the daily number of ac ve cases and the instruc ons above to calculate the rate. If you want to understand how TDH calculates "Total Ac ve" you can calculate it yourself by subtrac ng the number of recovered cases (Total_Recovered) and the number of cases who have died (Total_Deaths) from the total number of cases (Total_Cases).

3. Daily Percent of Posi ve COVID-19 tests (page 3)

The visualiza on on page 3 shows the daily posi vity rate (blue line) as well as two thresholds that indicate if the posi vity rate was above either 5% or 10%.

How is the daily percent of posi ve tests calculated? The daily percent of posi ve tests is calculated by taking the number of new posi ve tests for that day divided by the total number of new tests for that day. These numbers are publicly available in the downloadable data- Daily Case Info. While the number of new tests conducted that day can be found in the column New_Tests, the new posi ve number of tests can be calculated by subtrac ng yesterdays total Pos_Tests from today's total Pos_Test.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 14| Critical Indicators COVID-19 September 15, 2021

Daily Percent of Posi ve COVID-19 tests (page 3) con nued

Can I recreate this with TDH publicly available data? Yes. Using the public downloadable datasets (Daily Case Informa on) and the instruc ons above one is able to recreate the visualiza on. 4.TN SARS-CoV-2 Variant Case Summary (page 4)

The table on page 4 summarizes the COVID-19 variant cases iden ﬁed in TN (learn more about variants at h ps://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html?CDC_AA_refVal=h ps%3A%2F%2Fwww.cdc.gov% 2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fvariant-surveillance%2Fvariant-info.html).

Can I recreate this with TDH publicly available data? No. The count of variant cases is not currently available in the TDH provided public data sets. 5. Posi ve Tests per 100,000 Persons by Public Health Region (Over the last 7 Days) (page 4)

The regional level map shows the number of new posi ve tests per 100,000 persons by public health region in the last 7 days. The arrows indicate trends (up or down) of the new posi ve tests rate compared to the week prior.

How is the number of posi ve tests per 100,000 persons calculated in the map? These rates are calculated by the taking the number of new posi ve tests for the region divided by the region's popula on. This is then mul plied by 100,000 to have the number per 100,000 persons.

Are the number of cases the same as the number of posi ve tests? No, not necessarily. The number of posi ve tests is the total number of PCR-posi ve laboratory results that have been reported to TDH, while the number of cases are individual people who are either conﬁrmed or probable COVID-19 cases. Individuals are only counted once in this number, no ma er how many posi ve tests they might have had. Therefore, if an individual tested posi ve mul ple mes in a given week in the same area they would be counted mul ple mes in this map (but would only be counted once in the case counts) Can I recreate this with TDH publicly available data? Yes. The numbers required to create the calcula on explained above are publicly available in the County New dataset but only at the county level. In order to recreate this visualiza on one will need to group the coun es (and county popula ons) by their public health region (can be found at h ps://www.tn.gov/content/dam/tn/health/program-areas/oral-health/dental-regional-metro-areas.jpg). 6. Vaccine Breakthrough Cases in TN (page 5)

The table on page 5 shows some demographic, hospitaliza on, and death metrics for the COVID-19 vaccine breakthrough cases iden ﬁed in TN. Please note the 'Overall Metrics' sec on was updated on 9/17. This update removed the denominator and percentage data as they were not accurate representa ons of the propor ons of breakthrough cases. To learn more about breakthrough cases and how they are reported see h ps://www.cdc.gov/vaccines/covid-19/health-departments/breakthrough-cases.html.

What is a breakthrough case? CDC deﬁnes COVID-19 Breakthrough Cases as a U.S. resident with SARS-CoV-2 RNA or an gen detected on a respiratory specimen collected ≥14 days a er comple ng the primary series of an FDA-authorized COVID-19 vaccine. All cases mee ng this deﬁni on through April 30th are reported. As of May 1st, CDC asked that only cases with severe outcomes (hospitaliza on or death) be reported. Can I recreate this with TDH publicly available data? No, vaccine breakthrough informa on is not publicly available.

7.7 Day Running Average of New Cases in Metropolitan and Rural Public Health Regions (see page 7)

The visualiza ons on page 6 show the 7 day running average of new COVID-19 cases for all of the metropolitan and rural public health regions. These new case counts are based on their public report date and not specimen collec on date. A 7 day moving average is the average of one data point and the six preceding data points. Looking at the moving average helps to understand trends and account for ﬂuctua ons in the data.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 15| Critical Indicators COVID-19 September 15, 2021

7 Day Running Average of New Cases (page 7) con nued

Can I recreate this with TDH publicly available data? Yes, using the downloadable dataset- County New and the column New_Case, one is able to see the daily counts at the county level. These counts can added together to create the daily new case counts for each public health region. The 7 day average of new cases can be then calculated by totaling the daily new case counts (by region) for today and the previous 6 days and then dividing by 7.

8. Number of Deaths per Day (by date of death) (page 8)

The visualiza ons on page 7 show the number of COVID-19 deaths by date of death (blue bars) and the 4-day moving average of the number of deaths. A four day moving average is the average of one data point and the three preceding data points. Looking at the moving average helps to understand trends and account for ﬂuctua ons in the data.

What is a probable death? A probable COVID-19 death is if a person dies and the health care provider that signed their death cer ﬁcate determined that COVID-19 disease was their cause of death or a signiﬁcant condi on contribu ng to death, then the person meets the probable case criteria and would be considered a probable death.

Is date of the death the same day it is publicly reported? No, similarly to specimen collec on date, the date of death frequently occurs 2-5 days before the death is reported to the public due to lag me in repor ng. Therefore, the most recent day's data may not be complete.

How can I calculate the Case Fatality Rate? What about the 30-Day Case Fatality Rate? A case fatality rate is calculated by taking the total number of COVID-19 deaths divided by the total number of COVID-19 cases. A 30-day case fatality rate would only look at the total number of deaths and number of cases for the last 30 days. Both of these rates can be produced using the publicly downloadable datasets (Daily Case Informa on).

Can I recreate this with TDH publicly available data? Not exactly. The public downloadable datasets-Daily Case Informa on presents COVID-19 deaths based on the day they were publicly reported, not the date of death. However, using the New_Deaths column one can create a similar visualiza on. The primary diﬀerence between the visualiza on using the public dataset method and the one in this report would be the trends seen in this report should align with trends seen roughly 2-5 days later with the public dataset visualiza on. Again, this would be because of the 2-5 day lag between date of death and public report date.

9. COVID-19 Ac ve Cluster Monitoring Table (page 9)

The table on page 8 displays the number of ac ve COVID-19 clusters that are currently being monitored by region and cluster type.

What the deﬁni on of a COVID-19 Cluster? A COVID-19 cluster is two (2) or more conﬁrmed cases (with posi ve lab results) of COVID-19 that are linked by the same loca on of exposure (for example a hospital, nursing home, grocery store, correc ons facility, etc.) or exposure event (for example a work party, vaca on, etc.) that is not a household exposure. In TN, the most commonly reported clusters have been in correc ons facili es and nursing homes.

Cluster Types Quick Deﬁni ons- Community clusters include those associated with: First Responders Religious/spiritual organiza ons Daycares, educa onal se ngs Apartment complexes

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 16| Critical Indicators COVID-19 September 15, 2021

COVID-19 Ac ve Cluster Monitoring Table (page 9) con nued

Businesses Shopping facili es Sports/ﬁtness facili es Other facili es clusters include facili es such as camps. Other Healthcare clusters include provider types such as: Mental health ins tu ons Pharmacies Home health agencies Den st oﬃces

Metro/Regional Health Department Abbrevia ons: CHR Cha anooga Hamilton County Health Department ETR East Tennessee Regional Health Department JMR Jackson Madison County Health Department KKR Knoxville Knox County Health Department MCR Mid Cumberland Regional Health Department MSR Memphis Shelby County Health Department NDR Nashville Davidson County Health Department NER Northeast Regional Health Department SCR South Central Regional Health Department SER Southeast Regional Health Department SUL Sullivan County Health Department UCR Upper Cumberland Regional Health Department WTR West Tennessee Regional Health Department

Can I recreate this with TDH publicly available data? No, cluster informa on is not publicly available.

10. COVID-19 Conﬁrmed Clusters by Week (page 9)

The visualiza on on page 8 shows the new clusters iden ﬁed in Tennessee each week.

Can I recreate this with TDH publicly available data? No, cluster informa on is not publicly available.

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 17| Critical Indicators COVID-19 September 15, 2021

11. Syndromic Surveillance (Emergency Room) Data (page 10)

The visualiza ons on page 9 shows the percent of all emergency room visits in that are repor ng both Cornavirus like Illness (CLI) and Inﬂuenza like Illness (ILI) in TN. This dashboard can also be found online here.

Can I recreate this with TDH publicly available data? Yes and no. While ESSENCE data is not included in the publicly available datasets, the dashboard above does provide the weekly percent of ILI and CLI symptoms in the tool ps. Therefore, one could recreate the visualiza on if desired.

Can I recreate this with TDH publicly available data? Yes and no, while lab turnaround me is not publicly reported, the lab tes ng volume can determined using the New_Tests column of the Daily Case Informa on public dataset.

The visualiza on on page 10 shows the volume of COVID-19 lab tes ng and average turnaround me for the months of March through October (so far) in 2020.

Can I recreate this with TDH publicly available data? Yes and no, while lab turnaround me is not publicly reported, the lab tes ng volume can be determined using the New_Tests column of the Daily Case Informa on public dataset. This dataset can be found at h ps://www.tn.gov/health/cedep/ncov/data/downloadable-datasets.html.

13. HRTS-Reported Hospitaliza ons & Bed Capacity (page 12 and 13)

The visualiza ons see on pages 11 and 12 shows TN's hospital capacity through ac ve hospitaliza ons, current bed u liza on, and bed availability.

Can I recreate this with TDH publicly available data? No, HRTS data is not publically available.

To access all the downloadable datasets men oned in the technical notes, please see: h ps://www.tn.gov/health/cedep/ncov/data/downloadable-datasets.html

This report was produced by the Tennessee Department of Health on September 17, 2021. PAGE 18|