Health experts are calling Indiana an emerging coronavirus hot spot. But how bad is it?

The comments from leaders out of Washington, D.C., about Indiana last week were unnerving. 

U.S. Surgeon General Jerome Adams characterized Indianapolis as an emerging COVID-19 hot spot. The head of the White House coronavirus task force, Dr. Deborah Birx, echoed a similar assessment for Indiana.

Coronavirus cases are rising quickly. Deaths are mounting. The percentage of positive tests is drawing attention.

"At this juncture it’s hard to say for sure exactly why we’re now on the leading edge," said Brian Dixon, an associate professor of epidemiology at the Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis. "We’re certainly on the leading edge, not on the bleeding edge like New York."

Coronavirus in Indiana: See confirmed cases with these maps

But just how bad is Indianapolis, and Indiana, compared to other places? It's not an easy question to answer.

Simply put, the public does not have access to any set of comprehensive data.

Not everyone who shows symptoms of COVID-19 is getting tested nationwide. Not all test results, say some from private labs, are being reported. Some test results are unreliable.

Drawing sweeping conclusions from existing data is foolhardy. Still, a look at some key indicators helps us better understand Indiana's position fighting this global pandemic, and a glimpse into how other Midwestern cities are coping provides additional context. 

Gauging how cities and states perform in contrast to one another is a key part of what public health officials and epidemiologists do, said Thomas Duszynski, director of epidemiology education at the Indiana University-Purdue University Indianapolis Fairbanks School of Public Health

"It is important to make comparisons," he said. "We want to make comparisons because that’s how we measure where we’re at."

For this story, IndyStar analyzed data from the COVID Tracking Project, a website run by volunteer journalists who have been gathering publicly available data from state health departments.

Data is reported at different times or days, which limits direct comparison between states. This story relies on data posted on the website at 9 a.m. Friday, as well as new data reported by Indiana health officials at 10 a.m. Friday. 

How many positive cases of coronavirus does Indiana have? 

At 3,437 people on Friday, Indiana has the 15th-highest number of positive coronavirus cases. In the Midwest, only Michigan and Illinois have reported more cases.

Indiana's number amounts to 51 cases per 100,000 people. 

Again, it's important to note that not everyone is being tested. Also, some test results, say from private labs, are taking as long as two weeks before being reported. So cases reported each day by the Indiana State Department of Health are not necessarily new cases from the prior day.

A variety of factors could contribute to why Indiana has a high number of coronavirus cases relative to other states, experts say.

Some of the first cases came in people who attended a conference in Boston, became infected, and came back. If those people were well-connected socially, Dixon said, the disease could have started to spread that way.

Indiana also has an airport that connects to many major hubs, so people traveling through and outside of Indiana could have spurred disease transmission. Plus at least the northern and central parts of the state have connections to Chicago, where disease rates are even higher.

The overall poor health of Indiana residents also may contribute. Indiana has among the highest rates of smoking and diabetes, both of which may predispose someone who falls ill with coronavirus to develop severe disease, Dixon said. These people are more likely to be hospitalized and therefore tested.

"What we are likely to see throughout the rest of the month, many metropolitan areas all over the country will increase in their cases," he said. "I think we are a little bit ahead of these other areas. … With respect to coronavirus, it’s not a matter of if a city is going to be hit but when."

How many tests have been done? 

On Friday, Indiana officials reported that 17,835 tests had been conducted. That number includes figures reported to the state health department and does not necessarily reflect every test conducted by private laboratories.

By that metric, Indiana is ranked in the middle of all states in terms of total tests conducted for the coronavirus.  

But on a per capita basis, Indiana's total testing falls far short of most other states. 

Indiana has conducted 265 tests per 100,000 residents, placing it 39th out of all states. New York, Louisiana and Washington are all triple that rate; several other states are double. Oklahoma ranks the worst at 54 people test per 100,000 residents. 

With a shortage of tests available, health experts have said, we simply do not know whether Indiana actually has the 15th highest number of coronavirus patients.

Perhaps Indiana is identifying and testing more coronavirus patients than other states are. Indiana has primarily tested health care workers, people with severe symptoms and those most vulnerable who are elderly or have underlying health conditions.

Or maybe the opposite is true: Maybe Indiana has a higher number of coronavirus cases. 

Either way, we just do not know because so few people have been tested.

Although Indiana may have been behind other states at first, the entrance of Eli Lilly and Co. and Indiana University Health into the testing arena has helped Indiana pull alongside other states, experts say.

"We’re right where we need to be in terms of where other states are," Duszynski said. "Our testing right now is adequate for what we’re trying to achieve."

How many coronavirus deaths does Indiana have? 

The number of deaths caused by the coronavirus is a slightly more reliable piece of data. And it does not look good for Indiana.

The death count is not as affected by testing inconsistencies across the country. As The New York Times' Upshot reported late last month, most states are testing the sickest people, which leads to more reliable data on the number of deaths resulting from the virus. 

Indiana has the 12th most deaths resulting from the coronavirus, with 102 dead. New York is far ahead, with 2,373 dead. In the Midwest, only Michigan and Illinois have seen more deaths than Indiana. 

Indiana's death toll amounts to 1.52 deaths per 100,000 people, placing it 11th among all states. New York, meanwhile, is seeing 12.2 deaths per 100,000 people. On the other end is Wyoming, which has not reported a death, and West Virginia, which has reported 0.11 deaths per 100,000 people. 

Even this data has its limitations. The reporting lags mentioned earlier are a factor. And because states are reporting their data at different times, direct comparisons are difficult. 

How does Indianapolis look compared to other Midwest cities? 

The COVID Tracking Project collects only statewide data, so IndyStar only anecdotally looked at the situation in a handful of other Midwestern cities.

Compared to Indianapolis, some cities were taking more proactive steps to prepare for the surge in cases. Others, though, fared far worse.

In Detroit, bus driver Jason Hargrove took to Facebook two weeks ago to vent about a woman who boarded the bus and coughed without covering her mouth.

“For us to get through this and get over this, man, y’all need to take this s**t serious,” he said in a video. “There’s folks dying from this.”

By Thursday, Hargrove himself was dead from the virus.

The virus also swept through the Motor City's police department, killing three of its members while infecting Police Chief James Craig.

The disease has crippled the city’s first responders, with 106 police department employees testing positive and 524 police officers in quarantine as of Thursday. In the fire department, 24 employees tested positive with an additional 126 firefighters in quarantine.

In Indianapolis, 14 firefighters and 17 police officers tested positive for the disease as of Friday. 

In Columbus, Ohio, medical and other local officials are converting a portion of the Greater Columbus Convention Center into a temporary facility for suspected or confirmed coronavirus patients. The move is expected to add up to 1,500 beds.

That should prepare the Columbus area with about 10,000 beds, the estimated amount needed at the peak of the pandemic, said Robert Falcone, CEO of the Columbus Medical Association.

“We’re getting a lot of help from the National Guard, and we think we can do this,” Falcone said. “Once we think that the pandemic curve is real and is imminent, we can set up the full facility with staff and equipment within 72 hours.”

The Franklin County Board of Commissioners approved up to $5 million for the effort on Thursday.

In Milwaukee, the Children's Hospital of Wisconsin tested more than 100 people who had come into contact with a doctor who contracted the virus. All of those tests came back negative, according to a hospital spokeswoman.

No city should be complacent. 

Former Centers for Disease Control and Prevention head Dr. Tom Friedan warns that any place in the United States or the world could become the next coronavirus hot spot.

“Every city is in danger of looking like the challenges we have seen in Wuhan, in Italy and New York City,” said Friedan, now president and chief executive officer of Resolve to Save Lives, an initiative of the global public health organization, Vital Strategies. “There is no city anywhere in the world that can withstand an outbreak of coronavirus.”

The need for better data

Without comparable data from city to city or even state to state, drawing conclusions about whether one area of the country is faring worse than another is difficult.

Until last week,  Indiana had not released data about what percentage of people with confirmed cases of COVID-19 had been hospitalized. State health officials said they were waiting until April 1, when hospitals would start using a specific diagnosis code to denote a COVID patient in the medical record.

Other states such as New York have been reporting hospitalizations for weeks. That could be because New York has an all-payers claims database law that requires insurers to report data to the state. States that have laws mandating such a database likely have a clearer window into what is happening, Dixon said.

Indiana does not have such a law.

Indiana at first only provided numbers of cases, tests performed and deaths but more recently has added demographics such as age range and sex on the patients with confirmed cases and those who have died.

Additional information could prove helpful, experts say.

Sharing recovery rate could help ease some people’s fears about the disease, Duszynski said, as would the rate of who has been hospitalized as well as those who have required ventilator care.

At the same time, study after study on various aspects of COVID-19 are being published, some of which yield conflicting conclusions.

“The more information, the more accurate data we can put out, that helps the public understand everything going on,” he said. “The challenging thing is this is rapidly changing, sometimes by the hour. We’re kind of drinking from a fire hose in terms of the information we’re getting.”

Contact IndyStar reporter Shari Rudavsky at 317-444-6354 or shari.rudavsky@indystar.com. Follow her on Facebook and on Twitter: @srudavsky.

Call IndyStar reporter Amelia Pak-Harvey at 317-444-6175 or email her at apakharvey@indystar.com. Follow her on Twitter @AmeliaPakHarvey.

Contact IndyStar investigative reporter Ryan Martin at ryan.martin@indystar.com or by phone, Signal or WhatsApp at 317-500-4897. Follow him on Facebook or Twitter: @ryanmartin.