COVID-19 (f/k/a "the Coronavirus")

[lawdog77]

Its species jumping viruses/diseases.

Is this the next one?
https://www.cdc.gov/prions/cwd/index.html

[StillAWarrior]

I don't know if it's a sense of invincibility, willful ignorance or just plain ol' American stupidity, but a lot of people have their heads in the sand on this... honestly, very few Americans understand what is actually going on here, and it has nothing to do with politics, the media, etc.  People are going to read and believe whoever or whatever suits them, but there are certain Covid-19 facts that are not in dispute here:

1) The incubation period seems to average ~5 days but the range is 2 to 14 days.  IOW, you could be infected for up to two weeks and not even know it.
2) Some people who are infected are asymptomatic.
3) The virus can be shed by people who are asymptomatic, i.e. you can be infected via exposure to someone who is asymptomatic.
4) The virus does not immediately deactivate upon coming in contact with a non-host surface.

So think about how many people you came into contact with 5 days ago, and how many people with whom you've come into contact since then.  Then think about all of the people those people came into contact.  And those people and those people.

On average, do we come into contact with 20 people/day?  Fifty?  Five?  One?

As a hypothetical, I was at the Bucks game last week... I probably came within six feet of at least 200 people, maybe more.  I was fortunate enough to have a pass to the BMO Club, so I also was touching serving spoons at the buffet (that we also being touched by others), so add another 200-300 that I might have "touched."  So if just one out of those 500 were infected, there's a pretty good chance I was exposed to the virus.  I take it home, and now 9 days later, I start exhibiting symptoms, so I go into self-quarantine... but in the last 9 days: I also went to mass, and even though there was no contact, I was still within six feet of 5 other people.  But then my three kids, who are now asymptomatic carriers have taken it to school and exposed another 20 kids each directly, and maybe another 50 (total) through surface touching.  Don't forget my son's volleyball game, so another 10-15 there as well.  And then there's my wife, also an asymptomatic carrier by now, who rides the Metra every day... conservatively, let's say that's another 500, but then 10% of her coworkers are exposed, so another 40.

In the 9 days between infection and symptoms, my family and I have potentially exposed - but not necessarily infected - almost 700 people.  The question is: how many of those 700 will be infected?  Even if it's 5%, that's still 35 people... each of whom will now spread the virus - asymptomatically - for the next five days to another 35 people.  And then to another 35 people in five days, etc.  The math goes like this:

Day 1: Just Benny
Day 9: 35
Day 14: 1,225
Day 19: 42,875
Day 24: 1,500,625

In just over three weeks, 1.5M have been infected by me, of which 1,457,750 aren't exhibiting any symptoms.  But let's say I'm off by a factor of 10x... that's still 145,000. 

Now, if I was at the Bucks game on 2/19 instead... today is Day 24.  The population of Ohio is 11.6M and 1% of that is 116,000 people.

True?  No.

Plausible?  Yes.  And that's where the problem lies... most people don't quite understand what we could be facing here.

I suppose this is, at least in part, directed at me because I raised and have discussed the Ohio number.  I would be far more comfortable if the head of ODH would have said that it is "plausible" that 100,000 are infected. Keep in mind that if 100,000 are infected, you need to perform your calculation for every single one of them. What number does that give you? Does it take you beyond the total population of Ohio? Of the United States?

For my work and due to personal interest, I have read an awful lot about this in last week to ten days. I've come around from being largely skeptical to recognizing that this is a very serious situation. In my own personal circles, I'm certainly way  on the "this is a huge deal" end of the spectrum. I just believe that as of yesterday, when the statement was made, it is extremely unlikely that 100,000 were infected in Ohio. Is it possible? I suppose it is.

[Hards Alumni]

I don't intend to be argumentative here, but I note that you didn't answer the question. While I believe you have, at times, moved closer to the panic line than I think is necessary, I give you genuine and sincere respect for standing your ground more than a month ago when a lot of people - including me - thought this was no big deal. I was wrong; you were right. But that doesn't mean that every dire pronouncement is correct. I personally think that the statement that there are 100,000 cases in Ohio at this time is incorrect and is a little irresponsible. If I'm wrong - and that is certainly possible - I'll admit it. And that doesn't mean there won't be 100,000 people infected in Ohio before this is all said and done.

For the record, I don't want to estimate individual state numbers since I don't have any information.  Having said that, I am with forgetful on this.  Numbers seem way too high to be real.

[Coleman]

Here's what I don't get. China was basically able to stem the outbreak after what was a very scary start. Why is it so implausible that we could do the same thing?

[skianth16]

Day 1: Just Benny
Day 9: 35
Day 14: 1,225
Day 19: 42,875
Day 24: 1,500,625

In just over three weeks, 1.5M have been infected by me, of which 1,457,750 aren't exhibiting any symptoms.  But let's say I'm off by a factor of 10x... that's still 145,000. 

Now, if I was at the Bucks game on 2/19 instead... today is Day 24.  The population of Ohio is 11.6M and 1% of that is 116,000 people.

True?  No.

Plausible?  Yes.  And that's where the problem lies... most people don't quite understand what we could be facing here.

My sticking point that has yet to really be answered is - if your scenario were actually plausible, then why are there only 120,000 cases globally right now? Why have only a handful of areas around the world had high concentrations of infection? I do understand that we aren't testing enough, so that keeps the confirmed cases down in the US. But if your scenario (which has been repeated by many people) were anywhere near the reality we're facing, then areas with better testing, like South Korea, would have enormous numbers of reported cases. We're just not seeing that.

I can't get past the disconnect between all the hypotheticals and the actuals. They're just way too different to make sense of for me.

[Hards Alumni]

Here's what I don't get. China was basically able to stem the outbreak after what was a very scary start. Why is it so implausible that we could do the same thing?

Cultural differences.  Americans are more independent and distrustful of government.

[skianth16]

Notes from a recent (3/10) UCSF panel:

o   How many in the community already have the virus?  No one knows.
o   We in the US are currently where Italy was a week ago.  We see nothing to say we will be substantially different.
o   40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
o   [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  Assume 50% of US population, that’s 160M people infected.  With 1% mortality rate that's 1.6M Americans die over the next 12-18 months.] 
   The fatality rate is in the range of 10X flu.

It sounds like you've dug into this quite a bit, so maybe you can help me with some questions.


- Right now 0.025% of Italy's population is infected, according to the reported cases. In China, the reported cases represent 0.006% of the population. Why do experts assume the worse scenario as the baseline for the US? Why wouldn't Italy be viewed as an extreme?

- If the spread is expected to be so rampant, and current actual cases are assumed to be substantially higher than confirmed cases, why are future mortality rates based off current confirmed cases? This seems to be a vast over-estimate. Why not adjust the denominator?

[MUBurrow]

Here's what I don't get. China was basically able to stem the outbreak after what was a very scary start. Why is it so implausible that we could do the same thing?

I also found this explanation of containment in China vs the US very illuminating. WARNING its a Rachel Maddow interview with the NYT Science and Health reporter, so if for you that invalidates this discussion from the jump, just don't click.
 https://www.youtube.com/watch?v=e3gCbkeARbY.

[StillAWarrior]

Here's what I don't get. China was basically able to stem the outbreak after what was a very scary start. Why is it so implausible that we could do the same thing?

Largely because self-centered jerks like me insist on going out to dinner with my wife and daughters.

Only kind-of kidding. Although I think I'm buying into/supporting the social distancing concept much more than many I know.

[mu03eng]

Notes from a recent (3/10) UCSF panel:

•   Top takeaways
o   At this point, we are past containment.  Containment is basically futile.  Our containment efforts won’t reduce the number who get infected in the US. 
o   Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak.  In other words, the goal of containment is to "flatten the curve", to lower the peak of the surge of demand that will hit healthcare providers.  And to buy time, in hopes a drug can be developed.
o   How many in the community already have the virus?  No one knows.
o   We are moving from containment to care. 
o   We in the US are currently where Italy was a week ago.  We see nothing to say we will be substantially different.
o   40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
o   [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  Assume 50% of US population, that’s 160M people infected.  With 1% mortality rate that's 1.6M Americans die over the next 12-18 months.] 
   The fatality rate is in the range of 10X flu.
   This assumes no drug is found effective and made available.
o   The death rate varies hugely by age.  Over age 80 the mortality rate could be 10-15%.  [See chart by age Signe found online, attached at bottom.] 
o   Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
o   I can only tell you two things definitively.  Definitively it’s going to get worse before it gets better.  And we'll be dealing with this for the next year at least.  Our lives are going to look different for the next year.
 
•   What should we do now?  What are you doing for your family?
o   Appears one can be infectious before being symptomatic.  We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms.  We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
o   How long does the virus last?
   On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
   The virus is very susceptible to common anti-bacterial cleaning agents:  bleach, hydrogen peroxide, alcohol-based.
o   Avoid concerts, movies, crowded places.
o   We have cancelled business travel. 
o   Do the basic hygiene, eg hand washing and avoiding touching face.
o   Stockpile your critical prescription medications.  Many pharma supply chains run through China.  Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.
o   Pneumonia shot might be helpful.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
o   Get a flu shot next fall.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
o   We would say “Anyone over 60 stay at home unless it’s critical”.  CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
o   We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes.  Then are not letting them out of the house.  The other members of the family are washing hands the moment they come in.
o   Three routes of infection
   Hand to mouth / face
   Aerosol transmission
   Fecal oral route
 
 
•   What if someone is sick?
o   If someone gets sick, have them stay home and socially isolate.  There is very little you can do at a hospital that you couldn’t do at home.  Most cases are mild.  But if they are old or have lung or cardio-vascular problems, read on.
o   If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
o   There is no accepted treatment for COVID-19.  The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease.  ie to prevent sepsis.
o   If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use" of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China.  Need to find a doc there in order to ask to enroll.  Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19.  If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.  [More I found online.]
o   Why is the fatality rate much higher for older adults?
   Your immune system declines past age 50
   Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness.  These conditions are higher in older adults.   
   Risk of pneumonia is higher in older adults. 
 
•   What about testing to know if someone has COVID-19? 
o   Bottom line, there is not enough testing capacity to be broadly useful.  Here’s why.
o   Currently, there is no way to determine what a person has other than a PCR test.  No other test can yet distinguish "COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
o   A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA.  However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.
o   The PCR test requires kits with reagents and requires clinical labs to process the kits.
o   While the kits are becoming available, the lab capacity is not growing. 
o   The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day.  For the nation.
o   Expanding processing capacity takes “time, space, and equipment.”  And certification.   ie it won’t happen soon.
o   UCSF and UCBerkeley have donated their research labs to process kits.  But each has capacity to process only 20-40 kits per day.  And are not clinically certified.
o   Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.
 
•   How well is society preparing for the impact?
o   Local hospitals are adding capacity as we speak.  UCSF’s Parnassus campus has erected “triage tents” in a parking lot.  They have converted a ward to “negative pressure” which is needed to contain the virus.  They are considering re-opening the shuttered Mt Zion facility.
o   If COVID-19 affected children then we would be seeing mass departures of families from cities.  But thankfully now we know that kids are not affected.
o   School closures are one the biggest societal impacts.  We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects.  If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services. 
o   Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis.  They do not have the capacity to sustain for outbreaks that last for months.  Other solutions will have to be found.
o   What will we do to handle behavior changes that can last for months?
   Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
   Kids home due to school closures
o   [Dr. DeRisi had to leave the meeting for a call with the governor’s office.  When he returned we asked what the call covered.]  The epidemiological models the state is using to track and trigger action.  The state is planning at what point they will take certain actions.  ie what will trigger an order to cease any gatherings of over 1000 people. 
 
•   Where do you find reliable news?
o   The John Hopkins Center for Health Security site.   Which posts daily updates.  The site says you can sign up to receive a daily newsletter on COVID-19 by email.  [I tried and the page times out due to high demand.  After three more tries I was successful in registering for the newsletter.] 
o   The New York Times is good on scientific accuracy.
 
 
•   Observations on China
o   Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19. 
o   While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
o   Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand.  Wuhan built 2 additional hospitals in 2 weeks.  Even so, most patients were sent to gymnasiums to sleep on cots.
o   Early on no one had info on COVID-19.  So China reacted in a way unique modern history, except in wartime. 
 
•   Every few years there seems another:  SARS, Ebola, MERS, H1N1, COVID-19.  Growing strains of antibiotic resistant bacteria.  Are we in the twilight of a century of medicine’s great triumph over infectious disease?
o   "We’ve been in a back and forth battle against viruses for a million years." 
o   But it would sure help if every country would shut down their wet markets. 
o   As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa.  See article on Wired magazine on sequencing of virus from Cambodia.


https://www.linkedin.com/pulse/notes-from-ucsf-expert-panel-march-10-dr-jordan-shlain-m-d-/

This is really good stuff. Thank you for posting it. The one thing that popped out to me is the definitive statement that children are not impacted by Covid-19. Three reasons, hope for my kids, I thought we'd heard of a few cases in kids/teenagers....maybe not?, and if kids are off the table how does that change the numbers? So if the US is 330M, how many are kids and does that impact the worst case scenario.


Seems like next Friday or so is when the fit will hit the shan potentially.

[Hards Alumni]

It sounds like you've dug into this quite a bit, so maybe you can help me with some questions.


- Right now 0.025% of Italy's population is infected, according to the reported cases. In China, the reported cases represent 0.006% of the population. Why do experts assume the worse scenario as the baseline for the US? Why wouldn't Italy be viewed as an extreme?

- If the spread is expected to be so rampant, and current actual cases are assumed to be substantially higher than confirmed cases, why are future mortality rates based off current confirmed cases? This seems to be a vast over-estimate. Why not adjust the denominator?

The issue boils down to testing.  There is a zero point zero chance that China tested everyone in their country who was suspected of having Covid-19.   There are tests now, but there weren't in the first stages.  Confirmed cases do not equal total cases.  Mild symptoms probably never got tested.  They just locked it all down because they're the CCP and can do that without a rebellion.  I'm sure post lockdown, they tested the people who came into hospitals very sick and counted them... but the family members at home are not confirmed cases.

Capacity of health care systems is generally the reason the numbers are lower than they should be.  Its also why South Korea is testing like crazy and following up on positive results.  Both China and SK figured out how to deal with this.  Right now Italy is early stage Wuhan with more knowledge.  We are going to look like Italy next week or the week after.  I'd prefer to be more like SK, but I think the month and a half of governmental dithering and denial put that behind us two weeks ago.

[rocky_warrior]

I also found this explanation of containment in China vs the US very illuminating.

Super interesting.  I had heard about the fever clinics, had no idea everyone got a CT scan.  Just wouldn't happen here with our healthcare system.

[skianth16]

The issue boils down to testing.  There is a zero point zero chance that China tested everyone in their country who was suspected of having Covid-19.   There are tests now, but there weren't in the first stages.  Confirmed cases do not equal total cases.  Mild symptoms probably never got tested.  They just locked it all down because they're the CCP and can do that without a rebellion.  I'm sure post lockdown, they tested the people who came into hospitals very sick and counted them... but the family members at home are not confirmed cases.

Capacity of health care systems is generally the reason the numbers are lower than they should be.  Its also why South Korea is testing like crazy and following up on positive results.  Both China and SK figured out how to deal with this.  Right now Italy is early stage Wuhan with more knowledge.  We are going to look like Italy next week or the week after.  I'd prefer to be more like SK, but I think the month and a half of governmental dithering and denial put that behind us two weeks ago.

I agree with most of what you said, but it still leaves me with the same questions. Why are we assuming the US will be similar to one of the worst scenarios encountered? And why are mortality rates assumed to be so high when we know we near certainty that actual cases far outnumber reported cases?

If anything, your comment seems to be aligned to my thought that there should be some discussion about how to adjust the mortality rate given the issue with the denominator being off by a wide margin.

[injuryBug]

so we take away large groups for 1-2 months how do we know it is safe to go back to going to games/events?

[TallTitan34]

Cruise ship filled with elderly Penn State alums and donors and Sue Paterno left dock today.  TODAY!

What could go wrong?

[rocky_warrior]

so we take away large groups for 1-2 months how do we know it is safe to go back to going to games/events?

I think the *hope* with that is after a couple months a few things happen, that we don't have now.
1) A higher percentage of the population will already have had it and built up a short term immunity.
2) Knowing the symptoms and testing will be much more advanced
3) Along with #2, the virus will be much better understood.  This includes potential vaccines and medicines for helping our body handle it.

Now, that may all fail, and we need a few more months of isolation.  But we need to slow the spread now, and figure out if that is enough for a couple months from now.

[mu03eng]

I will say this, when the dust settles if we aren't talking about closing all wet markets...with violence if necessary....then imma be really pissed

[Galway Eagle]

I will say this, when the dust settles if we aren't talking about closing all wet markets...with violence if necessary....then imma be really pissed

This

[MU Fan in Connecticut]

I think the *hope* with that is after a couple months a few things happen, that we don't have now.
1) A higher percentage of the population will already have had it and built up a short term immunity.
2) Knowing the symptoms and testing will be much more advanced
3) Along with #2, the virus will be much better understood.  This includes potential vaccines and medicines for helping our body handle it.

Now, that may all fail, and we need a few more months of isolation.  But we need to slow the spread now, and figure out if that is enough for a couple months from now.

After hearing from multiple customers in different parts of China this week, they all indicated that things are almost returned to normal so it sounds like what Rocky said is happening there so could conceivably happen here.

[rocky_warrior]

Well then...

https://finance.yahoo.com/news/marty-makary-on-coronavirus-in-the-us-183558545.html

According to Dr. Marty Makary, a medical professor at Johns Hopkins University, the coronavirus is something that “people need to take seriously.”

{snip}

“Don’t believe the numbers when you see, even on our Johns Hopkins website, that 1,600 Americans have the virus,” he said. “No, that means 1,600 got the test, tested positive. There are probably 25 to 50 people who have the virus for every one person who is confirmed.”

He added: “I think we have between 50,000 and half a million cases right now walking around in the United States.”

[mu_hilltopper]

Not sure about MPS, but nearly every suburban school around Milwaukee is closing for a month, as of end of business today.

My son excitedly emailed me, and I replied (cc'ing his teacher) that he should ask her to really cram a lot of knowledge into the next two hours and skip recess, stay late, like smacking an empty ketchup bottle.

[Jockey]

I suppose this is, at least in part, directed at me because I raised and have discussed the Ohio number.  I would be far more comfortable if the head of ODH would have said that it is "plausible" that 100,000 are infected. Keep in mind that if 100,000 are infected, you need to perform your calculation for every single one of them. What number does that give you? Does it take you beyond the total population of Ohio? Of the United States?

That is why she was irresponsible. The choice of words in a crisis is very important.

[Galway Eagle]

Not sure about MPS, but nearly every suburban school around Milwaukee is closing for a month, as of end of business today.

My son excitedly emailed me, and I replied (cc'ing his teacher) that he should ask her to really cram a lot of knowledge into the next two hours and skip recess, stay late, like smacking an empty ketchup bottle.

My GF teaches at Bayview and said they intend to keep open. Also they really haven't added any real precautionary measures, sounds like a clusterf*ck

[skianth16]

Well then...

https://finance.yahoo.com/news/marty-makary-on-coronavirus-in-the-us-183558545.html

These experts sure hand-wave a lot of their numbers. I find that concerning.

[mu03eng]

$hits getting real, 30 day lock down starting as soon as Monday....Pentagon has been briefed(multiple folks there say so that I know)