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

[skianth16]

I think the long incubation period complicates the math. If she is correct, the majority or all of those 100K may be asymptomatic right now and if they all become symptomatic around the same time that is pretty problematic (theoretically at 1% fatality that means at least 1,000 critical patients within days of each other)

What I can't get a sense of with stories out of China from a couple of weeks ago and Italy now, how many of the deaths are infrastructure based(the overwhelming of) and how many are "inevitable" because of the disease.

The next 10 days will be interesting because if we say 1M people are currently infected but asymptomatic and the conversion rate from infected to requiring hospitalization is 2% that means 20,000 hiting the hospital systems within a matter of days. If the infection volume is 5M at the same conversion rate its 50,000. If its 1M but a conversion rate of 20% we're talking 200,000.

 So how spread the infection is and what the conversion to hospitalization rate is is critical to whether the US can handle it. And I don't think we really have any idea right now regardless of what the OH health director says.

I still have a hard time thinking that the 1% figure is supported by what we've seen in other countries. Even in the Hubei province where this all started, the reported cases didn't even come close to 1% of the population. The province is about 55 million in population, and even if every reported case in China came from that area (which is obviously an overstatement) that would still only be about 0.2% of the population there.

And if the assumption that confirmed cases isn't really representative of actual cases due to people not showing symptoms or just not getting tested, then I would find that to be pretty reassuring. Ohio has 4 or 5 confirmed cases so far, but the assumption is that a significantly higher number are infected just not confirmed. So let's use Hubei again and assume that 50x or 100x more people were sick than were actually confirmed (conservative compared to Ohio). That's great, right? That significantly lowers the hospitalization and mortality rates.

In all the numbers, the one thing I keep coming back to is that the assumptions being made here in the US are substantially higher than what we've seen globally so far. 1% of Ohio being infected would represent a doubling of all cases globally. Why would Ohio be so much more susceptible to the virus than the rest of the world?

And I'll add the note here that I'm not trying to say I don't believe the experts or that I think this is a fake panic. I just have trouble making sense of the estimates when they seem so different from what we're actually seeing so far. A lot of this is just "thinking out loud" to see if someone can help me understand better or provide another way of thinking.

[GooooMarquette]

Although I have previously expressed my opinion that CDC.gov is the gold standard for info on the covid-19 situation, I wanted to alert folks to another good source. The NYTimes is providing FREE ACCESS (even for non-subscribers) to its news about the pandemic. Though some may disagree, my experience has been that the NYT is better than most media outlets as providing fact-based, non-sensationalized journalism.

https://www.nytimes.com/news-event/coronavirus?action=click&module=Spotlight&pgtype=Homepage

[GooooMarquette]

I agree completely. Here is a disturbing article about how bureaucracy and red-tape slowed testing in Washington.

Legitimate concerns about the FDA here.

But FWIW, the FDA is in a "damned if you do, damned if you don't" position. If it had given the UW lab the go-ahead without "normal" approval and the error rate turned out to be high (whether false positives or false negatives), they would have been crucified for inappropriately allowing clinical testing through a research lab.

The FDA has reason to be worried about toeing the line. In another of its functions (drug approval), it constantly walks a line between getting drugs to market faster (at the urging of the pharmaceutical industry, and often patient advocacy groups desperate for cures), vs taking more time to be relatively sure they provide more benefit than harm. And they have been stung many times over the years for letting a drug get to market too quickly, only to have to rescind its approval after it hurt or killed many people. For some good examples, look up Accutane, Baycol, Bextra, Nuplazid and Uloric.

Like I said, damned if they do, damned if they don't.

[StillAWarrior]

Legitimate concerns about the FDA here.

But FWIW, the FDA is in a "damned if you do, damned if you don't" position. If it had given the UW lab the go-ahead without "normal" approval and the error rate turned out to be high (whether false positives or false negatives), they would have been crucified for inappropriately allowing clinical testing through a research lab.

The FDA has reason to be worried about toeing the line. In another of its functions (drug approval), it constantly walks a line between getting drugs to market faster (at the urging of the pharmaceutical industry, and often patient advocacy groups desperate for cures), vs taking more time to be relatively sure they provide more benefit than harm. And they have been stung many times over the years for letting a drug get to market too quickly, only to have to rescind its approval after it hurt or killed many people. For some good examples, look up Accutane, Baycol, Bextra, Nuplazid and Uloric.

Like I said, damned if they do, damned if they don't.

Very true. None of this is easy.

Along similar lines...

Listening to a podcast earlier this week with a leading infectious disease expert. Essentially he said, "developing a vaccine for this is simple...we could do that over night. Making sure it is effective and safe takes time, and there really is no way to speed that up too much."

In case anyone is interested.  Head to 1:30:15 for specific discussion.

In case anyone is interested.

[mu_hilltopper]

As an aside .. the UK health minister said they have 459 cases, but they believe they are off by a factor of 10-20x.

[Hards Alumni]

I see the ODH Director's statement that 100,000 have it in Ohio is getting some national attention.  While I do admit to having some doubts about her statement - and particularly how definitively she presented it - I also note that if she's correct that he existence of seeing community spread means that "at least 1%, at the very least 1% of our population" is carrying the virus..." then the fatality rate is not nearly as high as many of the estimates. By her theory, somewhere in the neighborhood of 3.3 million have been infected in the US. We have had 36 deaths in the US. If 1% of the country is already infected, that would make the mortality rate very, very low -- 0.00001. So, something obviously is off. I suspect she's very high. (*Edited: I suspect her estimate is very high.) Data from everywhere else this has spread shows that there is a death rate considerably higher than the common flu. It would appear that it's somewhere between 0.7% (which is still considerably higher than the flu) and 2 or 3%.  Any estimate of total cases that would suggest a mortality rate that is much lower than the flu is, presumably, a bit off.

Problem with that sort of reasoning is people don't die the second they get the disease.  Its progresses over a week or two.

[StillAWarrior]

As an aside .. the UK health minister said they have 459 cases, but they believe they are off by a factor of 10-20x.

If you told me that Ohio has 50-100 cases (10-20x what is reported), I wouldn't bat an eyelash and would suspect you were low. Hell, if you told me Ohio has 500-1000 cases, I wouldn't be overly critical of that estimate. As I've said already, what surprised me was the State's top health official stating definitively that we are off by a factor of 20,000x.

[forgetful]

For those looking for other sites tracking data. This one is pretty good.

https://www.worldometers.info/coronavirus/coronavirus-incubation-period/

The link is specifically for incubation period, but at the top you can access a lot of other data, including country by country specific data.

[StillAWarrior]

Problem with that sort of reasoning is people don't die the second they get the disease.  Its progresses over a week or two.

Of course. But give it a week or two. Do you honestly believe their will be 1,000 deaths in Ohio within "a week or two"? I don't.  Good Lord, I certainly hope not. By all accounts, Italy - with a population of 60 million - is a mess right now and they have just barely over 1,000 deaths as of today.

[mu03eng]

To be fair to yourself and most everyone else, we have been through pandemic scares several times over the past 20-30 years, so it was natural for the "here we go again" attitude to take hold. Part of that is based on real-life experience, and part on wishful thinking (the "bad things like car accidents and cancer happen to other people, but not me" attitude). And hopeful attitudes like that are part of what help us get from one day to the next. After all, if we treated every possible pandemic (H1N1, SARS, MERS, Ebola) the way we have learned to treat this one, we would be so wound up in anxiety that we'd never get anything done.

I would also add that this occurring in an election year made things much worse IMO. The political and media based finger pointing and spinning has really slowed the public's ability to understand what is going on and react in a collaborative way. Even know every story has a who's to blame, what went wrong, etc....and I know its fantastical think but I would love to see a refocus on here and now, what do we need to do now and leave the recriminations until the worst is passed.

[Jockey]

I would also add that this occurring in an election year made things much worse IMO. The political and media based finger pointing and spinning has really slowed the public's ability to understand what is going on and react in a collaborative way. Even know every story has a who's to blame, what went wrong, etc....and I know its fantastical think but I would love to see a refocus on here and now, what do we need to do now and leave the recriminations until the worst is passed.

This is one of those rare times that I disagree with you, Eng, but, sad to say, finger pointing is absolutely necessary. We have zero leadership in this crisis and have reacted to it worse than every single industrialized country in the world.

Tests are "available" for anyone who wants one, yet people cannot get tested. And as if that isn't bad enough, the leadership has been the single biggest reason for the Stock Market crash with their lies and incompetence.

We need to finger-point more as that seems to be the ONLY way for our leaders to be goaded into taking even the most basics actions.

[Frenns Liquor Depot]

I have to say this guy has really stepped up.

https://thehill.com/homenews/administration/487425-top-health-official-fauci-coronavirus-crisis-could-last-8-weeks

[Hards Alumni]

Of course. But give it a week or two. Do you honestly believe their will be 1,000 deaths in Ohio within "a week or two"? I don't.  Good Lord, I certainly hope not. By all accounts, Italy - with a population of 60 million - is a mess right now and they have just barely over 1,000 deaths as of today.

I hope not too.  Lockdown would give me some additional confidence.  Not just canceled schools.

[mu03eng]

This is one of those rare times that I disagree with you, Eng, but, sad to say, finger pointing is absolutely necessary. We have zero leadership in this crisis and have reacted to it worse than every single industrialized country in the world.

Tests are "available" for anyone who wants one, yet people cannot get tested. And as if that isn't bad enough, the leadership has been the single biggest reason for the Stock Market crash with their lies and incompetence.

We need to finger-point more as that seems to be the ONLY way for our leaders to be goaded into taking even the most basics actions.

It's a fair argument to make, and while I agree we have a systemic leadership failure I also no that dude up top has preconditioned folks to disbelieve info from the media and any appearance of politicization gives that crackpot judo move more power. Deal in facts, predictions, and gaps....leave the recriminations for a time when we can actually focus on them. Just my opinion.

[shoothoops]

Chinese billionaire Jack Ma donating 500,000 test kits to U.S. and over 1 million masks. Previously U.S. had 14k test kits. (He's also donating to other countries)

[Coleman]

Chinese billionaire Jack Ma donating 500,000 test kits to U.S. and over 1 million masks. Previously U.S. had 14k test kits. (He's also donating to other countries)

Nice!

[lawdog77]

Rumor is Trump is going to order a national shutdown today at a press conference at 3.

[🏀]

My little school districts in northern, rural Illinois are shutting down.

[Pakuni]

Rumor is Trump is going to order a national shutdown today at a press conference at 3.

Doesn't seem to be the case.

https://www.cnn.com/2020/03/13/politics/donald-trump-emergency/index.html

[Pakuni]

My little school districts in northern, rural Illinois are shutting down.

Most of suburban school districts are shutting down, as are all Archdiocese of Chicago schools.
I imagine they'll all be closed by the end of the day.

[Chili]

Most of suburban school districts are shutting down, as are all Archdiocese of Chicago schools.
I imagine they'll all be closed by the end of the day.

CTU is demanding CPS shutdown.

LA school district just shut down.

[GooooMarquette]

My wife works in the Rochester Public Schools, and learned yesterday that they are having a mandatory all-staff meeting today after school. Hmmmm...

[Benny B]

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.

[StillAWarrior]

I hope not too.  Lockdown would give me some additional confidence.  Not just canceled schools.

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.

[Eldon]

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-/