COVID-19: A few thoughts... Finding tranquility in a time of panic.

Greetings,

For the most part, I talk about rather petty stuff like sound equipment and audiophile discussions on this blog. :-) However, nothing has stopped me from posting on other topics of interest over the years! I was supposed to be on Spring Break this week but with all the flight shutdowns, I'm staying put in Vancouver which gives me time to watch the news, check in on work once awhile, and think about the state of the world.

Needless to say, things have changed markedly within weeks due to the SARS-CoV-2 virus and the COVID-19 disease pandemic that it causes. I thought I'd put up a post this week to document a few facts and figures I've come across, many of which not seemingly focused on as much in the media. As usual, I'm interested in the big picture and let's try to see the context of what's going on.

As per audiophile discussions here, let's remain science-driven and not get off track into tinfoil-hat, homeopathic, conspiratorial, la-la-land, OK?

We're seeing a world shutting down daily, upheaval in the normal business mechanisms as well as the financial systems. People are anxious, others are in a state of panic. Let's think about this from a Canada & USA perspective. As some of you know, I work in a hospital and in my daily duties both on the acute treatment side and longterm care facility side, much of the news and ideas out there are not new nor foreign within hospital contingency plans.

1. Background...

First case reports of COVID-19 out of China were on November 17, 2019. 27 cases by December 15. 60 cases December 20th. 180 by December 27th. While the data is likely an underestimate, remember that the province of Hubei was not locked down until January 23, 2020. By that time, we were looking at 581 presumed cases, around 23 (4%) deaths, 29 critically ill, and 93 severely ill worldwide with 375 (65%) in Hubei province alone (WHO Situation Report - 3). The province of Hubei has a population of 60M, if this were the US with a population of around 330M people, it would be like having 2050 presumed cases and 127 deaths by the day of the "Wuhan lockdown".

Compared to China, the western nations are "locking down" at a slower pace (for the most part in N. America we can still travel city-to-city, no restrictions on how many members in a household able to leave the home), with known larger numbers infected already. We can't know for sure, but we're probably not underestimating as much as in Wuhan in those early days. Remember that there was suppression of news early on in China as well.

In the USA, today (March 17) the number of cases is around 6500 with 115 deaths already. Notice that 115 deaths represents 1.8% mortality at this point. This is lower than the initial China numbers perhaps reflective of the Chinese underestimation in the early days. Then again, this may still be the beginning and the mortality rate could worsen.

Although Western nations do not have as strong control over population behavior, for the most part, sanitary conditions, self-care, and overall hygienic practices are better here in N. America. It's also worth thinking about the population density of Wuhan which has about 3.2M people in the "Central District" with density of around 15,000/km². Remember that within China, >60% of cases were contained to this one city. This is certainly a testament to how effective the country was able to contain the spread within the population!

Make sure to follow this Our World in Data site for an updated graph using WHO numbers of the infection trajectory curve for each nation. For the record this is what it looks like on March 17, 2020 with USA and China data highlighted.

At this point, hopefully the US can get their test kits out in quantity very soon. The only major decrees left to do in many jurisdictions are locking down travel between towns and cities if needs be, and perhaps instituting a one-person-per-household leave policy.

2. Remember that the Trajectory Graph above is not normalized to population size nor geography.

This is important because the cases are going to be geographically spread out for countries like Canada and the USA; this fact should be a powerful ally in reducing speed of transmission broadly. Population-dense areas need to be especially careful like Wuhan; it should be no surprise that New York City would be on high alert with an even higher population density in Manhattan (1.6M people, almost 28,000 people/km²).

From what I have seen of hospitals in China compared to N. America, I do believe we will do a much better job in N. America so long as people get the health care they need. This should be OK in Canada with universal health coverage, and I see the Americans are in the process of extending the coverage broadly. Compared to China, the hospitals in North America tend to be smaller in size. We have better staff-to-patient ratios (in many Asian hospitals, family are expected to come and care for their sick members). These factors plus early awareness should help reduce nosocomial (in hospital) spread.

3. Remember that the total number of infected is not necessarily that important but rate of change is.

Interesting that people are freaking out over this when with high likelihood, asymptomatic infected people are likely common. This is actually GOOD. It means that the virulence of this pathogen is LOWER on average, and the mortality rate is an overestimation. But it does mean that one has to be more careful of those vulnerable to getting sick as one would with a bad strain of other respiratory infection. It is unfortunate that this coronavirus has higher mortality risk by 10x compared to the flu for those vulnerable which we'll talk about below.

The total numbers infected will increase each day. And we will see an acceleration in numbers as more and quicker testing is done. Expect that this will happen; it doesn't mean the sky is falling!

4. Be mindful of those at risk.

I'm actually surprised that we're not seeing more detailed data on the mortality correlated to age, health status, and what conditions make a person more vulnerable. From all that I've seen, the factors are the same as influenza - here on the CDC website. Older, those with immune deficiency, chronic medical conditions (diabetes, cancer, cardiac disease), and respiratory conditions. Notice that compared to flu, children are not as susceptible which is great news!

In fact, based on limited data of the first 100 deaths in the USA, gleaning from this news report today where only 51 of the cases had an age attached, the graph looks like this:

Based on that data, we should definitely be most protective of those >65 years old.

What would be interesting to see is morbidity data being reported on more thoroughly. Is "full recovery" absolute with no lingering residual pulmonary or cardiac effects? Any significant evidence of folks <65 years old recovering with clearly reduced pulmonary function? Basically, does recovery look any different from a typical influenza infection when looking at the population broadly? Need I remind everyone, in a bad flu year like 2017-2018, about 61,000 Americans died and >800,000 hospital visits happened!

I'm not sure I hear these kinds of questions being asked in the medical briefings by reporters of the experts to explain more thoroughly the experience and data from Asia and Europe. This speaks to what the media is interested in hearing about rather than what a medical professional might want to truly understand to grasp the scope and severity of this condition.

5. China has already closed all 16 of the emergency hospitals they built for COVID-19 by March 11, 2020.

Folks, it doesn't look like it's the end of the world - alas this is not the zombie apocalypse! Remember all the buzz with that hospital built in 10 days in early February? Well, in less than 50 days (probably only around 40 days since not all hospital sites opened/converted around the same time) the temporary hospitals were closed.

China is reopening. Disneyland Shanghai at least partially reopened. Starbucks is putting more money overseas. It's interesting that the North American press isn't balancing out our news coverage with these reports as well - at least confirm or deny if this is is true. Remember all the fearful coverage of the terrible lock downs, people taken down by police officers, trucks going around disinfecting streets on social media videos? Apparently that's old news.

Where are the good news stories to celebrate a country that appears to be recovering and using that to calmly explain to the public what was learned? Why is it that when I search "China recovering from COVID-19" in Google, that I don't see a single story from CNN, MSNBC, or FoxNews for pages of search items?

6. Government aid is needed.

For the most part, I'm a conservative, free economy, capitalistic guy. But there are times as in natural disasters where assisting those in need is the moral thing to do. COVID-19 assistance is in the same category as providing assistance after hurricanes, tornadoes, earthquakes, and tsunamis. I think this will be an important "stress test" of medical systems around the world. Beyond obvious public health and epidemiological reviews, I suspect there will be a time when we look back at this and analyze the health care models in this world and learn about the best ways to deliver care just like the lessons of SARS back in 2003.

What will be worrisome is how the financial system will weather this natural disaster. Humans and government systems alike are not good at maintaining discipline during the good times. Apparently only 40% of Americans are "liquid" enough to pay a $1000 unexpected bill. Supposedly "64% of Americans will retire broke". And we're about to see public debt sky-rocket as aid gets rolled out worldwide...

While COVID-19 will subside and we can see gradual resumption of normality and travel in the not-too-distant future, alas, the financial damage could have unintended and unforeseeable consequences much further into the future.

As the economy shuts down out of necessity, and the government starts providing relief from the public purse, let's hope societies tread carefully so that the response itself does not destroy the host. Analogous to how an immunocompetent patient might over-respond to an infection and inadvertently trigger a cytokine storm in the process with even more severe consequences.

7. Remember human emotional and cognitive biases.

"We are more often frightened than hurt; and we suffer more from imagination than from reality."
Lucius Annaeus Seneca ("Seneca the Younger, 4BC-65AD)

What a powerful insight from 2000 years ago. Remember that behavioral economics research in loss aversion shows us that negative emotions are typically twice as potent as positive ones unless we train ourselves to maintain composure. I don't think this is as obvious as what we're seeing and hearing about these days.

Seriously folks, yes, COVID-19 is significantly worse than a "normal" flu. It is more contagious, and mortality for the older folks is high. That's why we practice good hand hygiene, reduce droplet spread with sneezing, cleaning with soap/water/disinfectant, and maintain distancing. Stuff we should already be doing in a normal flu season but in this case more deliberately. But why the Costco supply lines and empty shelves? Why hoarding toilet paper? What use is there in buying N95 masks on eBay at scalper prices at this point if we're taking all these other precautions already? Definitely watch out for snake-oil miracle cures and the like.

Every day, the number of infected increases (again not necessarily worrisome unless it doesn't flatten out). Multiple times a day the leaders of nations and public health officials go on TV to issue another emergency declaration. Like the reaction we're seeing in the economy and stock markets, there is a time to be worried, but ratcheting emotions to the point of panic on a daily basis cannot be good for wise decision-making and will create an unnecessary emotional burden for the population at large.

I don't typically speak about political issues on this blog. However, in the case of COVID-19, it's patently obvious that the character flaws, communication inadequacies, and "leadership" style of Mr. Trump has exacerbated the situation for our friends in the USA. This is most unfortunate. Perhaps it is too much to expect anything more of the man.

But just the same, watch the kinds of questions the reporters ask. Why are they bating Trump with such rhetorical queries? Do they really need to keep pushing the question as to why he thought things were under "tremendous control" the other day? Is this just to get another headline quote considering the countless inappropriate comments he has already expressed on Twitter and captured on video over the last 3.5+ years? Focus on the professionals behind him. Anxieties are running high and this is not the time or place to push some kind of "entertainment value" into the public health conferences... Leave it for the debates later this year in the election run-up, and express your views on election night.

In summary...

Well folks, we are certainly living in "interesting times". The fascinating thing is, as far as I can tell, other than the potential for hospitals to be over-run with the vulnerable and elderly, there is no cataclysm. In fact, the financial system looks to be more in distress than anything else at this point in North America.

Yeah, it will suck for the next month(s) as the already anticipated primary wave of COVID-19 cases hit the local hospitals. Many will be infected with minimal symptoms (as reported with the Diamond Princess passengers). In time, "herd immunity" will build among the population to this novel virus strain and the population will be stronger for it. We'll see "flare-ups" of cases here and there for months with public health officials putting out "fires". I suspect this is the kind of "crisis" they're speaking about until 2021; not constant lock-down for a year. "The lens of fear magnifies the size of uncertainty". Probably next year, we'll have a specific vaccine or treatment (vaccine already being tested in Phase 1 trial, an antiviral has been reported as effective, good news about azithromycin+hydroxychloroquine - meds already available worldwide). Beyond that, the virus will spread around the globe and perhaps become part of the yearly flu-season cycle or completely disappear if we're fortunate like SARS-CoV-1 (SARS from 2003)...

Remember folks, SARS in 2003 was less infectious but had way higher mortality rates up to 6.8-13.2% for younger people. IMO, SARS-CoV-1 is more scary than catching COVID-19, yet we didn't see this kind of pandemic panic as today with all kinds of social media feeds and 24/7 access to news on our "smart" phones!

Hopefully, as a society, as we get through the difficulties ahead, we will have learned a few things. Among them, just like how "absence makes the heart grow fonder", perhaps in the months of "social distancing", we will learn to value togetherness in a new light.

Stay healthy friends. Until next time...

Addendum: Allan commented on the importance of the fecal-oral route. Indeed it is important to be careful about keeping surfaces and hands clean. Early suggestion that SARS-CoV-2 does shed in stool in ~50% of cases. Here's the graph of duration of virus on various surfaces. Basically, be particularly careful of hard plastics and stainless steel - 1000 --> 100 drop takes about 24-48 hours.