Sunday, 5 April 2020

MUSINGS: COVID-19 mortality, age distribution, underlying health conditions and hope beyond...


As I publish this, it's April 5, 2020. We are in the midst of the coronavirus/SARS-COV-2/COVID-19 pandemic. The world is afraid. Borders are shut. Stores are closed. Concerns with crime increasing as a sign of social stress and perhaps distress.

We're also at a bit of a loss in terms of leadership through this. Again, speaking from a North American perspective, there is no "vision" of what the future might hold or any talk as far as I am aware of plans to relax restrictions. If anything, it's the opposite, an atmosphere of rule by fear with threats of further shutdowns. As I expressed in the second half of March, we are in a state of fear, with "abundance of caution" being as good a catchphrase as any of what's happening here; uniformly expressed among governments and public health experts.

In all this, let's look at some statistics and think about this more, shall we?

First, here's some of what we probably all know:

1. It's a pandemic. The numbers of infected people are growing. WorldOMeter tells me that we are well past 1.1 million people infected worldwide. No country is spared. You cannot really run from this as some might (I've heard of people going back to Asia for example). And these numbers are just the people who were tested and found to be positive; countless have already been infected, and many likely already past their symptomatic phase and recovered.

2. We cannot test everyone. There is essentially no medical test in this world with 100% sensitivity and specificity. Statistically there will be "false negatives" using the swab test. Most importantly, the standard RT-PCR test for COVID-19 has a false negative rate of up to 30%. If we're filtering coffee and up to 30% of the coffee grounds pass through, that would be rather terrible, right?

By this point, even with tight contract tracing and smartphone apps that collect data on cases, a place like Singapore suddenly had 75 cases reported in 4 clusters on April 3, 69 of whom not travel related - so it's spreading in the community. That is of course what is expected when a population remains
naïve to a highly contagious pathogen. An unending "war" against clusters and "hot spots" until either herd immunity increases a population's resilience, or when a vaccine is available and large proportions of the population get immunized. It's going to be a worrisome "Whack-A-Mole" situation until either of these things happen.

To make matters worse, with up to 50% of those infected being asymptomatic, the potential of spread for 10 days or more, one has to really start wondering how much effort it's worth to broadly track down cases and enforce quarantine by this stage with such numbers in North America and Europe.

3. A vaccine is going to be at something like 12-18 months away.

4. Yes, like any contagious illness, anyone can get the illness. Here are the New York City statistics up to April 3:

Remember that these stats are related to who gets tested. Clearly these numbers are also correlated to the folks who are symptomatic and going for testing in the community or showing up in hospitals. Notice that the rate for kids <18 is remarkably low! Only 57/100,000. Also, those <45 years old are at significantly lower rates than >45. This may be evidence that asymptomatic infections are more common in the younger adults.

5. Yes, the health care resource utilization will be large. Hospitalization rates are high including young adults. In the data, we can't tell though if the hospitalizations include overnight ER visits vs. inpatient stay for days vs. ICU with ventilation - this makes a huge difference in terms of treatment needs.

Again, NYC:


This is where we start to see a more drastic age distribution. Notice that hospitalization rate for those <45 years old is very low overall. It almost quadruples for the 45-64 year olds and then the rate doubles again for those >65.

6. Let's talk about the big one - DEATH RATES - those >65 and with underlying health conditions. By April 3rd, there were almost 1900 deaths in NYC. They are already well into the surge of cases. Based on NYC, who are the people who died?

Remember that I wrote weeks ago, we are very fortunate that kids and teens are spared. Below 65, the number is also low, death rates go up 3x for the 65-75 year olds, and 7x for those 75+!

As I said before as well, infectious diseases like this and influenza do discriminate based on age.

There is also another population who must be careful - those with underlying medical conditions - check out this chart from the NYC Daily Data Summary:

Interesting isn't it? Even if we take out those who have "underlying conditions pending", and we just look at the total of 1,313 people who died with known data, only 28/1,313 who died or 2.1% are otherwise health people without "diabetes, lung disease, cancer, immunodeficiency, heart disease, hypertension, asthma, kidney disease, and GI/liver disease".

Furthermore, isn't it interesting that of the >65 year old patients, those without the underlying conditions did not die at a higher rate either!

Notice that these NYC findings are consistent with elsewhere. Here's the Italy and China data showing the strong age distribution towards the older population:


For a more up to date data set of Italy, here's the age distribution as of April 3rd:


As you can see, the highlighted portion represents those >60 years old. That is the vast majority of deaths. Notice the massive increase from 70+.

And likewise here's some Canada data from the province of Ontario - everyone can contract the illness but it's by and large those who are older (specifically >60, probably >65 if the data were more detailed) that actually will die from this condition:


So what now?

Knowledge is power, right? When we know what's going on, that should help us make informed decisions about the path forward. It should hopefully reduce some anxiety especially when it comes to the primal fear of death. And in this regard, I think the facts are very useful in reminding us of 3 things:

1. Because the rate of hospitalization is high including those 45-64, it's good that we're doing the social/physical distancing for a number of weeks now. It has been 20+ days now since the US Coronavirus Task Force's "Slow the Spread" campaign from March 16. Obviously this was too late for New York City where peak daily growth rate was around March 20th (remember, there is a lag time between infection and onset of symptoms typically 5-10 days):


Since deaths are a lagging statistic, even if not worked through at the hospital level, there is reason to be optimistic that the "light at the end of the tunnel" is approaching for NYC (indeed, earlier today, there is good news of number of deaths dropping in NYC for a few days plus lower new hospitalizations).

Good to see that Italy is experiencing a drop in critical care cases now which is probably one of the last lagging indicators of improvement. In order to achieve this, it must mean that the inflow of cases into the ICU is slower than discharge now; people are leaving the ICU either better or have succumbed to the illness and unfortunately died.

2. For cities that have implemented the measures early and which have not turned into major "hot spots" by now, I think it's not unreasonable to be optimistic that the mitigation measures have worked to significantly reduce the growth rate.

While early, looking at the numbers locally here in Canada, so far there doesn't seem to be anything alarming as a whole. Sure, some cities will be strained for resources but I don't think this will be across the board. I know that in Vancouver, contingency plans upon contingency plans have been put in place. The convention center is getting ready with a few hundred beds if needed for hospital overflow. COVID-19 positive shelters are in place for the homeless with illness that do not need hospital stays. More than 22 local nursing homes have been affected in Metro Vancouver and precautions so far appear to be working so as not to result in high mortality for the most part.

Over the next week, I suspect if we do not see a major surge into Easter with many of the large cities, this would be a sign that mitigation has worked for this first COVID-19 "wave".

3. Remember, given that a vaccine is >12 months away, and it would be ridiculous to think that we can "eradicate" this virus given how ubiquitous it is. The only value of social/physical distancing is to reduce the surge in hospitals and prevent resources being overwhelmed.

Over the next year, accept that the majority of us will get infected. The only way we will feel somewhat secure is once there is adequate herd immunity in the population (which likely includes a large number of asymptomatic infected individuals). While there will be "hot spots" here and there, the extent of these "surges" in numbers probably will not be as extreme as what we're seeing currently, the result of delayed vigilance in reducing the rate of spread. So long as the hospital system can handle the numbers and terrible decisions like triaging ventilators do not need to happen due to scarcity, that is as good as it gets.

For the good of the many...

I know that over the last month, "distancing" has taken a toll. But given what we've seen with regions like Wuhan, Italy, and New York, I agree that it is a necessary sacrifice. This has also given us time to examine the data like that above and understand this "enemy", coming to terms with what it is and what it does over the populations of millions.

If in the next couple weeks, the "surge" can be overcome without massive difficulty, I think we can say that the mitigation procedure with social distancing has worked for the good of many who might have been affected to an even greater degree if such measures were not put into place.

The question is - are we still afraid?

I suppose that answer for each of us will depend on our own risk factors. In USA and Canada, those above 65 years old represents about 15% of the population who will have to be more cautious. Likewise, for those with underlying conditions as listed above will need to be more vigilant. For example, in Canada we have a 7% rate of diabetes in a population, yet a "brittle" diabetic with highly elevated HbA1c will obviously have a different risk profile compared to a person with diet-controlled Type II diabetes in otherwise good health.

For the public good, as a population, these last few weeks has resulted in indiscriminate use of public health and government policy with the threat of law enforcement and fines for violators in many districts against those not distancing themselves. However, knowing the risk factors posed by this illness, there will come a time where prolonged blunt policies will inevitably be doing harm to the quality of life of many unnecessarily.

I believe that the time is coming where each of us will need to be more mindful of individual responsibility rather than depending on blunt, broad public policy.

The policy of doing everything to escape death...

Instead of a blunt policy inspired by a fear of "reducing death" as the main driver, and as the initial wave passes in the weeks ahead, we must start asking the question of what policies will need to be implemented to embrace life, overcome fear, and emphasize the quality of life versus quantity.

In fact, I think this question is of relevance even now. Already, we are hearing stories of the thousands of seniors who have already died in Italy, New York, and China spending their last moments alone in an ICU, without the opportunity to say goodbye to their loved ones. As this disease continues in the months ahead and as the virus I believe inevitably work its way to the point where most will be infected in Europe and North America, are we to maintain this barrier indefinitely?

If the current projections are right, and something like 100-240k Americans die, the vast majority of whom are seniors >65 years old as per the data above, is this how public health and citizens of the free world would want significant members of the Silent Generation (born 1925-1945) and older Baby Boomers (1946-1964) to say "goodbye"?

I seriously hope not. That would truly be a heartless outcome for all who deserve better.

As I hinted at in my comments in mid-March, I do believe that we all need to think about the inevitability of mortality and consider the question, "Are there fates worse than death?" While this answer is highly subjective and will depend on one's philosophy, values, perhaps faith, for me, I would say "Yes" as one who have worked for many years in the medical system and involved in the care of many who have severe, often progressive illnesses. In fact, among medical circles, it has been spoken of fatalistically since the days of William Osler that pneumonia was the "friend of the aged" in that the process of death was not accompanied by prolonged suffering. Of course this was in the late 1800's and early 1900's before the advent of modern vaccines and antibiotics; in many ways, we are at that same place today with this novel coronavirus where we have no proven effective treatment and a vaccine is not in our immediate future.

If I were 60 years old, otherwise healthy, then please, by all means do CPR if you have to and hook me up to a ventilator in the ICU. But if I were close to 80, have had heart troubles, and facing catastrophic oxygen desaturation as my lungs filled with fluid from COVID-19 pneumonia, to send me to an ICU, intubated, connected to a ventilator with likely poor prognosis, poor prospect of seeing loved ones again or speaking any last words to my grandchildren might be a fate worse than what should always be a dignified death.

I know. Nobody wants to talk about dying. It would be very bad for the public image if the public health doctor suggested anything else but preservation of life apparently at all cost. No politician would want to be seen as hinting that any life lost would be "acceptable". But just the same, death does come for all of us whether we want to think about it or not especially as we get older or develop chronic conditions.

The question is, what wise choices are we to make for ourselves especially in the face of death? Unless we can appreciate this, much of the talk in the news media would be nothing more than superficial. In all these discussions in the news about the number of ventilators and whether it's "enough", let's make sure that we do not lose track of such important details like who they're using the tens of thousands of machines for, whether patients and families understand the implications, and ultimately to what end, and sometimes, for what benefit.

A policy of life...

Nobody knows when the initial "hit" will definitively pass for most cities, and I'm sure this will vary depending on where you live. My suspicion is that it would not be long from now for most of us living in large centers. And from there onwards, I suspect the cases will ebb and flow with "hot spots" started in a mall, perhaps another in a condo building, another from a church gathering... These are to be expected as the virus makes its way through the population.

Remember that viruses are not "smart", and I think anthropomorphizing this "enemy" is simply silly. In fact, they are not even "alive" in that they do not have their own metabolic machinery. What matters in all this is actually how we as humans choose to respond to it knowing the facts highlighted above.

For me, everything going forward points to these 5 factors:

1. We need to protect the vulnerable who actually could die. Remember though that the elderly, and those with underlying conditions are a minority among our midst. Be mindful of them if we're in the healthy, young cohort. These are the individuals who would benefit most from social distancing measures, hand washing, use of masks to reduce droplet spread, etc... again, we need to balance this with quality of life because the risk of death for this population will remain high indefinitely.

Depending on risk tolerance, protective measures towards the vulnerable will need to continue until herd immunity is strong if enough are infected (how much is needed is dependent on contagiousness and the R0 value I'm sure we've all heard about already) or a vaccine is available - whichever comes first. It makes no sense to open and close businesses and disrupt life of large numbers of people.

2. While life will not be "normal" for months, I do believe that societal productivity must resume gradually. Otherwise as a matter of "public health", one will see the unintended consequences of such drastic actions harming more than helping society.

Continued job losses, financial distress with mounting debts, erosion of supply chains, loss of small business viability, resultant emotional instabilities among some, unhealthy coping like increased alcohol consumption, reduced physical activity, are being felt and I am seeing this in my work beyond medical concerns around COVID-19 already. To protect the few from death, are public health measures willing to lower the standard of life and health for the many for long periods of time? In countries where liberty is a foundation of the society, how long can this last without any significant social push-back?

For those <17 years old, the data show that they barely require hospitalizations and as a general rule do not die unless there are clear health issues. For the kids, what is happening with their maturation and learning of social skills? What is happening to the quality of education? This is the mirror effect of the fear of the elderly dying on the young if conditions persist chronically without hope of normalization.

By the way, when I say "few" people die from COVID-19, that is of course a relative statistic. Yes, I know that as of April 5th, almost 16,000 people have died in Italy but it is gradually declining in numbers. However if you take a step back and look at the death rate of Italy over the years, this is what you see:


About 10.5/1000 (~1%) individuals die there in the last 4 of 5 years due to them having one of the oldest populations in the world with about 23% seniors. In a population of about 60.5 million people, this means that more than 630,000 people died annually. All the people who have died with COVID-19 thus far constitutes just over 2.5% of those who would have died in any other year. Remember that it's not even as severe as this because many of those who died probably would have succumbed to another illness. Yes, this is bad from the hospital perspective when it all happens over less than a month and governments need to boost resources, but beyond this, logically, the numbers are far from catastrophic.

3. IMO, discussions about further restricting freedoms and implementing all kinds of privacy encroaching technologies like smartphone tracking are not likely of significant benefit for the public good. The job is to slow down spread. The rules are already in place. Police officers already have the power to deal with jerks who purposely spread the virus and officers can break up parties when they have to using their emergency powers. There is no need "lock down" the Western world further...

Remember, this virus is actually not that virulent and only few will actually die! Governments should not act like this is some kind of existential threat.

4. Allow the virus to work its way through the system (EDIT: I used the word "endemic" here before which is not technically correct and refers to longterm R0 around 1) in a slowed fashion. "It's in the cards" as they say. With hundreds of thousands of known active cases in the US, and many more unknown, other than in special cases, there is no point doing mass contact tracing now. Limit testing to symptomatic people for confirmation and quarantine, for health care professionals of course so as not to spread further in hospitals and nursing homes among the vulnerable.

Myself and most of my colleagues working in hospitals fully expect that over the next months, there will be high exposure and contraction of the illness. Yes, we are concerned and do not want to bring this home to loved ones. But honestly, as professionals, there's no need to freak out. Hysterical doctors and nurses interviewed in the news might attract clicks and views, but do realize that most of us probably are not impressed by this kind of emotionally-driven reporting.

Remember, it's highly contagious for all but not highly virulent for most.

5. As I expressed recently, so long as hospital systems can handle the patients who need intensive care, we must look at a step wise reopening of social life, business, and allow the financial system to recover. Let the younger people work.

I've been hearing people talk about new antibody tests as almost some kind of "certification" before people can go back to work again. Sure, this could be good for healthcare workers, direct care-givers, and perhaps other limited cases. Also, this would be an important research tool to understand baseline prevalence of the illness in the community already including those that were asymptomatic. But this will not ensure viral particles are absent on clothing, dirty hands, shopping bags, etc. Let's just say that I'm more than a little suspicious about a push for fancy testing, apps on phones, etc. as simply a cash grab taking advantage of the fear currently and ultimately there is little actual benefit for most.

The only things that could help are supportive care (which we already have and making sure those who need a hospital bed, IV, ventilators available), a vaccine (Gates apparently funding some trials), and it would be nice to get confirmation of some useful medications like potentially hydroxychloroquine, remdesivir, etc. I see Italy might be using hydroxychloroquine on a mass scale now.

Realize that even if Gates, et al. do find a useful vaccine, it will likely be of little impact for this specific strain since it'll likely have affected most by the time the vaccine is ready for use anyway. It could form the basis of future coronavirus protection in yearly "flu vaccines" we get of course.

Allowing SARS-CoV-2 immunity to gradually become common in a population will convey herd immunity to Europe and North America (likely to other parts of the world also). This actually could put Asian countries who implemented rather draconian measures like China at a social and economic disadvantage in the months ahead. While it's remarkable that they used such strong measures to control the virus that they were able to contain the spread, they are now "stuck" with needing to control every "leak in the dam" with travelers into the nation and persist with strong contact tracing for fears of another massive epidemic sweeping through their highly dense cities and wreaking havoc. My fear in terms of suffering is more for Asia (the billions in China and India) and the developing world than for us here in the months ahead.

In North America, we appear to have an opportunity now to "take the hit" and allow the disease to spread in a more controlled fashion. This potentially will have a positive impact for the rest of the year relative to other places as it will allow us to have a smoother trajectory back to "normal".

Postscript:
The almost "post apocalyptic" vision of post-pandemic New York in this article is shockingly pessimistic to me!

Yes, there will be hard times ahead and I'm not saying that the future rebound in life and the economy will be like it was in late 2019; most likely it will not. In the years ahead, I don't think the thoughtful historian will put all the blame on COVID-19 for how the world has changed. Rather, if we are to be going down a path of economic and even social decline, numerous factors will need to be considered including the strength and viability of financial systems, bloated projections of growth, political discord, and certainly the choices in public health that governments and health care systems will be making over the next few month.

My friend in Germany recently E-mailed me about implementing their "digital contact tracing" system after Easter (based on papers like this claiming that apps can reduce viral spread) and already in use in places like Singapore (TraceTogether). Remember people, be careful with the liberties we give up in times of distress! Are we sure that what is being done will actually have broad value for citizens with a clearly mandated social contract?

Hope, advocate, maybe even pray for wisdom above all else. Have a voice in your local leadership and honestly, openly examine the facts not with fear, but courage.

Stay healthy everyone.

57 comments:

  1. I’m 69. As one of the vulnerable, I find it interesting that you suggest “the only value of social/physical distancing is to reduce the surge in hospitals and prevent resources being overwhelmed.” Glad to see you’ve written me off so folks can get back to making money. So much for our shared sense of purpose.

    Seriously, though, the two groups who will end up most hurt by this are the young and poor, who deserve help but will not be helped much by the economic measures recently taken, and the sick and aged, who deserve not to be written off quite yet by people who just want to get back to strong markets. (Of course, as someone who has his retirement savings in the market, I’d love to see the markets rise again, and who wouldn’t?)

    Right now, better paid knowledge workers might only face the nuisance of working at home, or taking paid leave, but service industry workers in the millions have been and will be laid off. Then there are low-paid but “essential” workers, who have the benefit of a job at the risk of their safety. I’ve come to conclude that we must offer restitution to those who bear the greatest economist burden for keeping us safe. This will likely require measures thought radical just weeks ago. Wealth taxes, basic income, universal health care (radical to some in my sad country). I fear that wealth inequality may otherwise doom my country.

    Fun fact: while viruses usually kill mostly the old and the very young, sometimes they mutate to the “w” curve, involving a huge spike in mortality among those in the prime of their life. It happened in 1918. Let’s hope it doesn’t in 2020, or 2021.

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    1. Yes. Health first, economics important but second.

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    2. Hi guys. Economics is health.

      These things are all interconnected and I think we will see this in ways we might not imagine in the years ahead if things fall apart.

      I'm not talking about strong markets either by the way if you're referring to stocks. In fact, I'm pretty well as bearish as it comes as an aside and I don't expect the stock market to rebound anywhere close to the peak for years if we're thinking speculating in that casino. I'm talking about actual productivity because that's necessary for society as a whole both psychologically and in the physical realm. Prolongation of that for weeks and months will take a toll that IMO will dwarf the deaths by COVID-19.

      As a 69 year old, I expect society to be fully supportive of you. You're right about the potential that this converts into a "W" shaped curve. How do you expect to protect that population in the middle if we don't build immunity while the predominant strain is weaker and in fact KIDS and YOUNGER ADULTS have lower mortality rates?

      Protect the older. Take the pain in the near future. There is no "black or white" here, just a shade of gray to find a balance that results in the least harm. Those who are at risk takes it easy, those who are aching to get going because they have a career to build and young family to feed should be given a chance, and the government should IMO preserve opportunities within reasonable guidance from health care research once the acute system can handle the strain.

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  2. It’s important to remember that the best case IHME model, which predicts about 100,000 deaths in the U.S., is predicated on the notion that only 3% of the populace will be infected. Mass screening, contact tracing, and quarantines would be required to prevent a second wave. The worst-case Imperial College model predicts 1.1 to 1.2 million deaths even if we employ mitigation measures. Half-way measures, such as sending a lot of folks back to work, may end up killing millions and overwhelming hospitals such that any sort of serious illness, for those of any age, may be a death sentence.

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    1. That 1.1 million figure is actually assuming everyone gets treatment (p16 of the report). Many more are likely to die due to over whelmed healthcare systems. Doctors and nurses will continue to die and future treatment will be even harder.

      A mitigation strategy is incredibly cruel. Millions will die and those you put as cannon fodder in front of the sick so regular society can get back to work is insane. I do agree that we’re not good with dealing with death in our society – the death positive movement has great ideas on that.

      I think a better approach is to think about what it means to generate wealth. We don't have to get back to normal. We know that's doomed anyway - more unsustainable farming practices that cause environmental damage; those same practices enable mixing up more diseases in a toxic petri dish of eating anything we like. Continuing tourism industry that causes huge harm to the environment and spreads these diseases. Lets stop and use this as a pause to think about we generate wealth. Lets see what the young people in movements like extinction rebellion think about it. Not central bankers and hedge funds.
      Pump liquidity into the economy directly to consumers rather than the traditional institutions, explore ways we can generate wealth online to spend this money and move into a sustainable economy.
      The imperial paper (https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-03-16-COVID19-Report-9.pdf) has ideas on how we can also get back to normal too. It’s a stair stepped approach (adaptive triggering of suppression strategies) p11-12. That’s sensible without condemning millions to die.

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    2. Good read on the Imperial College report although I think we need to be a bit cautious about the underlying assumptions they're making which are already proving to be questionable.

      For example, in their model, they anticipate about 0.2% hospitalization + 5% of those requiring critical care for <19 years old. Are we seeing that? Remember that <18 year olds represents about 25% of our population. Of the older folks from 70+, they're estimating 25%+ requiring hospitalization with something like 50% needing ICU and presumably some form of ventilation as part of that. Is that also realistic? Do hospital systems regardless of whether this is COVID-19 or the flu do this typically with a large percent of the cases in this demographic (for example what I'm seeing here locally in nursing homes of chronically ill COVID-19 cases)?

      Also, another big one that we're still in the dark about is the actual rate of infection in the population already. Until wider testing with antibody serology is complete we will not know the extent of this and some early suspicions are that infection rate is much larger than previously assumed. It'll be interesting to see results such as this from San Miguel County, Colorado what their open blood testing shows:
      https://www.sanmiguelcountyco.gov/CivicAlerts.aspx?AID=519

      Some early data from March 26 + 27 with much needed background info to understand what it means:
      https://www.sanmiguelcountyco.gov/590/Coronavirus

      As for the IMHE model, well, we can keep an eye on this:
      https://covid19.healthdata.org/projections

      as the data rolls in. Peak death rate projected is around April 16th with about 3100 deaths nationwide. Not good to have thousands die per day. But manageable? Most likely.

      Current projections are significantly <90k deaths in the whole US which is less than 100-240k being spoken of and way less than 2.2M from last month with the Imperial College model. Heck, even just a few days ago, the model was predicting a bed shortage of >80k beds yet this morning it's down to less than 37k (and ventilator needs also lower).

      Let's see how this goes. Historically, remember that during times of fear, there tends to be overestimation of resource needs. This was seen in the 2009 H1N1 pandemic as well:
      https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0030223

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  3. We can be a bit more relaxed concerning the restrictions in the near future and gradually, but we must not do experiments with "let it spread" approach. Not only the existence of the virus, but also the intensity and number of contacts with virus matter. Yes probably this virus will stay with us, but we must be careful and limit its damage as much as possible!

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    1. Correct Honza: "but we must be careful and limit its damage as much as possible".

      The key word is "damage" and how we define this damage. And of course how much of this damage is actually related to the virus or what we do in response! Remember the "cytokine storm" example. The virus itself is the catalyst, but much of the damage is actually the body's own response. As we go forward, likewise we should be careful of our response to the threat as well...

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    2. It's pretty simple. Healthy population is a prerequisite to strong economy, not vice versa. We must not sacrifice the weaker people intentionally. Summer weather can help, and vaccine+treatment method search too. But arguing with economic losses coming from the restrictions is wrong - long-time economic losses from those who have been hit by the virus would be much higher, and even if they would not for soem reason, it is not ethical to do a bigger "trade-off" in this sense. Yes, we must be reasonable and limit risks gradually, as the outbreak varies. But not reverse the basic logic of our thinking. More here
      https://medium.com/@tomaspueyo/coronavirus-out-of-many-one-36b886af37e9

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  4. I think the number of cases curve blows the lid on the experts telling us this is a pandemic with hundreds of thousands of deaths imminent.

    I see absolutely no reason to believe 75+ are exposed to the virus any more than any other age cohort.

    If anything, they would be less exposed owing to their decreased mobility. If you put a cross-hatch on each of the other bars to bring them up to at least the 75+ (one could argue that they should be approximately a bell curve with 75+ being smaller than the others), then suddenly you have not only thousands of asymptomatic individuals but thousands more for the denominator in all the CFR (I reckon IFR) calculations that are being used to justify unprecedented governmental intervention in every detail of private life.

    In truth, the curve is already flat. Further, the second wave that everyone will be so fearful of when the shelter orders are lifted, and that will be used as justification for yet more unprecedented governmental intervention, will be like waiting for Godot.

    It's incredible when you think about it.

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    1. Yup, I agree Allan,
      75+ are certainly not exposed any more and like you said, logically, less. The numbers are just reflective of higher virulence towards the older with likely more comorbidities. Likewise, no reason why <18 year olds or kids in daycare not exposed more yet show up MUCH less in hospitals.

      As you suggest, I think we are looking at just the "tip of the iceberg" in terms of those infected. Indeed, the official models are not even looking at much if any bump into the summer.

      Some places BTW like Austria already looking at loosening restrictions next week:
      https://www.axios.com/austria-lifting-coronavirus-lockdown-68ee62c4-5865-4ccc-b4dd-7937c691cdaa.html

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    2. You might want to to look at outbreaks in nursing homes, and reconsider. Vulnerability is not just from too much social mobility (wide scale); it is also increased by social *immobility* (restricted social mobility), because in a setting where people maybe *can't* distance enough, like a nursing home, all it takes is one infection brought in from 'outside' to start a wildfire.

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  5. The elderly are not more likely to be exposed to the virus (other than by contact in elder-care facilities, where many were exposed early on and died), but if they get the virus they are much, much more likely to die. If half on the U.S. population (170,000,000) is exposed, and only 2% of those die, that would be 3,400,000 dead. The governmental intervention is necessary and hardly unprecedented. Without it countless more would die.

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  6. I totally disagree about allowing now the virus to become endemic. With no vaccine it's like condemmning thousands to die.

    What is the purpose of a society ? Let people die because "economy matters" ? Or protecting people's life ? Oh, c'mon,...

    Any path is full of uncertainities but I wouldn't like to live in place in which certain persons should be consciously left to die ... justs because .... ¿ pieces of paper (money) ?...

    Maybe tons of efforts in our societies don't aim to "good" goals for humans or for the society itself. Difficult to judge. But maybe it's time to re-focus capitalism priorities.

    I hope we learn some lessons.

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    Replies
    1. I think that, Archimago's points are:
      - it is too late to contain it effectively (e.g. test increase won't help due to wide spread). It can be slowed down, but can't be stopped.
      - Danger of Covid-19 might be over-emphasized, it don't need to be that drastic, as long as the hospitals are NOT overwhelmed.
      - effect of Covid is dramatically different between different people (age groups, conditions), and we should take note/use of it.
      - Let's keep calm and try to help others.

      So, I think this is NOT about "let people die because of economy matters". This is more about, "don't panic, and let's be hopeful."

      I actually don't agree to many of his observations. For example, his calculations are a bit optimistic. (his death count estimations are far lower than my own, but we will see how it goes shortly. I really wish his estimation is more accurate than mine...). Also, some arguments are IMHO just wrong: e.g. his comparison of Italy Covid death count, just 2+% of yearly death, so not that serious? Man, that's not a fair comparison, especially if you consider the deaths are concentrated on a region. In Northern Italy, if you compare 2019 March and 2020 March, it is +200% increase, and it is about 1000%+ for age group 65+. (Lombardia) It is a tragedy, in any way you see. Basically 1 year deaths concentrated in 1 week! Another point I disagree is the test accuracy: there are products with different ways to confirm the virus; from near random 60% accuracy to best 95% claims; according to the medias in South Korea and Germany, currently employed best method's accuracy is estimated as 90%, not 70%.

      But all those differences are minor: as I read his postings, his point is never about "let people die"; it is rather "People always die, and it is hard to be objective when you see number of increased death by one disease. It is very easy to make thing more dramatic than as-is. But that doesn't help. No need to panic, let's carry on calmly and let our hospitals work and protect." ...

      On those points, I just agree.

      Delete
    2. I understand, but letting this disease become endemic, right now, it's a really serious risk. Virus can mutate and become really more dangerous. And right now, tons of people out there could have hidden patologies they aren't aware. This disease is really cruel among weaker ones. I truly think that most modern countries can re-organize priorites for some months without letting people to fall in serious poverty risk. If we are unable to do that... our societies, states, countries are sadly very weak organizations in protecting people, hence, not very useful for humans, but really great for economy!

      Delete
    3. Yeah... It's not about "letting people die".

      It's about recognizing that there is an inevitability to how things are going and that we're actually very fortunate that the disease is not as bad as feared. Opening up restrictions and allowing those healthy to maintain productivity and develop herd immunity will in the long run protect the elderly while maintaining an economy that can bounce back.

      A balance must be struck. The idea of keeping everything locked down like now until death rate reaches close to 0 or somehow the virus will disappear from this world is of course impossible... And IMO cruel because of the disaster that would ensue way beyond the deaths from COVID-19.

      Delete
    4. If you please, check this article when you have time

      https://www.wsj.com/articles/the-false-choice-between-lockdowns-and-the-economy-11586164745

      Delete
  7. Arch - have you seen the Imperial paper that convinced the Trump and Johnson regiemes in the US/UK to change their stance: https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf

    It offers numerous real strategies that won't risk millions of lives. You can't do epidemiology by looking at actuals and extrapolating or comparing numbers like death rates, as tempting as that is.

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    1. Remember Dush, I'm not talking wholesale "opening up" like a 100%! I've never said this in fact, as I mentioned in my post March 23, I've always believed that we do a phasic opening every 2 weeks and letting the data tell us.

      The Imperial model lays down their various policy levels which are good, but I think each city, state, province, etc... can implement depending on their needs even more defined interventions.

      BTW, Austria anticipates relaxing restrictions next week with the 1st phase being small shops. Others like Denmark looking at staggering days of work, etc.
      https://www.dailymail.co.uk/news/article-8191185/Austria-Denmark-plan-lift-lockdown-restrictions-week.html

      I think some people might be surprised at how quickly things "improve".

      Delete
  8. There are two issues; 1.) China should have fessed up sooner when they first discovered the problem and alerted all other countries and then passed along accurate numbers. Honesty is a friend not an enemy, but not to them, evidently. 2.) This idea that the government must decide everything is a false narrative. I, 72, my wife, 69, daughter 45 have quarantined for over month now; our son 25 who works for Home Depot has continued to work overnight restocking shelves per company directive, but the store is closed with a cleaning crew in while his team restocks. Way too many will not self-quarantine, keep social distances and here, even as of last week video showed people out and about as if nothing was going on. These were not just grocery, pharmacy trips, but just out driving or running in town, out to eat, or at some park. There were even officials in major cities telling folks to go out and live their lives in early March, even city health officials; subway cars full with no attempt at social distancing; and people partying in large groups, but now the arrests are starting for irresponsible behavior. People don't want intrusive government, but can't take initiative and do the right thing on their own? Pretty sad commentary on something as serious as this. Rumors of price gouging of medical supplies and medical equipment suppliers not keeping up with demand, of course no crystal ball to see this pandemic coming, but no doubt business very slow to react. The respirator issue is over 10 years in the making. Not new! America should learn its lesson now about how bad outsourcing is. I have said for the last 30 years that any country that stops making things puts itself in great peril. How badly did we need that $29 DVD player? $75 blue jeans not even made in America anymore.

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    Replies
    1. Yeah, you've hit on some important points here Jim:


      1. China needs to be more transparent for sure. I seriously hope there will be some final accounting for exactly how many died in Wuhan and at what point it was clear that things were getting out of hand. They obviously engaged in suppression of information from the hospitals, from the doctors, the "independent" reporters who had no choice but to "leak" information through social media. I don't think many of us are hopeful that such honesty can be expected from the regime.

      2. The relationship between the democratic world and China needs to be re-evaluated... Not just with this virus of course. It'll require all of us to readjust to life without cheap DVD players and more as you alluded to. This is a 2-way street. For years we've had this unhealthy relationship making China the manufacturing facility of the world. The blame goes both ways since capitalism is about making money and the best way is to optimize margins and reduce costs as much as possible. Trade imbalance flows to China, we get the cheap goods, N. Americans lose manufacturing capacity.

      To rebalance will not be easy and many will complain if we are to honestly change this system!

      3. Decency and personal responsibility in the face of this pandemic. Sadly, lots of entitlement and narcissism to go around these days. I hate talking politics but it's obvious that the Leader in Chief has a personality problem that reflects this aspect of modern N. American society ("Peak Narcissism" anyone?).

      Manners and etiquette have gone out the window. Civility (hey, including audiophile forums, right?) in short supply. The popular media in general (music, movies, TV, YouTube...) tending towards the coarse and sensual rather than noble or intellectual over the years.

      No surprise then that there will be many not heeding precautions. That this infection isn't any worse than the data is showing is a blessing for us.

      Delete
    2. What actually happened in China is this, according to the best reporting I've seen: local officials saw something bad happening. But they were afraid to report it to central authority, because traditionally Central does not like to hear bad news, to put it mildly. So the local authorities covered it up. Once Central found that out, there was in fact a rush to address the outbreak, resulting in a massive, by our standards draconian lockdown (and also resulting, I might add as a genome biologist, in rapid sequencing and release of the first SARS-CoVid-2 genome). It is a somewhat more complex narrative than the simple 'China covered it up' meme that Trumpsters are pushing now in an obvious attempt to polish the turd that was Generalissimo DT's tardy and reality-denying response.

      Delete
  9. An edit I made was to take out the word "endemic" in the text since I was not using it in the technically correct fashion which is when R0 is close to 1 in a population and persists continuously; something like chicken pox or herpes simplex having a base rate in the community.

    While there might very well be a persisting rate of infection going forward, the expectation is that this will dissipate and "disappear" over the months ahead as it works its way through the population. Of course, another strain can come around next year or in future years. The hope of course is that if it makes its way around this time next season, the population immunity will render the contagiousness weaker with health effects attenuated for most.

    A good vaccine remains important of course.

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  10. I think it was the Chairman of the St. Louis Federal Reserve who made a comment about testing and the economy that made a lot of sense to me. He said the only way to restore the economy quickly would be to enable *universal, at will* testing along with identifying badges. If you test negative, go out and spend money or whatever. If you test negative, go home for 14 days. Stores and other public facilities would require a “green” badge, or negative test result, to let you in. Depends on accurate testing, but seemed sensible, if not immediately do-able.

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    1. Hi Brucedgoose,
      Yeah, I think if one needs "confirmation" that a person has been infected and recovered, for sure, mass open testing with IgG serology will get us that.

      But consider the cost to doing such a thing broadly. How many tests do we need in USA with >300M people for example? Given that kids are broadly safe <17 years old, do we need to poke them?

      I think this might be useful for say 55+ and those with chronic health conditions if we want to have some "buffer room" for safety. If I were 70 in the community, and have the IgG, then that would certainly make life much better and I can go see my kids and go the grocery store without too much concern (still should wash hands, etc...) while others might remain in quarantine or be much more careful.

      But if I'm 45, otherwise healthy and generally quite resilient to the yearly flu, I'm not sure I would need the "green badge" to go back to work. There is always some element of risk in life and I'm not seeing the numbers to be that unreasonable for those not at particularly high risk of high morbidity and mortality.

      Delete
    2. Great idea, Chairman, but there is no simple RDT (rapid diagnostic test, like a pregnancy test) yet for SARS-CoVid-2 infection. Typically RDTs are testing for an antibody or enzyme. Antibodies (produced by the infected person) only begin to be detectable well into an infection -- something like a week or more in SARS-CoVid-2 case. PCR is more sensitive , as it detects nucleic acid of the virus itself, but PCR takes times and hardware; PCR RDT is an oxymoron. PCR also requires careful vetting of the primers (the detecting agents) to avoid high false negative and positive rates (as Arch refers to).

      Delete
  11. Hey Arch, I hope everyone is well.

    I don't know if you have seen this before, a kid from BCIT has created an informative website focused on Canada: COVID-19 (Coronavirus) Updates: Canada

    What is going on in QC?

    Be well my friend!

    Mitch

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  12. Living in Quebec, I can answer that. The main reason there are more cases in Quebec than Ontario that has a larger population is that the spring break (semaine de relâche) for schools was earlier than in Ontario, from February 29 to March 8, so a lot of people traveled to regions where the virus was getting more present but still not so well known, and so brought more infections back. There is also the snowbirds, people who spend the winter in Florida and hurried back home as the virus spread.

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    1. Also we are first in social distancing according to Google...
      https://www.macleans.ca/society/technology/what-google-data-says-about-canadian-vs-u-s-social-distancing-efforts/

      Delete
    2. Yup Gilles, that's the general consensus I've heard as well.

      Earlier Spring Break plus as a population Quebec has the oldest population west of the Maritimes. Compared to Canada on average, Quebec has about 2% more older folks >65 years old (about 170,000 more Quebecers older than 65 in the province compared to if they were the Canadian average).

      Notice it was reported that despite an increase of 29 deaths from yesterday, ICU needs did not increase in the last 24 hours in Quebec. This is reported as a good sign that the rates are slowing. Another possibility is that many of the patients that died are older with significant health issues and may not have needed an ICU bed because they were at lower "care option" levels (eg. DNR, no intensive care) and were not transferred into the ICU; this is very common but news media people might either not know about this or want to talk about this.

      Delete
    3. With the highest per capita cases and deaths in Quebec, it's good that citizens are doing what's needed right not to stabilize things, Gilles.

      For perspective, Quebec's number of deaths - 150 - for the population is still less than 18 deaths/million. The US is over 2x that amount currently so far we've been fortunate up north. For a condition like this there are benefits to low population density and a public health care system which can be more efficiently mobilized and coordinated.

      Delete
    4. Thanks Gilles for your response.

      Delete
  13. Did you see these google-tracked graphs on changes in people's mobility since lock-downs?

    https://www.macleans.ca/society/technology/what-google-data-says-about-canadian-vs-u-s-social-distancing-efforts/

    Quebec and Ontario coming out pretty well.

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    Replies
    1. Yeah, good for ON and QC for getting the job done. Will clearly reduce hospital and intensive care needs.

      Going forward, there will be a need to start talking differently and that's what I'm most interested in seeing if it transpires. Media and government need to start building a vision of a "resurrection" of a locked down and scared world into their Easter narrative :-).

      Delete
  14. I do hear that rates are slowing, but when I look at the charts that come off MSN on the Edge browser and I look at all the graphs of countries and then look at the U.S. state graphs I do not seen a flattening of any curves, and we are sure not here in Georgia. This puts me in the "I am not on board talk" of this being a two week thing of people getting back out. I think that would be a foolish thing to do.

    I know folks want to get back to normal, but I think we are in a time where "normal" is a changing, moving thing, and more like the ebb and flow of a baseball, football, or basketball game...a step forward and a couple back if we aren't diligent about this quarantine and social distancing.

    My wife said she read an article about China and the "living" being put in body bags who cannot be helped and being sent off to crematoriums and people heard the screams. God, I hope that is not the case as that will be a terrible sign of our lost humanity vs our fellow man. We may never know that truth. Maybe life is imitating ART these days. If we lose our civility and common sense we may be lost and allow this to continue into the fall and winter of 2020.

    Maybe some of you are seeing different numbers?

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    1. Hi Jim,
      Different states will of course present at a different phase. Up here in the Pacific Northwest where the 1st case of Coronavirus in Washington was on Jan 21, and here in Vancouver on Jan 29th, folks have been at this for awhile now. (I see Georgia's 1st cases reported around March 3rd.)

      While the province here is massively prepared, it would not be surprising to see if we're already past our peak in terms of health care utilization. I think it's good that in British Columbia, we did not need a formal lock-down of nonessential services but rather depended on the good-will of citizens which has been working. Many shops have temporary closed anyway and malls are open but maybe only 20% shops open.

      Of course back in late March when the government here announced that they would not institute a mandatory closure of non-essential stores, the media dragged up freaked out physicians in their news items like this:
      https://bc.ctvnews.ca/strict-covid-19-shutdowns-are-in-place-in-other-provinces-why-not-b-c-1.4865383

      Don't know about the live people in body bags in Wuhan. I've seen the news items as well; who know. Terrible things happen in this world. We won't be seeing that here with SARS-CoV-2; certainly not with this strain...

      Delete
    2. The curve is flattening here in New York. However, we are now beginning to add in *probable* (i.e. not tested before death) Covid-related deaths to the stats, which will shoot the curve up. The inference is that if we had been doing this from the start, it would still be flattening, just at a higher level.

      Delete
  15. Guys, take a look at the updated IHME model:
    https://covid19.healthdata.org/united-states-of-america

    Down to 60k "projected" death rate now. US peak resource use down to 3 days, maximum mortality 4 days away now. Hmmm... Clearly the model was overly pessimistic and now getting in line with the reality as data comes in.

    I seriously hope that Canada looks at our numbers as we get past Easter and be reasonable about gradually reopening. We can either see this as the "mitigation measures worked!" or more realistically, that in fact the assumptions were exaggerated and ultimately overly cautious. Watch in the days ahead as the public gets a bit upset about the situation if they do not see a gradual reduction in restrictions and if the government and media do not act reasonably with what the data is telling us.

    The idea that we will remain locked down for "months" is simply not on balance going to be good.

    COVID-19 "fatigue" from all the news is here and growing... Impatience and perhaps anger could be coming next.

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  16. Talk about a lack of honesty coming out of the far east...how can it be that our U.S. DEATH total can be more than just the reported cases in CHINA? It is time to leave the U.S. and the U.N and the WHO. Where is the mainstream media in all of this? Silent as usual.

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    1. Hi Jim,
      We definitely expected US to have a higher death toll than China.

      Remember that China was so strong in its response that they confined the known infected to basically 1 province (Hubei) and mainly one city (Wuhan). As a result they have their official numbers dead at "only" <3,500, the vast majority (last I checked something like 80+%) in Wuhan.

      In North America and Europe, the disease has infected every state/province/city now. The Hubei province has 60M people, USA with >300M will clearly be experiencing a much larger denominator of those infected and death rates follow...

      The outbreak in China is like if the US confined the disease to just California and Texas (but much more intense in China because their population density is so much higher and it took awhile to identify what was going on), sparing the rest of the country except for a small number who left those states when the disease started.

      This is why I think North America and Europe could be at an advantage because it's not inconceivable that a substantial % of the population has already been infected and immune. We will see once the IgG antibody tests come online in the next few months. If this is the case, this could help protect us from an even more virulent strain later on if there is to be a second wave like in 1918. This too is a balance we need to think about... So long as people don't die or have severe morbidity, it could be better in the long run to allow those resilient to be infected, recover, and strengthen community resilience.

      Delete
    2. One more thing, I still think the IHME current projection of 60k deaths in the US (down from the 100-240k before, and the ridiculous 2.2M Imperial College number to scare people "if you do nothing!" before that) is an overestimate.

      Suppose China undercounted the deaths as has been reported, say by 50% (many deaths may have happened at home, country purposely suppressed numbers, etc.). Back on March 19th I suspected the number of deaths in US might be "<15,200" based on the China mortality curve. This means I should double that expected number to something around 30,000 deaths in the US which is not good but I think still much more "optimistic" than we hear in the news. Will see...

      As for Canada, I said "<2000" deaths on March 19. We're at 402 as of this AM. Given how well measures have been taken and how well the people have followed the strategies, it still looks on target barring any unexpected flare-ups.

      People have talked about the 2009 H1N1 swine flu pandemic which compared to COVID-19 was less severe (~13,000 deaths in the US). But remember to keep in context that the worst "flu season" was back in 2017-2018 with around 80,000 deaths in the US that year:
      https://www.statnews.com/2018/09/26/cdc-us-flu-deaths-winter/

      That will be another interesting statistic to review later this year. What the influenza + influenza-like-illness rates and mortality including COVID-19 looks like this season. Since yearly flu deaths fluctuate between 40k to 80k per year, would the total mortality be worse than 2017-2018 this year?

      Delete
    3. One last thing :-).

      The emergency rooms here have been very quiet for weeks now. This weekend, rooms and hallway stretchers that typically would be used were empty.

      All cause mortality these last couple months should be very low as a result of reduced accidents, MVAs, sports injuries, etc.

      This doesn't mean that health care demand isn't pent up however... Massive reductions in elective procedures for example which will need to work through. That dynamic will need to be worked through for the remainder of the year once things lift.

      Delete
    4. I remain skeptic of the China numbers and NY congestion is much like China. Now that China is allowing those in Wuhan to go about their lives, every photo and video I saw everyone was wearing masks. That is not a confidence builder for me and more of "show" for China. We are seeing more folks dying the longer their hospital stays are as they are not recovering with extensive help to do so. Our numbers are still going up here in cases and deaths. China 81,000 cases and 77,000 recovered? Pretty amazing numbers. U.S. 431,000 cases and only 24,000 recovered, 14,700 deaths. Are the rest of ours recovering, still sick??

      Delete
    5. The imperial 2.2 million estimation wasn't ridiculous. In fact, it was the paper that influenced both the UK (who were dragging their feet massively) and the maniac in the US to actually introduce measures officially. Otherwise we (in the UK) would have been totally screwed.

      An article that speaks to this: https://www.telegraph.co.uk/global-health/science-and-disease/terrifying-data-behind-government-coronavirus-lockdown/

      It has literally saved lives. Far from scare mongering - it was a scientific paper that worked a model.

      Personally I've stopped watching the news or reading any clinical paper. It's the epidemiology that's going to be the best predictor of this. At least for the UK the outputs from the model which is coded in Python is available to planners here: https://imperialcollegelondon.github.io/covid19estimates/#/details/United_Kingdom

      Delete
  17. I was going to ask:

    When might researchers have answers to the questions surrounding immunity?
    In other words: once someone has had COVID, are they immune and if so for how long?

    I wonder how this is determined, and when it can be determined.

    On that note, this doesn't seem to indicate good news:

    https://www.scmp.com/news/china/science/article/3078840/coronavirus-low-antibody-levels-raise-questions-about

    Clearly preliminary, but if this research bears out that some significant portion of people who get COVID don't make enough antibodies to be immune from re-infection, what do we do? The article alludes to a problem of a vaccine based on weakened versions of the virus (if the full strength virus isn't enough to cue antibody protection in some people, a weakened version would seem less likely to do so).

    Would some of the other vaccine strategies get around this problem?

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    1. Yikes, that would not be good Vaal. Clearly this needs to be reviewed and replicated.

      Interesting that they're seeing a strong immune response with the older. Suggests that perhaps in the young folks (15-39), the infection did not trigger much more than the innate immune response and it was fought off without developing specific immunity; the bug was relatively "easy" to fight off for these people?

      Here's a link to the paper:
      https://www.medrxiv.org/content/10.1101/2020.03.30.20047365v1.full.pdf

      Haven't had time to look in detail. Interesting but seems too preliminary to be concerned one way or another. Remember, these folks had "mild" symptoms which I don't think was clinically described. Still looks like most people developed antibodies and the threshold of how much antibody is enough I'm not sure was addressed.

      Delete
    2. Those are excellent questions Vaal , that scientists are definitely worried about and trying to answer. A very good recent summary of immunity-related questions here :
      https://www.nytimes.com/2020/04/13/opinion/coronavirus-immunity.html

      Delete
  18. Early antibody result from the town of Gangelt in Germany - ~14% immunity rate.

    https://www.technologyreview.com/2020/04/09/999015/blood-tests-show-15-of-people-are-now-immune-to-covid-19-in-one-town-in-germany/

    Looks like the town was relatively "hard hit" and still only 14% caught it.

    Remember that depending on the R0 transmission rate of a virus, the proportion needed in the population to have "immunity" in order to not allow the infection to spread can be calculated:

    herd immunity threshold = (R0-1)/R0

    For SARS-CoV-2, R0 has been calculated as between 2.2-5.7. The number of course will depend on physical distancing measures. This is not good. If R0 is "only" 2.2, the threshold will only be hit once we reach ~55% of the population immune. If R0 is 5.7, we need ~82.5% immunity!

    Oh boy... If the world's solution to this problem is to have an "abundance of caution" and keep things locked down until a vaccine is available, or opening and closing whenever an outbreak happens, we are obviously going to be in big big trouble!

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  19. Archimago,
    you are wrong. No matter how many lines of text you type, you are on the wrong side of this, scientifically and ethically. So please stop. Let it go.

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    1. We'll see Tired,
      The issue is of course complex and there will be different paths for different jurisdictions. It's one thing to be scientifically "wrong" but unless grossly immoral, what is "ethical" is highly relative.

      Delete
  20. Remember when news stories told about how the China authorities executed criminals, some even for rather petty crimes, and harvested and subsequently sold their organs?

    China is a stone cold place to live, and I have never trusted them or their numbers, not to mention their public claims about anything. They have picked up the Russian model of ruling, and made it worse. The Chinese people in general have no empathy for living beings.

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    Replies
    1. I agree. Must be careful about what's coming out from there. Like it or not, we're seeing the beginnings of what could evolve into a dangerous conflict ahead.

      Delete
  21. Re : affected age groups, Iceland has done more extensive testing than any other country (as of Apr 12, 10% of its ~364,000 population has been tested!). Big findings are the prevalence of infection among the young, and the prevalence of asymptomatic infections. Here's a graph from the end of March illustrating the first point (comparing a wide-testing country to one that only tests the sick):
    https://www.economist.com/sites/default/files/20200404_STC086.png

    Elsewhere it's reported that fully *half* of Iceland's ~1600 detected infections are asymptomatic!
    https://www.usatoday.com/story/news/world/2020/04/10/coronavirus-covid-19-small-nations-iceland-big-data/2959797001



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  22. Thanks Steven,
    Very interesting data out of Iceland. Certainly adds to the awareness that the virus is highly discriminatory of age to the point where the younger folks (approximately <50) likely have more asymptomatic cases than symptomatic. Just got off a conference this evening and indeed childhood cases resulting in severe disease remaining thankfully very rare.

    With the "hotspots" in many parts of North America clearly slowing down, the question is "now what?".

    I know there's good preliminary news about Gilead's remdesivir but the study is small, it's a 5-day vs. 10-day comparison, and the drug itself is a daily IV infusion so only appropriate for those quite sick and hospitalized.

    In the last week, it looks like the prospect of hydroxychloroquine has dipped after this study:
    https://www.medrxiv.org/content/10.1101/2020.04.10.20060699v1

    With the announcement today of the criteria in the US for reopening, it will be interesting to see how this unfolds and what conflicts will inevitably arise between the layers of government. One thing we can say about places like China and Singapore is that the hierarchy of power is well defined compared to large liberal democracies of the West.

    Alas, I suspect we're "bogged" friends for the foreseeable future. No prophylactic treatments. Large numbers infected already. Large number of likely asymptomatic spreaders. The potential of prolonged viral shedding >14 days. Potential for multiple transmission routes beyond droplets and including fecal-oral and surface survival >24 hours. Starting to see suggestions of relatively low rates of IgG immunity and even questionable whether a substantial number of infected are able to mount a strong, enduring, acquired immune response. This could be a problem for those trying to produce a vaccine that works well.

    This is likely going to be a slow, highly contentious, murky path forward.

    There are risks in life; some will find certain risks more acceptable than others and that discussion I'm sure will spark many conflicts in the weeks and months ahead.

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  23. Very thoughtful analysis of the situation.

    While I'm in very much favor of managing the situation to avoid overflowing the healthcare system and realize how painful this situation is (a good friend of mine was very ill with Covid) it is also important to maintain a sense of perspective on the situation.

    So for now talking on the "it's not quite an apocalypse right now" side of the scale, some stats to consider:

    1) According to worldometer as of April 17 there have been approximately
    17.6 Million people worldwide who died from all causes - of these approximately 165,000 from Coronavirus
    (somewhat relates to the graph on iItaly)

    https://www.worldometers.info/
    https://www.worldometers.info/coronavirus/

    2) On the question of mortality rate for Covid:
    A recent study from California seems to show that the number of people infected is about 50 to 85 more than official stats (due to people being asymptomatic and who gets tested). If that is correct it implies that mortality rate for Covid is likely more in line with "regular" flu. I.e say for the moment mortality rate is 4% for Covid (based on official stats), if the actual # of people infected is 50 times higher that means we get to about 0.1% mortality rate (similar to regular flu). And I readily concede that this would need more careful analysis.

    https://www.cnbc.com/2020/04/17/santa-clara-covid-19-antibody-study-suggests-broad-asymptomatic-spread.html
    https://www.nytimes.com/article/coronavirus-vs-flu.html

    Of course numbers like these are meaningless to anyone who is ill or who has friends or family members who have passed away or are ill.

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  24. I am thankful for living in a small country where the government has take good measures in good time. As of today, we have less than 1% unemployed due to the virus.
    We have per April 21st 7695 cases registered, 364 deaths, 84 critical cases with around 100000 tested persons.

    I am fully aware, this is not over, and it won't be over in 6 months from now. Perhaps the virus itself will have disappeared, no one knows, but the economy will suffer for a long time after this.

    I am proud of the sincerity and activeness our government has shown, and especially our prime minister, who has shown unprecedented human love and care together with a keen eye towards our economy. Proud to be Danish!

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