Wednesday 18 March 2020

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


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.


  1. And another juwel of writing that only Archimago is capable of. Thanks!

  2. Hi Archi, any thoughts on how the virus is spreading in the Southern Hemisphere and if it will transition there as the temperature shifts through the seasons?

    1. Good question.

      Don't know how that is going down there but their numbers are currently low with officially <500 cases so far. They are a smaller nation than Canada with ~25M people and they're actually at around the same per-capita numbers as we have here, so temperature/seasonality may not be as important. We will see in the week ahead as their curve is better understood. Their health care system is good...

      Should be the kind of question being asked at these public health meetings! :-)

      A few hours ago - Aussie PM says "stop hoarding, it's ridiculous". Agreed.

      Of interest, notice that the spread of the illness has been low in Africa so far... Again, is this bias due to lack of testing? Does temperature play a role?

      Maybe percentage of seniors is a key factor when it comes to public vigilance and concern about symptoms - those >65 years old in Africa is ~5% compared to >20% in Italy.

      USA ~15% over 65. Canada ~16%.

  3. A thought...

    From a market perspective, one of the best things that happened to China was that the coronavirus crisis happened over Chinese/Lunar New Years from Jan 24-30. While tensions were high during those days, at least they were not panicking like what we're seeing daily over the last 2 weeks with anticipatory anxiety building and feeding into a negative cycle.

    West Texas Intermediate is pricing for Y2K levels, threatening <$20/barrel. Commodities getting crushed. While the risk of the virus hitting hospitals is real and imminent, as I said above, I think the economic fallout here is getting way overdone (no, I'm not betting on stocks here BTW). Things better turn around or the doctor's gonna need to bring out the paddles.

  4. Italy's geriatric population has huge numbers of flu deaths a year. Something like 68,000 deaths in 2013-2014. As of today, they're looking at 3,000 deaths at Day 24 starting at 100 cases around Feb 22.

  5. Arch,

    Wonderful, balanced info, as usual!

    We have often heard of an overall mortality rate of 1 - 1.6 or so. But that isn't much info for an individual. If you are over 80, the mortality rate is obviously much higher.

    Like many I'm curious about the mortality rate among my own demographic. The info is sparse and I appreciate the chart you posted (which I'd seen before). Though there are still questions to untangle.

    In the chart the mortality rate for being in your 50's is 6 percent! I'm 56 so that is a rather concerning number!

    However, I'm wondering how that untangles in the variables.

    I'm 56 in quite good health: 22 BMI, good cardio shape (work out each day to some degree), no blood pressure/heart issues or chronic illness at all, recent tests have all standard health markers as in the healthy range. I feel lucky that way!

    So I wonder how this shakes out for inferring from the mortality rate among those 50 - 60 to a case like mine.

    It could be that the uptick in mortality rate for 50 - 60 is due to the fact that population starts experiencing more chronic diseases and similar factors that make a flu or this virus a greater threat. If THAT's the case, then it seems reasonable to infer that someone like me in my 50's who is healthy and without extenuating health factors would be less likely to die than the average person in my demographic.

    On the other hand: Maybe there is something I don't know about MERELY BEING IN YOUR 50's, whether you are fit/healthy or not, that increases the risk of dying from the virus. Which is certainly possible. I just don't know what factors those may be.

    Any idea? Does it make sense to infer that being fit without complications in your 50's should lower one's personal likelihood of dying from it, or is there something else going on?

    Fortunately my sons are 18 and 21, both healthy and fit so I'm less worried about them, and my wife who is a doctor tends to have the immune system of an is if the average ox has a strong immune system like my wife ;-)

    1. Hi Vaal,
      I think everything looks good for you. You're fit, no vascular issues, not insulin resistance, and I assume no respiratory issues - no smoking, emphysema, etc... Of course, graphs are useful for group data but cannot be used to be predictive for any one person. It gives us a snapshot that can be useful for the broader population only.

      Referring to the graph of mortality, I have not see any scary data about those who are <65 and healthy.

      For the time being, be mindful of the main variables we know about: age, respiratory disease, diabetes (insulin resistance), and cardiac disease (some have identified use of ACE inhibitor and ARBs, but DO NOT suddenly stop taking these drugs!). One highly prominent subgroup we might need to look at here in North America are the obese. Obesity not as much of an issue in other parts of the world. Might be interesting to correlate mortality with BMI.

      Best to you and your family. Good health & safety to your wife especially in the days ahead!

    2. Thanks for the replies Archimago. My sons and I continue to do basic exercises, cardio in the backyard etc. I figure good lung capacity/health is always better :-)

      Also, I have to say the hi-fi/music hobby can be a blessing in these situations. I'm finding listening to music on my system particularly calming and I might even get through my whole record collection by the time we can go outside again! (Though I have presumed we are all in this for the long haul, e.g. a year or significantly more of the virus disrupting our lifestyles).

  6. Sobering information on younger people needing hospitalization:

    1. Yeah, bad results can happen with any age. But a few points to still keep in mind:

      1. Death/mortality rates still very low for those <65. And according to that article, zero for less than 20.

      2. Until we have an account of comorbid illness - Type I diabetes, lung disease, cancer, congenital disorders like heart disease and genetic conditions, morbid obesity... We are not able to use the reported data to actually understand how the general population of young people to be faring. So far it's GOOD.

      3. ICU data BTW will be skewed to the younger populations. If a person is 80 years old and has comorbid issues (eg. significant heart disease, lung disease, dementia, overall poor quality of life), for the most part we SHOULD NOT be sending these people to the ICU and be intubated, etc. Therefore, the idea that "12% of the intensive care patients were between the ages of 20 and 44" is not a surprise and in fact is encouraging IMO. As the numbers increase and hospitals are near capacity, we should see this percentage increase. Again, that does NOT mean we should panic. We must triage resources to those who can return to full health.

      4. Related to (3) above. Remember folks, ICU is not a walk in the park. If I were 80 years old, have lived a fulfilling life, but at 75 suffered a heart attack, or stroke, or have moderate to severe lung disease, I WOULD NOT want to be in ICU intubated with lines everywhere, expecting anyone to resuscitate me if my heart & lungs fail due to a severe interstitial pneumonia from COVID-19. We value life but it's not about living forever. This is why among medical circles, we talk about pneumonia being "the old man's friend". For me personally, there are worse fates than death if I have already lived a good life... This is a calculation we always have to make when faced with death.

  7. Ouch... Watching Trump butcher hydroxychloroquine at the press conference this morning. Also rendesivir.

    Why does everything have to be "never done before", or "most", or "tremendous", or "fantastic"? No need to be so extreme... Applies to audiophilia... Applies here :-).

    1. There it is again, press more interested in baiting Trump than going after the main questions around health care... Clearly we know how the man is going to respond. It's going to be how he claims he saw it coming and closed borders to China. "Dishonest news", etc. Seems like they're trying to stoke a conflict with China like the idea that someone "over there" needs to be "punished". Give it up folks. That's simply inane.

      Hydroxychloroquine (Plaquenil) has been in use for ages for folks with autoimmune disease like lupus. It's quite widely prescribed. Doctors and hospitals I suspect should able to start using that (with azithromycin for bacterial superinfections) now as "off label" if needed in urgent situations although ideally wait for research to confirm if it actually works broadly. No need for special approval in many situations at least here in Canada and I assume the same with US so long as there is good informed consent.

      I suspect there will be a run on hydroxychloroquine including people asking for it as outpatients :-(. Remember to be careful with side effects: agranulocytosis, thrombocytopenia, QT prolongation, angioedema, Stevens-Johnson syndrome... All BAD things so be careful with it! DO NOT use it for prophylaxis, people!!!

    2. Caution with any medical advice online of course, but here's an ER doctor with COVID-19 on Twitter:

      hydroxychloroquine 400mg BID x 2 days then
      200mg BID x 5 days

      It's like treating active malaria. Not unreasonable doses but like I said above, side-effects can be dangerous (and I have seen them in patients). Make sure to work with your doctor if starting on something like Plaquenil.

      In the French paper I linked above, they used hydroxychloroquine 200mg TID (3x/day) for 10 days.

    3. As a follow-up, I went through the hydroxychloroquine (HCQ) paper and at best this is preliminary stuff. Need more information. Some more comments in my other post on COVID-19:

  8. As of today, number of deaths in Italy has officially surpassed China.

    Note that both Hubei province and Italy have around 60M people. Let's hypothetically run some numbers.

    If a major correlation can be made between age and mortality, then we actually EXPECT Italy to be worse in this regard. In 2018, World Bank data on China's population >65 years old stands at ~17% (let's assume this is the same for Hubei province).

    Italy's % of those >65 sits around 22.5%:

    On the whole then, Italy has 30% more seniors than China and there is likely going to be around 30% higher mortality rate for this first wave of COVID-19.

    Hubei currently has 3130 deaths reported which is probably an underestimation. It would not be surprising to see that Italy reaches around 4050 deaths in this first wave assuming this correlation holds and the curve is flattening at the same amount as China.

    By this same logic, I don't think it's unreasonable to see that demographics in Canada and USA would be better than those numbers. Senior population in Canada sits at ~16%, USA ~15%. Total population in Canada = 38M, USA = 330M.

    Expected mortality over next few weeks in Canada = <2000. USA = <15,200. I suspect these are significant OVERESTIMATES. I believe other than inner cities and highly dense areas will run into troubles, most places will be fine. Furthermore, we know more about this disease than when it started in China and health care quality is better overall here.

    Remember to put this into context - flu in a bad year kills upward of 60,000 in USA. Heck, around here in Canada, drug overdose deaths can easily hit 2000/year (2016, the number was 2861 for opioids alone!).

    Again, obviously we MUST take precautions to prevent making things any worse than they are. But this is NOT the apocalypse - keep this in context when you hear "Death toll in Italy surpasses China!!!" No surprise folks.

    1. Just looked around for Canada data on influenza. I think we have good screening and public health network and I see that yearly deaths from flu about ~3500 (~12,200 hospitalizations) based on Health Canada data.

      My estimate of <2000 deaths in Canada from COVID-19 I think will be a major overestimate given the amount of precautions we're taking here on top of normal health care practices!

  9. Gene DellaSala who owns contracted COVID-19. He met with an industry representative February 28. He started having symptoms about the middle of the next week.

    On Monday March 9 he received a call from a friend of the industry representative saying he was hospitalized with COVID-19. He contacted his Health department and was confirmed to have the virus. He is self-quarantining. My thoughts and prayers are with him.

    Now the 70-year old industry representative had been to a trade show in Florida and not disclosed he had returned from China weeks before. My prayers are with him as well.

    Wikipedia says that there was a very small number of cases before Gene was infected with the virus. I wonder if this person has spread COVID-19 far and wide.

    Audiophiles responsible for the spread of COVID-19 in the United States is not a headline I want to see.

    1. Yikes, wow. Thanks for the info. Wishing Gene and family well with speedy and full recovery. Love his stuff on Audioholics. Indeed, would not want to see "Patient Zero" in the region being an audiophile! Would this representative have visited the Florida Audio Expo from Feb 7-9? Might be useful for visitors to know...

      I still think the big question ahead is what is the morbidity of COVID-19. While I do not believe the death rate is anywhere near catastrophic in the big picture, I don't have a sense of longterm impact on health after recovery. Hopefully it will be no different from flu in general; this seems like the most likely base case.

      As far as I have seen, no significant number of cases with other issues like chronic lung disease or acute encephalitis (I read a report from Beijing of a case a week back)... Remember encephalitis lethargica back in the days of the 1918 pandemic as an example of the horrors back then.

  10. Young people shouldn't take it lightly, either. There are reports of healthy young people who've recovered from Covid-19, but have lost 15-30% of lung function due to scarring. That's pretty significant for all those remaining decades of life.

    1. Yup, that's part of the morbidity we need to know about.

      Interesting paper here about the "ground glass" appearance on CT which maximized ~10 days into symptoms:

      Unfortunately it's just a CT study of a small sample (n=21). No clinical correlation in the paper with pulmonary function results.

      Based on this other paper:

      We're looking at about 15-20% being the "severe group" requiring oxygen or assistance in respiration. Again, I'm not seeing data regarding loss of pulmonary function.

      Would be interesting to see where that "15-30%" quote is coming from and what population. Also very important to document the recovery process.


    2. "Would be interesting to see where that "15-30%" quote is coming from and what population. Also very important to document the recovery process."

      The report of loss of lung function was reported as coming from follow up reports in China from testing of "recovered" adults. I heard it from a spokesman for the national Health Ministry.

  11. Wow, Arch, incredible post. Incredible comments too.

    The juxtaposition of your reasonable and nuance take (and a lot of the information I've picked-up from self-study online) with what we're getting from our political leaders and the media that covers them is, well, odious.

    I'm really left to wonder, is hysteria being whipped up because it reliably sells clicks and commercials, or is something more nefarious being planned and coordinated? The lack of meaningful data for informing public policy is frankly astounding when you consider the scope of the counter-measures being instituted.

    We are spending billions in opportunity costs on quarantines, and have not spent 1/1000th the amount (ie. millions) to do any broad community-wide testing to first ascertain how wide-spread the infection is and how severe it is on average among the average population.

    Last, you touched on this, and I feel like it deserves an underscore. It's not entirely settled to me whether the comorbidities that associate with older age drive the increased severity, or the prescription drugs that associate with the comorbidities that associates with older age drive the increased severity. The virus seems tailor-made for exacerbating all the usual suspects in the over-60 cohort's medicine cabinet: ACE inhibitors, ARBS, blood thinners, statins, even baby aspirin. Something for readers to be aware of and keep in mind, I think. Certainly I'm not recommending anyone go cold-turkey on their prescriptions, however, at a minimum it is probably a good idea to lay off ibuprofen and aspirin until we learn more.

    Ok, one more. Last, last... the virus appears to have originated in bats, just like SARS1. Bat caves are notorious for aerosolized fecal matter. This class of virus evolved to infect via fecal-oral pathway. We saw this in SARS1 where the Amboy apt's faulty bathroom plumbing was the primary vector. We also know Covid19 hits hospitals and nursing homes very hard. Both places have lots of human waste being dealt with in a, well, more communal fashion. Bathroom hygiene, especially if a family member becomes sick is paramount. If you can have a separate dedicated bathroom so much the better. Do what you'd do if you had a norovirus in the house, which it so happens those are notorious in nursing homes too. And, ahem, cruise ships.

    Good luck.

    1. Excellent sharing Allan!

      Yeah, I think at this point with concerns, certainly it's a good point to consider laying off the NSAIDs:

      Alot we don't know at this point but certainly worth keeping an eye out to make sure we don't make things worse. If a person has been on the antihypertensive medications for awhile, yeah, definitely need to not go "cold turkey"; could exacerbate the stress on the body at a time like this.

      Interesting point about SARS1 and bats spread thru fecal-oral route. Definitely hospitals and nursing homes will need to be vigilant with keeping clean.

      I'll attach the Economist chart about COVID-19 survival on various surfaces in the post...

      Maybe there's something to all the toilet paper hoarding :-). Or more likely, it's just a sign of anal regression in times of stress...