Just curious, anyone have a plan, or preps for global pandemic?

[Dean Pomerleau]

Pretty sobering new podcast from Peter Attia with epidemiologist Michael Osterholm.

Good discussion on numerator and demominator uncertainty in the case fatality rate calculation around 15:00.

Discussion of how the US has more preexisting conditions than China, especially obesity around 19:00. We could have highest CFR of any country. He thinks fully diluted CFR will be "1.0 to 2.5%" but hopes he's wrong. 

24:15 - on a typical day in NYC, 100 people die from all causes. Right now (i.e. a couple days ago) he says they were averaging 150 per day dying from covid-19. [Yesterday - 505 died - DP]. 

At 24:45 the talk about how keeping US deaths below 100k would be a huge (and unlikely) victory. To do it would require Wuhan-like lockdown for many months, which isn't tenable. 

Discussion of PPE shortage for heathcare workers around 30:00. 

Discussion of lack of reagents for widespread testing around 39:00.

At least 18 months to vaccine around 50:00.

Antiviral discussion starting ar 53:30.

At 1:03:30 discussion of choir in Los Angeles where 60 people attended. No one was feeling sick. But someone had covid-19 and it spread to 45 of the 60 attendees with two of them having died so far. So much for going about life as usual and ignoring the risk.

1:15:00 - why is Germany different from Italy and Spain? Osterholm says it is likely a temporary artifact. It started in a younger population in Germany (skiers returning from Italy) and so they have a lower mortality. But it is now spreading to the older population in Germany and he expects the mortality rate in Germany to climb going forward.

1:17:00 - discussion of hydroxychloroquine and other therapeutic. The French study was very hard to draw any conclusions from due to lack of control group.

 

 

[Dean Pomerleau]

I wrote:

19 hours ago, Dean Pomerleau said:

... the half-hearted and spotty social distancing measure we're implementing in the US...

The NY Times has an article and infographic on just this issue, showing how some areas of the US have not dramatically reduced travel:

I'm afraid certain demographics in our country that have come to scoff at the advice of experts over the last few years are in for a very hard lesson over the next few months.

--Dean

[Sibiriak]

 

Stronger pandemic response yields better economic recovery
 

Quote

With much of the U.S. in shutdown mode to limit the spread of the Covid-19 disease, a debate has sprung up about when the country might "reopen" commerce, to limit economic fallout from the pandemic. But as a new study co-authored by an MIT economist shows, taking care of public health first is precisely what generates a stronger economic rebound later.

The study, using data from the flu pandemic that swept the U.S. in 1918-1919, finds cities that acted more emphatically to limit social and civic interactions had more economic growth following the period of restrictions[...]

Edited April 2, 2020 by Sibiriak

[Gordo]

US Jobless claims soar to record-breaking 6.648 million

Consensus expectations were for 3.76 million claims.

Prior to the week ending March 21, the previous record was 695,000 claims filed the week ended October 2, 1982

From the comments on that article: "It is rather shocking to watch in real time how people who been trading a bull market for 10+ years can't accept that the economy that supported these levels no longer exists. It takes 30 days for people to acquire a habit. I'm not sure that we have really had an event that has been so widespread failure of our government to protect us and that will drive at least half the people in this country to completely reorganize their lives. Companies are holding on to some people now because of 'compassion', but the bleeding will eventually force them to lay people off. The lockdown has not even really begun. It's going to really start taking place in the next 2 weeks as this spreads out past just a few hundred thousand to a few million. That is when we will be tested. So far we have failed."

*Note: I don't agree with the idea that government can magically stop new infectious disease (vaccines do better than governments)

Edited April 2, 2020 by Gordo

[Gordo]

There are some interesting observations in this new vid.  For one thing, if you get covid-19 you should not try to suppress the fever (indeed this is good advice in general, not just with covid-19).  Fever: suppress or let it ride? "Despite this evidence, treatment of fever is common in the ICU setting and likely related to standard dogma rather than evidence-based practice."

But beyond that, there is an interesting COLD EXPOSURE twist to this episode.  One hour of cold exposure (after heating) appears beneficial and can boost the innate immune response (looks like two hours of cold exposure was less effective in the study cited).  I've been doing my usual routine of sitting outside in the cold without shirt (but with sun on me) lately, feels great.  Maybe I'll try exercising beforehand though.

 

Immune changes in humans during cold exposure: effects of prior heating and exercise

01 AUG 1999https://doi.org/10.1152/jappl.1999.87.2.699

 

Edited April 2, 2020 by Gordo

[Sibiriak]

Coronavirus at beaches? Surfers, swimmers should stay away, scientist says

 

Quote

Kim Prather, a leading atmospheric chemist at the Scripps Institution of Oceanography, wants to yell out her window at every surfer, runner, and biker she spots along the San Diego coast.  "I wouldn't go in the water if you paid me $1 million right now," she said.

The beach, in her estimation, is one of the most dangerous places to be these days, as the novel coronavirus marches silently across California. 

[…] Prather fears that SARS-CoV-2, the virus that causes COVID-19, could enter coastal waters in similar ways and transfer back into the air along the coast. In her research, Prather has found that the ocean churns up all kinds of particulate and microscopic pathogens, and every time the ocean sneezes with a big wave or two, it sprays these particles into the air. She believes that this new coronavirus is light enough to float through the air much farther than we think. The six-feet rule, she said, doesn't apply at the beach, where coastal winds can get quite strong and send viral particles soaring.

[…]  while the virus has been detected in sewage, scientists are still investigating whether it remains infectious in fecal matter — and whether it survives treatment in a wastewater facility.

[…] Prather, who directs the Center for Aerosol Impacts on Chemistry of the Environment, a large research hub at Scripps backed by $40 million from the National Science Foundation, sent her researchers and students home long before California officials issued stay-at-home orders. She suspected this virus was contagious by air, and knew from past studies that coronaviruses can be excreted in fecal matter. She worries SARS-CoV-2 could enter the ocean from sewage spills and outfalls, and then reenter the atmosphere.

Wastewater treatment plants don't necessarily deactivate viruses before sending the sewage into the ocean — they tend to target bacteria like E. Coli, she said. And in areas like Imperial Beach, sewage from the Tijuana River often spills into the ocean completely untreated.

Coronaviruses are encased by what she calls a "hydrophobic" lipid, or fatty, membrane. Fat tends to float to the surface of water, similar to oil in a vinaigrette dressing. When waves break in the surf zone and all the foam and bubbles pop, Prather said, "all that stuff — the viruses, the bacteria, pollutants, all the gooey, oily stuff — just launches into the air."

The ocean, in fact, is the largest natural source of aerosol particles after dust. These marine aerosols affect the formation of clouds over the ocean and can spread over large distances.

Once in the air, studies have shown that aerosols can travel around the globe in as little as two weeks. Prather has found dust in microbes from Africa that changed the snowfall in California. She's been tracing the bacteria and sewage pollution dumped into the ocean from the Tijuana River, showing how much ends up transferring to the atmosphere.

"Once things are in the air, they can go pretty darn far. People are shocked whenever I talk about stuff becoming airborne," she said. "I see pictures of the beach shut down, and the signs tell you don't walk on the beach, don't swim, don't surf, but nobody tells you: Don't breathe."

Scientists are still debating the characteristics of this latest coronavirus. Recent research in the New England Journal of Medicine found that when the virus was suspended in a mist under laboratory conditions, it remained "viable and infectious" for three hours — though researchers have said that time period would probably be no more than a half-hour in real-world conditions.

Charles Gerba, a professor of microbiology at the University of Arizona who has studied coronaviruses in wastewater since the SARS outbreak, said these kinds of viruses have typically been found to survive two or three days in raw sewage.

With this new coronavirus, he's done a few molecular tests: While he's confirmed that the virus does wind up in sewage, he found that more than 90% of this new coronavirus was removed following typical wastewater treatment —"it's very sensitive to disinfectants."

Still up for debate, however, is whether the virus in the sewage is still infectious. "One report says yes, another report says no, so we don't really know yet for certain," said Gerba, whose research focuses on wastewater removal of viral pathogens. As for how long the virus could survive in saltwater, there's not much data, he said, but pathogens like hepatitis A or norovirus tend to survive much longer in wild environments.

[...] "People kept saying respiratory droplets and surfaces, surfaces, surfaces, but I just felt like no way, this is something special," she said. "This thing is so contagious …. Look at that choir in Washington — those people weren't coughing. They were just singing! But it got so many of them."

 

 

Edited April 2, 2020 by Sibiriak

[AlPater]

11 hours ago, Gordo said:

Such an interesting time. 😉

“It's the end of the world as we know it and I feel fine (time I had some time alone)”.

-- R. E. M.

[Todd Allen]

14 hours ago, Gordo said:

15 hours ago, Todd Allen said:

I expect this is going to accelerate China's ascendancy 

I see the opposite, this is going to hurt China badly for years to come and counties will rely less on China going forward, and also have no tolerance for their abusive practices (endless state run cyber attacks on nearly every US tech company for example, forced tech knowledge transfer, IP theft, fraud, the China hustle, counterfeiting, etc.)

I wasn't thinking in terms of popularity but rather dominance in things such as manufacturing, trade, technology, finance and control of capital and resources which provide the foundation for political and military dominance.

It looks like China has a good sense of who is infected and is able to implement focused quarantines which while challenging is likely sustainable versus our approach of blindly shutting down regional economies in fear of outbreaks or in response to outbreaks spiraling out of control.  The US and the EU have been operating on increasing levels of debt which was shakily sustained by economic growth.  But now we are piling on trillions more in debt as GDP shrinks without purchasing a solution to the crisis.  How long will lenders keep accepting paltry interest as the capacity for repayment becomes more tenuous and printing presses erode the value of our currency?  With the most expensive medical system in the world what happens when the bill comes due for extended ICU stays for possibly millions of people?  We also have sunk vast capital into unconventional oil and gas which was hemorrhaging money before the glut of Saudi Arabia's supply war with Russia and the demand destruction of globe spanning antiviral economic shutdowns.

The US has sailed into a rapidly developing shit storm with a mad captain at the helm and while kicking at our friendly EU poodle which is beginning to froth at the mouth and snap at its own tail.   If China avoids catastrophe they could come out on top.

Edited April 2, 2020 by Todd Allen

[Saul]

Bullshit.

  --  Saul

[AlPater]

20 hours ago, Dean Pomerleau said:

I'd love to hear what things are like where other people live. Here is an update from western Pennsylvania, where things aren't too bad yet. My county (which includes Pittsburgh) has 356 confirmed cases and 2 deaths among a population of 1.2 million people (~300 cases per million). Schools have been closed for about two weeks and we've been on a stay-at-home order for about a week.

My wife and I went grocery shopping for the first time in 1.5 weeks today. Shelves were pretty well stocked, except for toilet paper. People here are finally starting to wear masks, but only about 5-10% of customers (including my wife and me). People were pretty good at social distancing and the clerks were wiping down the carts and checkout areas at our upscale grocery store, but not at low-cost Aldi. We bought enough that we shouldn't have to shop for ~2 weeks.

Comparing Canada to the US, two countries equidistant from Europe and China, https://www.worldometers.info/coronavirus/#countries indicates Canada, which implemented travel restrictions to hot-spots later than the US, has fewer infections and deaths.

I live in Saskatoon, SK, where SK (population 1.1 million) has had as of yesterday, 193 cases, three in hospital, one in the ICU, 30 recovered and three deaths.  Saskatoon (population 250,000) has had 94 cases, 3 in hospitals, 0 in the ICU and an unknown number of deaths.

Grocery shopping here has been about the same as you describe, Dean.  There are plexiglass shields for tellers and markings on the floor for social distancing.  Toilet paper, flour, pastas and canned goods were in shorter than normal supply.

Government officials have many more messages to the public on TV here than those from the American government on the American TV channels.

Edited April 2, 2020 by AlPater

[Todd Allen]

9 minutes ago, AlPater said:

Comparing Canada to the US, two countries equidistant from Europe and China, https://www.worldometers.info/coronavirus/#countries indicates Canada, which implemented travel restrictions to hot-spots later than the US, has fewer infections and deaths.

Population density may be a significant factor.  Wyoming has far fewer infections and deaths per capita than New York despite far less effort to limit the spread.

Edited April 2, 2020 by Todd Allen

[Saul]

I'm in upstate NY -- Rochester -- in Monroe county -- due north of Pittsburgh, where Dean lives. 

We have very few cases so far, and even fewer deaths.

I'm continuing to work out on an elliptical cross trainer with arm motion -- fortunately, we have an excellent one at home, comparable to the one that I use in my (now closed) gym, at a comparable resistance.  And I'm teaching full time (on line) at UR.  I'm grading an on-line Midterm tonight.

  --  Saul

[Sibiriak]

21 hours ago, Ron Put said:

"Covid-19 Death Toll Passes The Death Toll From 9/11!"

If you like that headline,  you'll probably love the hot new hashtag #TrumpGenocide.

 

[Mike41]

I live about 50 miles southeast of Dean. My county has a population of about 85,000 and we currently have 6 reported cases and no fatalities. Pretty much shut down here. The university and all the schools and non essential businesses. 

 

https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/

I read this and he sounds on the mark imo. It may help to ease concerns about death rates. They are most likely higher due to underreported rates of illness very obvious reasons like the fact that we do not test everyone and very sick people are more likely to get tested etc. He has all the credentials and I think he raises some good points and that maybe we are overreacting. Emphasis on MAYBE

From the article

The data collected so far on how many people are infected and how the epidemic is evolving are utterly unreliable. Given the limited testing to date, some deaths and probably the vast majority of infections due to SARS-CoV-2 are being missed. We don’t know if we are failing to capture infections by a factor of three or 300. Three months after the outbreak emerged, most countries, including the U.S., lack the ability to test a large number of people and no countries have reliable data on the prevalence of the virus in a representative random sample of the general population

Edited April 2, 2020 by Mike41

[Ron Put]

3 hours ago, Todd Allen said:

... It looks like China has a good sense of who is infected and is able to implement focused quarantines which while challenging is likely sustainable versus our approach of blindly shutting down regional economies in fear of outbreaks or in response to outbreaks spiraling out of control.  ...

The US has sailed into a rapidly developing shit storm with a mad captain at the helm and while kicking at our friendly EU poodle which is beginning to froth at the mouth and snap at its own tail.   If China avoids catastrophe they could come out on top.

This post is a good example of why this is a huge coup for China. China has long been pushing the idea that it offers a better model than the liberal democracies, especially in the developing world. I'll summarize what I've already said in older posts.

China's stroke of luck was that it had been able to get their own choice, Tedros Ghebreyesus, as the head of the World Health Organization (which should be a reminder to Trump why international organizations are so important). China hid the Covid-19 epidemic for two months before Tedros flew to China at the end of January, when it suddenly clamped down hard on Wuhan,with a great show of force. Tedros met with Xi and then came out praising China's "cooperation" and the draconian measures, and WHO called on the rest of the world to follow China's model. The Right in Europe immediately got on board, with the greatest pressure first evident in Italy, where the government was bullied into imposing restrictions following the China model.

The WHO recommendations were heavily influenced by China and based on false premises: WHO's Tedros claimed that:
1. Covid-19 is much less contagious than the flu. According to Tedros, while the flu is too contagious to contain, Covid-19 is not easily transmittable and is thus containable, though the China model. We know that this is false.
2. Covid-19 is much deadlier than the flu. This is also false -- the current death rates appear to be closer to a bad flu season.

Experts and politicians who questioned the wisdom of imposing draconian measures were publically denigrated, mocked and their competence and credentials were attacked in social media, the news media and by political opponents. In Europe, most of the attacks came from the Right, while in the US it was the Democrats who used the Chinese narrative to attack Trump. The governors of the two largest US state economies, NY and CA, went on to shut down business activity, successfully presenting themselves as "strong leaders" in the vein of Xi, painting Trump as week and bumbling, and then turned around and asked the federal government to pay for the shutdowns they implemented. Trump, who in populist fashion flailed a bit and then fell into line, then presided over the over two trillion free money package just passed.

As I said, draconian measures, even though not based on any reliable data, are the safest path for virtually any politician right now, as they are supported by groupthink as "decisive" and as "saviors." Even if Covid-19 turns out to be more like a bad flu and we learn to live with its cycles, those like Dean will claim that the draconian measures were the reason for the low death rate, and by the time we've had enough cycles to be able to disprove this claim, the collective memory will be long faded. Which is why tremendous pressure is applied to those who don't fall in line, like Sweden, because they present an alternative which may prove dangerous to those who took the politically "safe" way and destroyed their economies.

But the bottom line is, right now Xi's China is presented as a better model than the Western liberal democracies, and this is being accepted by many in the West, especially among the European Right and the American Left. That this sentiment was planted and grew is much more dangerous, in my opinion, than Covid-19.

Edited April 2, 2020 by Ron Put

[Gordo]

1 hour ago, Ron Put said:

China's stroke of luck was that it had been able to get their own choice, Tedros Ghebreyesus, as the head of the World Health Organization

Martha McSally calls on WHO director to resign

Quote

Sen. Martha McSally is calling on the World Health Organization director general to step down from his post over what she deems assistance in covering up for China's underreporting of the coronavirus, part of an escalating series of GOP criticisms of the organization.

 

[Todd Allen]

Just learned our favorite veterinarian Dr. Peter Sakas, 67, died two days ago from Covid-19.  My wife and I saw him last on Feb. 29th in reasonable health although somewhat over weight and over worked where in a long conversation he freely shared his extensive experience in diagnosing and treating lead poisoning both acute and chronic in many different species of animals which was a rare treasure for us because despite extensive searching we have been unable to locate any other medical professionals with significant experience treating lead poisoning other than acute poisoning in children and factory workers.

[BrianA]

This would explain why choirs/churches/loud concerts/nightclubs can turn into super-spreader events:

 

Aerosol emission and superemission during human speech increase with voice loudness

https://www.nature.com/articles/s41598-019-38808-z

[Dean Pomerleau]

Disappointing results [1] from a very small trial in France with 10 patients (and no controls) of hydroxychloroquine and azithromycin - the same regime as the much touted study out of another French hospital claiming high efficacy.

Such a rapid and full viral clearance was quite unexpected and we wished to assess in a
prospective study virologic and clinical outcomes of 11 consecutive patients hospitalized in our department who received hydroxychloroquine (600 mg/d for 10 days) and azithromycin (500 mg Day 1 and 250 mg days 2 to 5) using the same dosing regimen reported by Gautret et al. (3).

There were 7 men and 4 women with a mean age of 58.7 years (range: 20-77), 8 had significant comorbidities associated with poor outcomes (obesity: 2; solid cancer: 3; hematological cancer: 2; HIV-infection: 1). At the time of treatment initiation, 10/11 had fever and received nasal oxygen therapy. Within 5 days, one patient died, two were transferred to the ICU. In one patient, hydroxychloroquine
and azithromycin were discontinued after 4 days because of a prolongation of the QT interval from 405 ms before treatment to 460 and 470 ms under the combination. Mean through blood concentration of hydroxychloroquine was 678 ng/mL (range: 381-891) at days 3-7 after treatment initiation.

Repeated nasopharyngeal swabs in 10 patients (not done in the patient who died) using a
qualitative PCR assay (nucleic acid extraction using Nuclisens Easy Mag®, Biomerieux and
amplification with RealStar SARS CoV-2®, Altona), were still positive for SARS-CoV2 RNA in 8/10 patients (80%, 95% confidence interval: 49-94) at days 5 to 6 after treatment initiation. These virologic results stand in contrast with those reported by Gautret et al. and cast doubts about the strong antiviral efficacy of this combination. Furthermore, in their report Gautret et al also reported one death and three transfers to the ICU among the 26 patients who received hydroxychloroquine, also underlining the poor clinical outcome with this combination.

In addition, a recent study from China in individuals with COVID-19 found no difference in the rate of virologic clearance at 7 days with or without 5 days of hydroxychloroquine, and no difference in clinical outcomes (duration of hospitalization, temperature normalization,
radiological progression) (4). These results are consistent with the lack of virologic or clinical benefit of chloroquine in a number of viral infections where it was assessed for treatment or prophylaxis with sometimes a deleterious effect on viral replication (5-8).

In summary, despite a reported antiviral activity of chloroquine against COVID-19 in vitro, we found no evidence of a strong antiviral activity or clinical benefit of the combination of
hydroxychloroquine and azithromycin for the treatment of our hospitalized patients with
severe COVID-19. Ongoing randomized clinical trials with hydroxychloroquine should provide a definitive answer regarding the alleged efficacy of this combination and will assess its safety.

------------

[1] No Evidence of Rapid Antiviral Clearance or Clinical Benefit with the Combination of Hydroxychloroquine and Azithromycin in Patients with Severe COVID-19 Infection

Author links open overlay panelJean MichelMolina(Dr)13ConstanceDelaugerre24Jerome LeGoff24BrenoMela-Lima1DianePonscarme1LaurianeGoldwirt5Nathaliede Castro1
Show more

https://doi.org/10.1016/j.medmal.2020.03.006

[TomBAvoider]

Let's face it, effective medications (as opposed to vaccines) against viruses are scarce, insofar as eliminating rather than just suppressing. It's not like antibiotics for bacteria. With viruses we don't have as many molecular tools, although we can get decent control for some classes of viruses, such as HIV. 

I imagine after this pandemic, perhaps there will finally be adequate funding and a real push to come up with anti-virals that are as effective as antibiotics are for many bacteria - you should be able to pop a pill (or get a shot) for a few days and get rid of the virus entirely. This was phantasy a few years ago, but these days with rapid progress in AI and bio-molecular science, hopefully it's withing at least striking distance.

[Sibiriak]

Estimates of the severity of coronavirus disease 2019: a model-based analysis   (March 30, 2020)

Quote

Summary

Background

In the face of rapidly changing data, a range of case fatality ratio estimates for coronavirus disease 2019 (COVID-19) have been produced that differ substantially in magnitude. We aimed to provide robust estimates, accounting for censoring and ascertainment biases.

Methods

We collected individual-case data for patients who died from COVID-19 in Hubei, mainland China (reported by national and provincial health commissions to Feb 8, 2020), and for cases outside of mainland China (from government or ministry of health websites and media reports for 37 countries, as well as Hong Kong and Macau, until Feb 25, 2020). These individual-case data were used to estimate the time between onset of symptoms and outcome (death or discharge from hospital). We next obtained age-stratified estimates of the case fatality ratio by relating the aggregate distribution of cases to the observed cumulative deaths in China, assuming a constant attack rate by age and adjusting for demography and age-based and location-based under-ascertainment. We also estimated the case fatality ratio from individual line-list data on 1334 cases identified outside of mainland China. Using data on the prevalence of PCR-confirmed cases in international residents repatriated from China, we obtained age-stratified estimates of the infection fatality ratio. Furthermore, data on age-stratified severity in a subset of 3665 cases from China were used to estimate the proportion of infected individuals who are likely to require hospitalisation.

Findings

Using data on 24 deaths that occurred in mainland China and 165 recoveries outside of China, we estimated the mean duration from onset of symptoms to death to be 17·8 days (95% credible interval [CrI] 16·9–19·2) and to hospital discharge to be 24·7 days (22·9–28·1). In all laboratory confirmed and clinically diagnosed cases from mainland China (n=70 117), we estimated a crude case fatality ratio (adjusted for censoring) of 3·67% (95% CrI 3·56–3·80).

 

However, after further adjusting for demography and under-ascertainment, we obtained a best estimate of the case fatality ratio in China of 1·38% (1·23–1·53), with substantially higher ratios in older age groups (0·32% [0·27–0·38] in those aged <60 years vs 6·4% [5·7–7·2] in those aged ≥60 years), up to 13·4% (11·2–15·9) in those aged 80 years or older.

 

Estimates of case fatality ratio from international cases stratified by age were consistent with those from China (parametric estimate 1·4% [0·4–3·5] in those aged <60 years [n=360] and 4·5% [1·8–11·1] in those aged ≥60 years [n=151]). Our estimated overall infection fatality ratio for China was 0·66% (0·39–1·33), with an increasing profile with age. Similarly, estimates of the proportion of infected individuals likely to be hospitalised increased with age up to a maximum of 18·4% (11·0–7·6) in those aged 80 years or older.

 

 

 

Quote

Implications of all the available evidence

 

Our estimates of the case fatality ratio for COVID-19, although lower than some of the crude estimates made to date, are substantially higher than for recent influenza pandemics (eg, H1N1 influenza in 2009).

 

With the rapid geographical spread observed to date, COVID-19 therefore represents a major global health threat in the coming weeks and months. Our estimate of the proportion of infected individuals requiring hospitalisation, when combined with likely infection attack rates (around 50–80%), show that even the most advanced health-care systems are likely to be overwhelmed. These estimates are therefore crucial to enable countries around the world to best prepare as the global pandemic continues to unfold.

 

Quote

Discussion

From an extensive analysis of data from different regions of the world, our best estimate at the current time for the case fatality ratio of COVID-19 in China is 1·38% (95% CrI 1·23–1·53). Although this value remains lower than estimates for other coronaviruses, including SARS 24 and Middle East respiratory syndrome (MERS), 25 it is substantially higher than estimates from the 2009 H1N1 influenza pandemic. 26, 27 Our estimate of an infection fatality ratio of 0·66% in China was informed by PCR testing of international Wuhan residents returning on repatriation flights.

This value was consistent with the infection fatality ratio observed in passengers on the Diamond Princess cruise ship up to March 5, 2020, although it is slightly above the upper 95% confidence limit of the age-adjusted infection fatality ratio observed by March 25 (of 712 confirmed cases, 601 have been discharged, ten have died, and 11 remain in a critical condition). This difference might be due to repatriation flight data slightly underestimating milder infections, or due to cruise passengers having better outcomes because of a potentially higher-than-average quality of health care.

Our estimates of the probability of requiring hospitalisation assume that only severe cases require hospitalisation. This assumption is clearly different from the pattern of hospitalisation that occurred in China, where hospitalisation was also used to ensure case isolation. Mortality can also be expected to vary with the underlying health of specific populations, given that the risks associated with COVID-19 will be heavily influenced by the presence of underlying comorbidities.

Our estimate of the case fatality ratio is substantially lower than the crude case fatality ratio obtained from China based on the cases and deaths observed to date, which is currently 3·67%, as well as many of the estimates currently in the literature. The principle reason for this difference is that the crude estimate does not take into account the severity of cases. For example, various estimates have been made from patient populations ranging from those with generally milder symptoms (for example international travellers detected through screening of travel history) 13  through to those identified in the hospital setting. 14 15

It is clear from the data that have emerged from China that case fatality ratio increases substantially with age. Our results suggest a very low fatality ratio in those under the age of 20 years. As there are very few cases in this age group, it remains unclear whether this reflects a low risk of death or a difference in susceptibility, although early results indicate young people are not at lower risk of infection than adults. 28

Serological testing in this age group will be crucial in the coming weeks to understand the significance of this age group in driving population transmission. The estimated increase in severity with age is clearly reflected in case reports, in which the mean age tends to be in the range of 50–60 years. Different surveillance systems will pick up a different age case mix, and we find that those with milder symptoms detected through a history of travel are younger on average than those detected through hospital surveillance. Our correction for this surveillance bias therefore allows us to obtain estimates that can be applied to different case mixes and demographic population structures. However, it should be noted that this correction is applicable under the assumption of a uniform infection attack rate (ie, exposure) across the population.

We also assumed perfect case ascertainment outside of Wuhan in the age group with the most cases relative to their population size (50–59-year-olds); however, if many cases were missed, the case fatality ratio and infection fatality ratio estimates might be lower. In the absence of random population surveys of infection prevalence, our adjustment from case fatality ratio to infection fatality ratio relied on repatriation flight data, which was not age specific. The reported proportion of infected individuals who were asymptomatic on the Diamond Princess did not vary considerably by age, supporting this approach, but future larger representative population prevalence surveys and seroprevalence surveys will inform such estimates further.

Much of the data informing global estimates of the case fatality ratio at present are from the early outbreak in Wuhan. Given that the health system in this city was quickly overwhelmed, our estimates suggest that there is substantial under-ascertainment of cases in the younger age groups (who we estimate to have milder disease) by comparison with elsewhere in mainland China. This under-ascertainment is the main factor driving the difference between our estimate of the crude case fatality ratio from China (3·67%) and our best estimate of the overall case fatality ratio (1·38%).

The case fatality ratio is likely to be strongly influenced by the availability of health-care facilities. However surprisingly, although health-care availability in Wuhan was stretched, our estimates from international cases are of a similar magnitude, suggesting relatively little difference in health outcome.

Finally, as clinical knowledge of this new disease accrues, it is possible that outcomes will improve. It will therefore be important to revise these estimates as epidemics unfold.

The world is currently experiencing the early stages of a global pandemic. Although China has succeeded in containing the disease spread for 2 months, such containment is unlikely to be achievable in most countries. Thus, much of the world will experience very large community epidemics of COVID-19 over the coming weeks and months. Our estimates of the underlying infection fatality ratio of this virus will inform assessments of health effects likely to be experienced in different countries, and thus decisions around appropriate mitigation policies to be adopted.

Edited April 3, 2020 by Sibiriak

[Sibiriak]

On 4/1/2020 at 11:13 AM, TomBAvoider said:

when is there going to be a serious discussion about the timeline for restarting the economy

 

Dr. Anthony Fauci:

Quote

April 1, 2020 | 8:15pm   [...]During the White House Coronavirus Task Force briefing, a reporter asked whether social distancing guidelines will be in effect until there is a treatment or vaccine.

“I think if we get to the part of the curve that Dr. Birx showed yesterday when it goes down to essentially no new cases, no new deaths at a period of time. I think it makes sense that you will have to relax social distancing,” Fauci said.

“The one thing we hopefully would have in place, and I believe we will have in place, is a much more robust system to be able to identify someone who was infected, isolate them and then do contact tracing,” he said.

“If you have a really good program of containment that prevents you from ever having to get into mitigation, we are in mitigation right now. That’s what the social and physical distancing is. The ultimate solution to a virus that might keep coming back would be a vaccine.
 

[...]“The vaccine is as I said, it's on target. We are still in phase one. There were three doses we had to attest to. We had been through the first two doses and were on the highest dose now. When we get that data, it will take a few months to get that data. A few months from now we will be in phase two, and I think they’re right on target to a year or year and a half,” he said.

 

Edited April 3, 2020 by Sibiriak

[mccoy]

The explanation elucidated in the Attia-Osteholm podcast posted by Dean on the initially tiny CFR in Germany has been around for only a few days and appears to be reasonable.

Apparently, SARSCOV2 has been introduced in Germany by skiers who went to the Italian ski tracks. The infected people where usually young and without comorbidities. So in their group fatalities were Nihil or little, until the virus worked its way to older and sick individuals. Presently, the CFR is approaching the range of 1 to 2% which is the one commonly accepted, when dealing with officially confirmed cases at the numerator.

I wonder why the propagation has been so slow, maybe in Germany young people do not live in the same house as older people, like it is the usual case in Italy.

So, anomalously low number of CFR are apparently a clue of a transient situation which will stabilize into a larger CFR.

[Dean Pomerleau]

A good article on how the models currently driving policy which show a benefit for short-term suppression of transmission of the virus through social distancing are likely misleading, simply pushing the peak beyond the duration of the model.

In fact, unless and until an effective treatment or vaccine is available, they say pushing the peak until fall/winter in the northern hemisphere may be counterproductive, since the virus will likely spread more viciously in the fall/winter. The authors acknowledge there may be some benefits to stalling the pandemic however, giving us more time to build health care capacity and develop treatments.

--Dean

 

 

[AlPater]

https://www.worldometers.info/coronavirus/#countries now shows that of cases that have resolved, 20% died; last I remembered the % it was 14%.

Analysis on 54 Mortality Cases of Coronavirus Disease 2019 in the Republic of Korea from January 19 to March 10, 2020.
Korean Society of Infectious Diseases and Korea Centers for Disease Control and Prevention.
J Korean Med Sci. 2020 Mar 30;35(12):e132. doi: 10.3346/jkms.2020.35.e132.
PMID: 32233161 Free Article
https://jkms.org/Synapse/Data/PDFData/0063JKMS/jkms-35-e132.pdf
Abstract
Since the identification of the first case of coronavirus disease 2019 (COVID-19), the global number of confirmed cases as of March 15, 2020, is 156,400, with total death in 5,833 (3.7%) worldwide. Here, we summarize the morality data from February 19 when the first mortality occurred to 0 am, March 10, 2020, in Korea with comparison to other countries. The overall case fatality rate of COVID-19 in Korea was 0.7% as of 0 am, March 10, 2020.
KEYWORDS:
COVID-19; Case Fatality Rate; China; Comparison; Coronavirus; Italy; Korea; Mortality; SARS-CoV-2