Coronavirus 2019-nCoV

[Kung Wu]

Therefore we should inoculate all children with a secret tracking microchip, right? It's for the safety of the country!

[wufan]

Nearly 10% of Iran’s gov is infected. Some are allegedly dead .

[ShockerFever]

I wonder what it would look like if we tracked every reported case of the flu and every death associated with it on the CNN newsfeed. Would it look scarier?

[DCShockerFan05]

Disclaimer right off the bat: I work in the health care field, though not as a clinician--I study and advise on hospital operations and strategy. My educational background is in mathematics and statistics. So my perspective and advice below is offered as a concerned citizen who knows his way around numbers, clinical literature, and real-world consequences. I am not a doctor and do not offer medical advice.

I have been watching the situation closely since late January when the WHO began issuing daily situation reports and the first papers hit the medical journals. I am disappointed that most media, regardless of political leanings, did not give much attention to coronavirus until very recently, even though it was quite clear some weeks ago that the virus would not be contained in China or indeed anywhere. Here's what I can tell you from my point of view.

This is a very serious situation. There's still uncertainty about the exact mortality rate, but some things are clear, and it's also helpful to understand where the uncertainty comes from. One useful but limited measure is the Case Fatality Rate, which is the number of deaths divided by the number of confirmed cases at a given point in time. Early estimates put the CFR somewhere around 2%, but the current CFR is closer to 3.5%. But there are some caveats to that:

1. Many cases aren't confirmed, or even observed. In particular, mild cases are probably underreported. If you don't feel sick or don't feel sick for long, you probably don't get tested. Underreporting of mild cases (which don't lead to death) would mean the true denominator in the CFR is larger, so true CFR is smaller. That would be good news.

2. SO FAR, the vast majority of cases have been in China and in particular in Hubei province. There are several reasons to think that the Chinese authorities may be underrerporting the situation in ways DISTINCT from the expected underreporting of mild cases described above. These include nefarious ones like top-down coverups, but we'd also see an underrerporting if infrastructure is simply overwhelmed, or if testing protocols are flawed, or all sorts of things. Any of these phenomena would make the CFR a less precise estimate, but it's not clear in which direction--if deaths are underreported, for example, the true CFR could actually be higher. So this one is ambigious. However, as more cases emerge in other areas, the effect of any China-specific factors will be diminished.

3. Many, many of the confirmed cases--about 40,000--have not resolved yet--that is, they have neither died nor recovered. Some patients who already have the disease will die, but haven't yet. They're in the current denominator, but not the current numerator. So this factor biases the CFR estimate downward. As time goes on, enough cases will be resolved, one way or another, to eliminate this bias. But that hasn't happened yet.

4. There is really no question at this point that this is significantly more deadly than seasonal flu. Exactly how much is still uncertain, but it is NOT the same thing.

5. The CFR is calculated across the entire population of confirmed cases. But as you might expect, the fatality rate for certain subsets is significantly higher (and lower for others). For example, around 15% of patients over 80 have died. As more cases resolve, we'll get a better picture of which underlying conditions are most risky. If you are young and healthy, this probably won't kill you, but you DO NOT want to get this if you are elderly or have heart trouble, lung trouble, etc. And that means if you have elderly parents or grandparents, you don't want them to get this either.

So I am worried my parents and other relatives. But I'm also worried about the health care infrastructure overall. While we have, in normal times, far too many hospital beds (ask me about this separately; it's what i do for a living), this is exactly the sort of rare event that could swamp the system, especially in urban areas. Around 15-20% of confirmed cases are considered "serious"--respiratory distress, pneumonia, various other complications. Most estimates now say that at least 20% of the country will get this--some say as much as 80%. But suppose it's 20%, and 20% of those are serious cases. That's about 13 million serious cases. That number could be lower if the percentage of cases that are serious is also biased by underreporting of mild cases. Even so, a lot of people, even if they survive, will still be very sick for a while--in some cases weeks, if the early patterns hold. Unless there's a dramatic decline in transmission rates very soon, we will need nurses, respiratory therapists, ventilators, etc, and we'll need lots of them, round the clock, for quite a while. While I'm sure the system could respond to a sudden surge in demand, I'm not nearly as sure that it could sustain that surge across weeks or months. My colleagues and I are working right now to estimate this. There's also the impact on the capacity to treat everything else--heart attacks and strokes and new babies and accidents don't stop.

Is it all doom and gloom? Not exactly. It is serious--please, please don't let anyone tell you otherwise. But it's also not cause for panic. What we should all do is prepare for a range of circumstances, including those we don't necessarily expect. Here's what I'm doing:

1. I'm definitely taking more care to wash my hands thoroughly and trying (tougher than I thought) to not touch my nose/mouth/eyes.

2. I am deciding ahead of time what developments would make me change my behavior so that I'm not making rash decisions later. For example: Right now I'm going to work but driving instead of taking public transit. I have decided that if (when) there is community transmission confirmed near me (Washington DC area) I am going to work from home whenever possible. I have decided that if local authorities, my employer, or my doctor recommend "social distancing" measures, I will follow their recommendations. I am NOT stockpiling food, though I have checked to be sure that I would be able to manage a 14-day quarantine if necessary. I have NOT cancelled upcoming domestic business travel, but I WILL do so if traveling between areas where one side has significant community transmission and the other does not. (If both do, nothing's really gained by staying put, though I will have to consider whether being on a plane for a few hours is a good idea.) I have NOT purchased surgical or N95 masks, as there's little evidence they help the common man prevent COVID, but are in short supply for clinicians who do need them for their work generally.

3. I am deciding ahead of time what would cause me to seek medical care and how I would do it, so that I don't put undue burden on the system but also get care (and isolation) quickly if truly warranted.

4. I'm reading objective, reputable, evidence-based sources. That doesn't mean I'm NOT consuming mass media--in fact local and national news are really important to understand what is happening society-wise. But for the facts about the epidemic itself, it's CDC and WHO for me. I'm skipping any story that is mainly about political finger pointing or about how other media is covering something. I am following politics as I normally do, and I'm interested about how leaders on all sides are addressing the issue, because that's their job and I have a duty in democracy to observe and judge their performance. But I'm not confusing the political angle for the public health angle.

5. I'm not making jokes about this, nor am I panicking. I'm staying as informed as I can and helping my family to understand their risks and how to mitigate them.

Your approach may be different based on where you live (big city vs. small town, apartment building vs. standalone house), your job, your health, etc. But I'd recommend deciding what that approach is before things get bad. If they never get bad, all it has cost you is a little bit of worry.

If this is all overblown I will very happily come back and eat crow (properly inspected, cleaned and prepared). I really hope that's the case.

All the best to all of you.

[Shocker1976]

Disclaimer right off the bat: I work in the health care field, though not as a clinician--I study and advise on hospital operations and strategy. My educational background is in mathematics and statistics. So my perspective and advice below is offered as a concerned citizen who knows his way around numbers, clinical literature, and real-world consequences. I am not a doctor and do not offer medical advice.

I have been watching the situation closely since late January when the WHO began issuing daily situation reports and the first papers hit the medical journals. I am disappointed that most media, regardless of political leanings, did not give much attention to coronavirus until very recently, even though it was quite clear some weeks ago that the virus would not be contained in China or indeed anywhere. Here's what I can tell you from my point of view.

This is a very serious situation. There's still uncertainty about the exact mortality rate, but some things are clear, and it's also helpful to understand where the uncertainty comes from. One useful but limited measure is the Case Fatality Rate, which is the number of deaths divided by the number of confirmed cases at a given point in time. Early estimates put the CFR somewhere around 2%, but the current CFR is closer to 3.5%. But there are some caveats to that:

1. Many cases aren't confirmed, or even observed. In particular, mild cases are probably underreported. If you don't feel sick or don't feel sick for long, you probably don't get tested. Underreporting of mild cases (which don't lead to death) would mean the true denominator in the CFR is larger, so true CFR is smaller. That would be good news.

2. SO FAR, the vast majority of cases have been in China and in particular in Hubei province. There are several reasons to think that the Chinese authorities may be underrerporting the situation in ways DISTINCT from the expected underreporting of mild cases described above. These include nefarious ones like top-down coverups, but we'd also see an underrerporting if infrastructure is simply overwhelmed, or if testing protocols are flawed, or all sorts of things. Any of these phenomena would make the CFR a less precise estimate, but it's not clear in which direction--if deaths are underreported, for example, the true CFR could actually be higher. So this one is ambigious. However, as more cases emerge in other areas, the effect of any China-specific factors will be diminished.

3. Many, many of the confirmed cases--about 40,000--have not resolved yet--that is, they have neither died nor recovered. Some patients who already have the disease will die, but haven't yet. They're in the current denominator, but not the current numerator. So this factor biases the CFR estimate downward. As time goes on, enough cases will be resolved, one way or another, to eliminate this bias. But that hasn't happened yet.

4. There is really no question at this point that this is significantly more deadly than seasonal flu. Exactly how much is still uncertain, but it is NOT the same thing.

5. The CFR is calculated across the entire population of confirmed cases. But as you might expect, the fatality rate for certain subsets is significantly higher (and lower for others). For example, around 15% of patients over 80 have died. As more cases resolve, we'll get a better picture of which underlying conditions are most risky. If you are young and healthy, this probably won't kill you, but you DO NOT want to get this if you are elderly or have heart trouble, lung trouble, etc. And that means if you have elderly parents or grandparents, you don't want them to get this either.

So I am worried my parents and other relatives. But I'm also worried about the health care infrastructure overall. While we have, in normal times, far too many hospital beds (ask me about this separately; it's what i do for a living), this is exactly the sort of rare event that could swamp the system, especially in urban areas. Around 15-20% of confirmed cases are considered "serious"--respiratory distress, pneumonia, various other complications. Most estimates now say that at least 20% of the country will get this--some say as much as 80%. But suppose it's 20%, and 20% of those are serious cases. That's about 13 million serious cases. That number could be lower if the percentage of cases that are serious is also biased by underreporting of mild cases. Even so, a lot of people, even if they survive, will still be very sick for a while--in some cases weeks, if the early patterns hold. Unless there's a dramatic decline in transmission rates very soon, we will need nurses, respiratory therapists, ventilators, etc, and we'll need lots of them, round the clock, for quite a while. While I'm sure the system could respond to a sudden surge in demand, I'm not nearly as sure that it could sustain that surge across weeks or months. My colleagues and I are working right now to estimate this. There's also the impact on the capacity to treat everything else--heart attacks and strokes and new babies and accidents don't stop.

Is it all doom and gloom? Not exactly. It is serious--please, please don't let anyone tell you otherwise. But it's also not cause for panic. What we should all do is prepare for a range of circumstances, including those we don't necessarily expect. Here's what I'm doing:

1. I'm definitely taking more care to wash my hands thoroughly and trying (tougher than I thought) to not touch my nose/mouth/eyes.

2. I am deciding ahead of time what developments would make me change my behavior so that I'm not making rash decisions later. For example: Right now I'm going to work but driving instead of taking public transit. I have decided that if (when) there is community transmission confirmed near me (Washington DC area) I am going to work from home whenever possible. I have decided that if local authorities, my employer, or my doctor recommend "social distancing" measures, I will follow their recommendations. I am NOT stockpiling food, though I have checked to be sure that I would be able to manage a 14-day quarantine if necessary. I have NOT cancelled upcoming domestic business travel, but I WILL do so if traveling between areas where one side has significant community transmission and the other does not. (If both do, nothing's really gained by staying put, though I will have to consider whether being on a plane for a few hours is a good idea.) I have NOT purchased surgical or N95 masks, as there's little evidence they help the common man prevent COVID, but are in short supply for clinicians who do need them for their work generally.

3. I am deciding ahead of time what would cause me to seek medical care and how I would do it, so that I don't put undue burden on the system but also get care (and isolation) quickly if truly warranted.

4. I'm reading objective, reputable, evidence-based sources. That doesn't mean I'm NOT consuming mass media--in fact local and national news are really important to understand what is happening society-wise. But for the facts about the epidemic itself, it's CDC and WHO for me. I'm skipping any story that is mainly about political finger pointing or about how other media is covering something. I am following politics as I normally do, and I'm interested about how leaders on all sides are addressing the issue, because that's their job and I have a duty in democracy to observe and judge their performance. But I'm not confusing the political angle for the public health angle.

5. I'm not making jokes about this, nor am I panicking. I'm staying as informed as I can and helping my family to understand their risks and how to mitigate them.

Your approach may be different based on where you live (big city vs. small town, apartment building vs. standalone house), your job, your health, etc. But I'd recommend deciding what that approach is before things get bad. If they never get bad, all it has cost you is a little bit of worry.

If this is all overblown I will very happily come back and eat crow (properly inspected, cleaned and prepared). I really hope that's the case.

All the best to all of you.

Thanks for such a well reasoned and clearly expressed post. Best I have read on this issue on any internet site!

[wufan]

DCShockerFan05, that is well said. I posses no special knowledge on this, but am also following it closely. This is a very good summary of the information I have consumed.

[wufan]

Side note: I too thought about quarantine as a worst case scenario, and as such I made sure that I had two weeks of food and I bought 10 liters of water. Then I realized, there’s no reason to believe that my tap will stop running. Oh well. Youth soccer starts soon.

[Napoleon Dynamite]

As of 03/04/2020 03:43 GMT, there are 38,988 active COVID-19 cases. Of those, 83% (32,217) are mild cases, and 17% (6,771) are serious or critical.

There are currently 54,172 closed COVID-19 cases. Of those, 94% (50,969) are recovered, and 6% (3,203) are deaths.

It seems that measuring deaths and recoveries on the closed cases gives a much better picture of the disease instead of using both active and closed cases as the denominator.
At present, it is tempting to estimate the case fatality rate by dividing the number of known deaths by the number of confirmed cases. The resulting number, however, does not represent the true case fatality rate and might be off by orders of magnitude [...]

A precise estimate of the case fatality rate is therefore impossible at present.



2019-Novel Coronavirus (2019-nCoV): estimating the case fatality rate – a word of caution - Battegay Manue et al., Swiss Med Wkly, February 7, 2020

AGE	DEATH RATE confirmed cases	DEATH RATE all cases
80+ years old	21.9%	14.8%
70-79 years old		8.0%
60-69 years old		3.6%
50-59 years old		1.3%
40-49 years old		0.4%
30-39 years old		0.2%
20-29 years old		0.2%
10-19 years old		0.2%
0-9 years old		no fatalities

In the chart above, Death Rate = (number of deaths / number of cases) = probability of dying if infected by the virus (%).

I realize the chart above uses total cases as the denominator, but I think it is illustrative of the impact by age.

[Shocker1976]

As of 03/04/2020 03:43 GMT, there are 38,988 active COVID-19 cases. Of those, 83% (32,217) are mild cases, and 17% (6,771) are serious or critical.

There are currently 54,172 closed COVID-19 cases. Of those, 94% (50,969) are recovered, and 6% (3,203) are deaths.

It seems that measuring deaths and recoveries on the closed cases gives a much better picture of the disease instead of using both active and closed cases as the denominator.
At present, it is tempting to estimate the case fatality rate by dividing the number of known deaths by the number of confirmed cases. The resulting number, however, does not represent the true case fatality rate and might be off by orders of magnitude [...]

A precise estimate of the case fatality rate is therefore impossible at present.



2019-Novel Coronavirus (2019-nCoV): estimating the case fatality rate – a word of caution - Battegay Manue et al., Swiss Med Wkly, February 7, 2020

AGE	DEATH RATE confirmed cases	DEATH RATE all cases
80+ years old	21.9%	14.8%
70-79 years old		8.0%
60-69 years old		3.6%
50-59 years old		1.3%
40-49 years old		0.4%
30-39 years old		0.2%
20-29 years old		0.2%
10-19 years old		0.2%
0-9 years old		no fatalities

In the chart above, Death Rate = (number of deaths / number of cases) = probability of dying if infected by the virus (%).

I realize the chart above uses total cases as the denominator, but I think it is illustrative of the impact by age.

Any idea what the underlying health issues were regards those patients who died?

[wufan]

Any idea what the underlying health issues were regards those patients who died?

I can’t answer the question you are actually asking, but age related illness is obvious. Think immunocompromised, lung disease, heart disease, and liver disease.

My company is projecting an increase in antibiotic sales due to coronavirus outbreaks. Obviously antibiotics won’t treat a virus, so it’s likely any comorbidities associated with hospitalization.

[SB Shock]

Any idea what the underlying health issues were regards those patients who died?

In order of death rate for ALL CASES

1. Cardiovascular Disease (10.5%)
2. Diabetes (7.3%)
3. Chronic Respiratory disease (6.3%)
4. Cancer (5.6%)

No preexisting conditions (0.9%)

Also at least in China they are finding smokers are hit harder. One hypothesis is that is why men in china have higher death rate than women because in that culture men smoke more than women.

[DCShockerFan05]

In order of death rate for ALL CASES

1. Cardiovascular Disease (10.5%)
2. Diabetes (7.3%)
3. Chronic Respiratory disease (6.3%)
4. Cancer (5.6%)

No preexisting conditions (0.9%)

Also at least in China they are finding smokers are hit harder. One hypothesis is that is why men in china have higher death rate than women because in that culture men smoke more than women.

Could you post your source for the comorbidities? Haven't seen updated numbers on this recently but maybe you've found something I didn't. Thanks.

[Napoleon Dynamite]

I can’t answer the question you are actually asking, but age related illness is obvious. Think immunocompromised, lung disease, heart disease, and liver disease.

My company is projecting an increase in antibiotic sales due to coronavirus outbreaks. Obviously antibiotics won’t treat a virus, so it’s likely any comorbidities associated with hospitalization.

Do you have a line of sight on antibiotics supply chain issues? Media reports state that 97% of antibiotics come from China.

One good thing from COVID-19 (hopefully) that we're going to take a serious look at our supply chain. We are totally at the mercy of China for almost everything we need for daily living, business, etc.

[SB Shock]

Could you post your source for the comorbidities? Haven't seen updated numbers on this recently but maybe you've found something I didn't. Thanks.

I am following sites. They are data driven, not political or rating driven.

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

https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

[wufan]

Do you have a line of sight on antibiotics supply chain issues? Media reports state that 97% of antibiotics come from China.

One good thing from COVID-19 (hopefully) that we're going to take a serious look at our supply chain. We are totally at the mercy of China for almost everything we need for daily living, business, etc.

I’m pretty sure all penicillin is produced in China. Not sure about other antibiotics, but it’s likely that the older ones come from there.

We get the API we use from China and Asia for the antibiotics we manufacture at my facility. The ones we manufacture are sometimes called “gorilla” or “last chance” antibiotics.