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COVID-19 Pandemic: Transmissions, Deaths, Treatments, Vaccines, Interventions and More...

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Many as in the same imbeciles who told us this was nothing to worry about and then fooked up the tests which eventually cost many Americans their lives.

The R0 is more likely between 2.5 to 3.0 so herd immunity would be 60 to 65%.
Not sure what your point is. Earlier you were complaining heads would roll for destroying the economy for a "bad flu season" and now you're complaining we didn't do enough to save lives. From a scientific perspective, I'm not sure what you were expecting, but this is hard shit, trying to figure out what's going on, while it's going on and changing and the data we have generally sucks, because it's a brand new freakin' virus for the entire planet. It's the classic case of building the plane while flying it.

Go back through this thread. There were some saying this was "nothing" to some worrying it was the end of mankind. In my first post on 3/4 in this thread, I said this could easily be 5-10X as deadly as the 35K per year that die in the flu, without interventions, and I mostly haven't wavered too far off that. I also said later that day to watch and learn from South Korea...
 
Not sure what your point is. Earlier you were complaining heads would roll for destroying the economy for a "bad flu season" and now you're complaining we didn't do enough to save lives. From a scientific perspective, I'm not sure what you were expecting, but this is hard shit, trying to figure out what's going on, while it's going on and changing and the data we have generally sucks, because it's a brand new freakin' virus for the entire planet. It's the classic case of building the plane while flying it.

Go back through this thread. There were some saying this was "nothing" to some worrying it was the end of mankind. In my first post on 3/4 in this thread, I said this could easily be 5-10X as deadly as the 35K per year that die in the flu, without interventions, and I mostly haven't wavered too far off that. I also said later that day to watch and learn from South Korea...
I never said this was a bad flu season. I said IF, no BIG IF, it turned out that 10-30% are already infected (numbers you have suggested are possible and I agree BTW) then the IFR would be down near a bad flu season. If that ends up being true then our government failed us at multiple levels. It could have protected us by a much earlier response/preparation including having testing available along with contact tracing etc. Then they could have further not messed things up by shutting down the whole country for something that was closer to the FLU than not... IF what was said above is true.

Instead we could have closed long term care facilities to all visitors and tested LTC workers routinely to avoid exposing residents. Asked independent seniors to SIP along with immunocompromised. We could have granted paid leave (basically unemployment) for those with co-morbidities. Kept businesses open with social distancing, hand washing, masks and gloves. I am sure we can come up with more ideas and details. It is called finding the ultimate solution instead of hunting mosquitoes with bazookas.

Summary (My point)
We could have done nothing and lost a million lives
We could have shutdown everything and await a vaccine to minimize life lost and have a complete economic collapse
We could have tested early and often while implementing some hybrid plan for reduced economic damage while only risking a minor pct of people

Our government downplayed the virus and did not get ready. Then they flubbed around telling people wrong info like no masks, not airborne, etc. Then they shut everything down including people who are in no/low risk categories.

In the time we needed them most our government failed us. The failure was a lot deeper than Orange Man Bad. It includes both sides of the aisle and all levels.
 
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I never said this was a bad flu season. I said IF, no BIG IF, it turned out that 10-30% are already infected (numbers you have suggested are possible and I agree BTW) then the IFR would be down near a bad flu season. If that ends up being true then our government failed us at multiple levels. It could have protected us by a much earlier response/preparation including having testing available along with contact tracing etc. Then they could have further not messed things up by shutting down the whole country for something that was closer to the FLU than not... IF what was said above is true.

Instead we could have closed long term care facilities to all visitors and tested LTC workers routinely to avoid exposing residents. Asked independent seniors to SIP along with immunocompromised. We could have granted paid leave (basically unemployment) for those with co-morbidities. Kept businesses open with social distancing, hand washing, masks and gloves. I am sure we can come up with more ideas and details. It is called finding the ultimate solution instead of hunting mosquitoes with bazookas.

Summary (My point)
We could have done nothing and lost a million lives
We could have shutdown everything and await a vaccine to minimize life lost and have a complete economic collapse
We could have tested early and often while implementing some hybrid plan for reduced economic damage while only risking a minor pct of people

Our government downplayed the virus and did not get ready. Then they flubbed around telling people wrong info like no masks, not airborne, etc. Then they shut everything down including people who are in no/low risk categories.

In the time we needed them most our government failed us. The failure was a lot deeper than Orange Man Bad. It includes both sides of the aisle and all levels.

Ok, nice summary - this makes much more sense, thanks. We're fairly closely aligned on this, then, except maybe for the no/low risk folks - if we didn't shut it all down, they would be asymptomatic carriers infecting others, although early aggressive testing/tracing/quarantining (at facilities not at home) with moderate SD might have worked, but I would have gone very hard on SD until I knew I had control and then backed off in stages, but that's a minor difference in views, I think.

As a pure aside, about 6 weeks ago, I half joked putting all the kids in schools and quarantining them for 4 weeks with very young teachers/chaperones, so they all got the virus and recovered from it with immunity and could no longer infect others. Epidemiologically, removing everyone under 18 from being carriers would have been fantastic as a way to then much more easily control the outbreak (especially along with quarantining nursing homes/retirement communities); ethically, probably a bit questionable...
 

@yessir321 said that there wouldn't be 100 deaths in the US. I offered to bet him $1000 on the spot. He then back-pedaled and said that there wouldn't be 1000 deaths.

One thing this incident has done, effectively, is reveal all of the passengers in the Intellectual Clown Car.
 
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Kind of. If we calculate like the CDC does for influenza, there's deaths divided by symptomatic infections, which is equal to the number of "cases" since there isn't an appreciable number who get infected by the flu but are asymptomatic (or at least nobody cares about them). So the IFR equals the CFR for flu and that is the 0.1% number we hear a lot for flu, where ~35K die in a typical year for every ~35MM symptomatic infections (which are estimated by a model).

For a novel virus like this one, the CFR is the number of deaths divided by the number of confirmed (by the PCR virus test) cases, which has been in the 2-10% range in various countries. But calculating the IFR is far harder. Until now, we've mostly been testing symptomatic people, but we know that from the PCR viral tests on confined ships, over half of those who test positive are asymptomatic and, furthermore, with the new antibody test we're seeing that the number of people actually infected could be 5-20-50X the number who test positive from the viral test. So, the true IFR would be the number of deaths divided by the number of infected (as per the antibody test).

But yes, if the number of NYers infected as measured by antibodies is 15% or 3MM, then the IFR (not CFR) would be 18,300/20MM or 0.6% as of right now. Pretty sure my original guess for an IFR was 0.5-1.0% (although I have way too many #s in my head right now and need to check that) and Fauci published a 2/28 editorial in the NEJoM saying he thought the eventual mortality rate would be "considerably less than 1%."

https://www.nejm.org/doi/full/10.1056/NEJMe2002387?query=recirc_curatedRelated_article
I’ve mentioned this before that everyone focuses on the undercounting if the denominator but not much focus on the numerator. Estimates of 40% undercounting if deaths in the UK.

https://mobile.reuters.com/article/amp/idUSKBN22310D
 
Your first post wasn't clear. You're right that 100 of 1800 positive and symptomatic (and 1700 asymptomatic) out of 2504 total inmates (all tested) is an amazing number.

The 73% infected number is almost the 82% "herd immunity" number epidemiologists have been batting about recently given the R0 transmission rate research recently suggesting R0 is 5.7 and not 2-3 as originally thought. Sucks for the prisoners, but if this number is right (and I worry about it, as the articles I've seen on it suck, like the one below), it's an incredibly important finding that near herd immunity levels can be achieved in a closed, close environment - even the Diamond Princess only reached 19% infected by the virus-PCR test (and the Teddy Roosevelt only reached 13% positive).

I think it also makes it more likely that the whole world will reach that level eventually, unless we continue some level of interventions until we get a vaccine. Will be interesting to see how many die (none so far), but the article also said that 7 of 2400 positives in the system (0.3%) have died so far (but it didn't say everyone was tested), so it's too early to extrapolate that to anything (but a 0.3% infection fatality rate for 73% of the population would be horrendous, with 1MM dead of 330MM - need more data to say that, though).

https://www.npr.org/sections/corona...-an-ohio-prison-test-positive-for-coronavirus
This would mean those 40-70% estimates eventually infected early on during the outbreaks weren't crazy. I mentioned back then most of those kind of figures were usually over a 2-3 year period and that I didn't think they were wild estimates and seemed possible. This makes it sounds like it is very possible especially over that longer time frame of a couple years. A large portion of people seem asymptomatic. Here in the prison, the pregnant women numbers in the two NYC hospitals as well.
 
Your first post wasn't clear. You're right that 100 of 1800 positive and symptomatic (and 1700 asymptomatic) out of 2504 total inmates (all tested) is an amazing number.

The 73% infected number is almost the 82% "herd immunity" number epidemiologists have been batting about recently given the R0 transmission rate research recently suggesting R0 is 5.7 and not 2-3 as originally thought. Sucks for the prisoners, but if this number is right (and I worry about it, as the articles I've seen on it suck, like the one below), it's an incredibly important finding that near herd immunity levels can be achieved in a closed, close environment - even the Diamond Princess only reached 19% infected by the virus-PCR test (and the Teddy Roosevelt only reached 13% positive).

I think it also makes it more likely that the whole world will reach that level eventually, unless we continue some level of interventions until we get a vaccine. Will be interesting to see how many die (none so far), but the article also said that 7 of 2400 positives in the system (0.3%) have died so far (but it didn't say everyone was tested), so it's too early to extrapolate that to anything (but a 0.3% infection fatality rate for 73% of the population would be horrendous, with 1MM dead of 330MM - need more data to say that, though).

https://www.npr.org/sections/corona...-an-ohio-prison-test-positive-for-coronavirus
Did this NPR link show how many in the prison were actually symptomatic or asymptomatic. I read it over a couple times but I didn't notice it. @bac2therac also said only 5% showing symptoms but couldn't find any link mentioning the number of symptomatic or asymptomatic in that prison. Just a generic statement saying many asymptomatic but not an actual number.

EDIT: found another link not about this specific case in that prison but others stating about 40-60% show no symptoms at all. One about a specific area of the prison and also that carrier and a Boston shelter. Good for herd immunity but also more reason to wear masks because many out there potentially spreading it.

From the article:

Some of the findings were likely specific to that prison, where COVID-19 has established a strong foothold already. Roughly 73 percent of the inmates at the facility — more than 1,800 prisoners — had the virus. But the alarming thing is that a large number show no symptoms at all.

In one shared dorm at the prison, all 152 inmates living there tested positive. But 60 — about 40 percent — didn't have any signs of the disease.

Other mass-testing situations have yielded similar results. The U.S. Navy tested all 4,800 crew members of the USS Theodore Roosevelt earlier this month after COVID-19 broke out there. The outbreak was more contained than it is in Ohio's prisons — 600 sailors tested positive. But of those, 60 percent have shown no symptoms.

“It has revealed a new dynamic of this virus," Defense Secretary Mark Esper said on NBC's TODAY show Thursday. "That it can be carried by normal, healthy people who have no idea whatsoever that they are carrying it.”

Mass testing of 397 residents of a Boston shelter for those experiencing homelessness had similar results, with almost all of the 146 residents who tested positive showing no symptoms. Another test at a shelter in Worcester, Massachusetts also saw a similar, very high level of asymptomatic confirmed cases.

https://www.clevescene.com/scene-an...s-underscoring-difficulty-of-reopening-states
 
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I’ve mentioned this before that everyone focuses on the undercounting if the denominator but not much focus on the numerator. Estimates of 40% undercounting if deaths in the UK.

https://mobile.reuters.com/article/amp/idUSKBN22310D
Belgium's very high death rate is partly due to half of the deaths being people in nursing homes that were mostly not confirmed as being COVID-positive, i.e., these are "presumed" deaths due to the virus. They're at ~500 deaths/1MM, the highest in the world, but this number would be about 250/1MM if they counted like everyone else. It's quite possible most are severely undercounting - or that Belgium is overcounting.

While most countries are only counting confirmed deaths in hospitals, Belgium is including all potential deaths in nursing homes — even if Covid-19 has not been confirmed as the cause of death.

Experts argue Belgium’s approach is more transparent, and that other countries are underreporting the total numbers of deaths. But there’s also growing political backlash that Belgium’s count could be just as misleading, but in the opposite direction.

Of Belgium’s registered deaths, 44 percent died in hospital (and were tested). The majority 54 percent died in a nursing home — and only in 7.8 percent of those cases was Covid-19 confirmed as the cause.


https://www.politico.com/news/2020/04/19/why-is-belgiums-death-toll-so-high-195778
 
I've been thinking all along that the widespread use if anti-malaria drugs is the reason. Of course this needs to be studied, but the its a strong piece of anecdotal evidence.
The TB vaccine is another theory out there as well. I’m not sure about either but still think the heat/humidity play a big role. I’ve thought that from the start cause the number of cases and growth have been slower in the Southern Hemisphere, although that might increase now with their colder seasons coming up. India is humid and hot a lot of the year for much of the country. This has been in their neighborhood for longer and they’re not as hygienic overall but they still don’t have close to the number of cases and growth as the west. Even if they’re not testing enough it would show up in the hospitals, you can’t hide that. I think I saw awhile back they have about mid 20K flu cases a year so multiply that by some factor for the year and I think that’s how many they might get and for a population of 1 billion plus that’s not so bad.
 
A big concern is the accuracy of all theses tests, especially the antibody ones. A lot of decisions are going to be made in the near future based on these findings. If the test is only 60-70% accurate and more so if the inaccuracies are mostly false positives, that will make it very difficult to conclude anything from the data.
 
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Did this NPR link show how many in the prison were actually symptomatic or asymptomatic. I read it over a couple times but I didn't notice it. @bac2therac also said only 5% showing symptoms but couldn't find any link mentioning the number of symptomatic or asymptomatic in that prison. Just a generic statement saying many asymptomatic but not an actual number.

EDIT: found another link not about this specific case in that prison but others stating about 40-60% show no symptoms at all. One about a specific area of the prison and also that carrier and a Boston shelter. Good for herd immunity but also more reason to wear masks because many out there potentially spreading it.

From the article:

Some of the findings were likely specific to that prison, where COVID-19 has established a strong foothold already. Roughly 73 percent of the inmates at the facility — more than 1,800 prisoners — had the virus. But the alarming thing is that a large number show no symptoms at all.

In one shared dorm at the prison, all 152 inmates living there tested positive. But 60 — about 40 percent — didn't have any signs of the disease.

Other mass-testing situations have yielded similar results. The U.S. Navy tested all 4,800 crew members of the USS Theodore Roosevelt earlier this month after COVID-19 broke out there. The outbreak was more contained than it is in Ohio's prisons — 600 sailors tested positive. But of those, 60 percent have shown no symptoms.

“It has revealed a new dynamic of this virus," Defense Secretary Mark Esper said on NBC's TODAY show Thursday. "That it can be carried by normal, healthy people who have no idea whatsoever that they are carrying it.”

Mass testing of 397 residents of a Boston shelter for those experiencing homelessness had similar results, with almost all of the 146 residents who tested positive showing no symptoms. Another test at a shelter in Worcester, Massachusetts also saw a similar, very high level of asymptomatic confirmed cases.

https://www.clevescene.com/scene-an...s-underscoring-difficulty-of-reopening-states
Sorry, I just quoted bac's post and didn't verify that 1700 of 1800 positives were asymptomatic. However, the big story, to me is 78% (1928 of 2500 inmates now, updated as per link) of the entire population, which were all tested, are positive. That's close to the herd immunity number of 82% expected to become infected if no interventions and if the R0 is 5,7, as many have been postulating lately. I'll admit I did not think that was likely, given that the Diamond Princess cruise ship and Teddy R carrier only has 19% and 13%, respectively test positive for the virus (and they also tested everyone on board). As I said last night, it will be interesting to see the % of deaths; as of today, 1 guard and 1 inmate have died (about 0.1%), but 34 are hospitalized, so that death number is likely to climb. 0.1% of ~78% of the US population is 275K...

https://www.marionstar.com/story/ne...avirus-prison-outbreak-largest-us/5166499002/
 
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The TB vaccine is another theory out there as well. I’m not sure about either but still think the heat/humidity play a big role. I’ve thought that from the start cause the number of cases and growth have been slower in the Southern Hemisphere, although that might increase now with their colder seasons coming up. India is humid and hot a lot of the year for much of the country. This has been in their neighborhood for longer and they’re not as hygienic overall but they still don’t have close to the number of cases and growth as the west. Even if they’re not testing enough it would show up in the hospitals, you can’t hide that. I think I saw awhile back they have about mid 20K flu cases a year so multiply that by some factor for the year and I think that’s how many they might get and for a population of 1 billion plus that’s not so bad.
I think we need to see if their stats balloon soon or not - if they are truly less likely to get it, it wouldn't be HCQ as Lupus patients haven't shown that elsewhere, but the TB vaccine is a possibility but others are skeptical as per the link. Could be lack of testing and reporting.

Also if warm/humid conditions were the key, SG is having a major outbreak right now and Louisiana has the 4th highest death rate per 1MM in the US (and 5th highest case rate). My guess is there are simply other factors as to why India appears to be so low, but who knows really?

https://www.statnews.com/2020/04/14...icism-as-a-potential-weapon-against-covid-19/
 
I think we need to see if their stats balloon soon or not - if they are truly less likely to get it, it wouldn't be HCQ as Lupus patients haven't shown that elsewhere, but the TB vaccine is a possibility but others are skeptical as per the link. Could be lack of testing and reporting.

Also if warm/humid conditions were the key, SG is having a major outbreak right now and Louisiana has the 4th highest death rate per 1MM in the US (and 5th highest case rate). My guess is there are simply other factors as to why India appears to be so low, but who knows really?

https://www.statnews.com/2020/04/14...icism-as-a-potential-weapon-against-covid-19/
I think India should have ballooned already considering it’s been in their neck of the world longer than ours.

Is SG Singapore? If so that is happening among their migrant workers in the dorms. So enclosed areas and probably air conditioned and they overlooked testing that population too. I have some acquaintances who live there so while it may be a tropical climate not sure how much time people spend out doors vs their air conditioned buildings and malls etc...so that might contribute to the transmission rates.

Louisiana had their big outbreak cause of Mardi Gras right and I’m not sure how warm humid it was at that time either. If not for that it might not be as bad there.

IMO it’s not that hot humid means everything goes to zero just that transmissibility goes down. Just exactly how much I don’t know but it also depends how people live. If it’s hot humid but everyone is still largely staying indoors with AC that will probably have some effect too that would blunt the effects of heat humidity.

So I do think it’s a combo of things but I feel heat humidity definitely play a decent size role.
 
Interesting letter to the Times from an ER doc and respiratory expert on how important it is for COVID patients to check their blood oxygen levels, since these often drop precipitously well before major breathing symptoms present (something that is almost never seen outside of COVID) and many doctors think treating this "silent hypoxia" early is helpful to avoiding patients going on ventilators, after which most die. Since many infected patients are self-monitoring at home, they all ought to have those little pulse-oximeters for their fingers, which quickly and accurately measure blood oxygen levels.

https://www.nytimes.com/2020/04/20/...M2_aWiOQax2blFi0Kqkq4gpDRy1mGvRpNhZWCXQG4OAnw
 
Interesting letter to the Times from an ER doc and respiratory expert on how important it is for COVID patients to check their blood oxygen levels, since these often drop precipitously well before major breathing symptoms present (something that is almost never seen outside of COVID) and many doctors think treating this "silent hypoxia" early is helpful to avoiding patients going on ventilators, after which most die. Since many infected patients are self-monitoring at home, they all ought to have those little pulse-oximeters for their fingers, which quickly and accurately measure blood oxygen levels.

https://www.nytimes.com/2020/04/20/...M2_aWiOQax2blFi0Kqkq4gpDRy1mGvRpNhZWCXQG4OAnw

Hypoxia is rarely, if ever, completely asymptomatic. If your O2 sats are low, there will be signs. I'm a little skeptical about the notion of hypoxia that is so utterly benign as to only be detectable by measurement.
 
New York yesterday- fewest daily new cases since 3/25 and The 4k cases came on 16k tests, for a ~25% postive test rate- very encouraging.
 
Interesting letter to the Times from an ER doc and respiratory expert on how important it is for COVID patients to check their blood oxygen levels, since these often drop precipitously well before major breathing symptoms present (something that is almost never seen outside of COVID) and many doctors think treating this "silent hypoxia" early is helpful to avoiding patients going on ventilators, after which most die. Since many infected patients are self-monitoring at home, they all ought to have those little pulse-oximeters for their fingers, which quickly and accurately measure blood oxygen levels.

https://www.nytimes.com/2020/04/20/...M2_aWiOQax2blFi0Kqkq4gpDRy1mGvRpNhZWCXQG4OAnw
Have used one of those in the past for a different elderly relative who has since passed. Very useful gadgets and not too expensive....30-50 bucks. Bought some more for some other relatives when this stuff started happening. Somewhat hard to come by for a time but I think that's improved now.
 
Have used one of those in the past for a different elderly relative who has since passed. Very useful gadgets and not too expensive....30-50 bucks. Bought some more for some other relatives when this stuff started happening. Somewhat hard to come by for a time but I think that's improved now.

I saw the guest column (not a letter)in the Times on-line last night, and promptly got one. Supplies are short, but Amazon still had some at reasonable prices. I wonder if that's still true now that more people have seen the article.
 
Probably the best analysis of the situation I've read, medically, epidemiologically, and socially by Tomas Pueyo. Scary as shit, but with serious data analysis (and great graphics for visualization) behind it.

Link not working. Go to medium.com/topic/coronavirus, then click on "Coronavirus, Why We Must Act Now" for the article/data.

He basically says we're in the exponential growth phase and are about to be hammered with actual cases, since the true numbers of people walking around with the coronavirus right now are 10-30X what we've measured so far (a bit over 2000) and the only way to stem the tide once a country has reached this kind of growth rate (especially without testing insight) is lockdown.

And while he's not a medical professional/epidemiologist, he's got an MBA from Stanford and two MS's in eng'g from top European schools and is one of the best data visualization experts out there and numerous other epidemiologists are sending the same message - it's just that he's doing it in a more convincing, data-rich, easy to understand way (see the Times link below for a similar article). So while there are a few weak points in the scientific discussion (he doesn't discuss age and probably overstates some of his mortality rates), the parts about exponential growth and the need for containment (testing. tracking contacts, quarantining infected people, etc.) and mitigation/social distancing are spot on if we want to prevent a bunch of Wuhans/Italys.

https://www.nytimes.com/2020/03/13/science/coronavirus-math-mitigation-distancing.html

We're making strides but we're not in true lockdown yet. In a week, when we have 10,000 cases and hundreds dead, we'll end up in lockdown, but unfortunately it will likely be a lockdown with an overwhelmed health care system, making the mortality rates much higher than they need to be. So why not do it now if you haven't already (and are able to do so) to try to "flatten the curve" so we at least don't overwhelm our medical facilities and health care system?

Below is his intro and in the link are all the graphics and explanations. Hard to read it without saying, damn this guy really knows his science and his data. A few bulleted highlights from the detailed sections:
  • Wuhan went exponential and out of control with over a thousand "actual" (but unknown cases when they had only confirmed about 100. We've all heard how bad it got there with their lockdown
  • The rest of China learned from Wuhan and every other outbreak was contained with lockdowns that were effective before the exponential growth phase was reached and the lockdown, high testing rate, and largely unaffected medical system made for a much lower mortality rate.
  • Hong Kong, Taiwan, Singapore, Japan also never hit the exponential growth phase, as all of them were hit by SARS in 2003, and all of them learned from it. They learned how viral and lethal it could be, so they knew to take it seriously. That’s why all of their graphs, despite starting to grow much earlier, still don’t look like exponentials.
  • South Korea is an outlier in many respects. The outbreak was under control until Patient 31, who was a super-spreader who passed it to thousands of other people in Daegu. Because the virus spreads before people show symptoms, by the time the authorities realized the issue, the virus was out there. They’re now paying the consequences of that one instance, but their testing and containment efforts have paid off, as Italy and Iran have caught up to and well surpassed SK, which is now showing a significant decline in new cases.
  • Washington State is the US’s Wuhan. The number of cases there is growing exponentially and the virus had been spreading undetected for weeks. If only the CDC had allowed Dr. Chu to test those reserve flu samples in early Feb, instead of Feb 25th, when she found the virus had been spreading for weeks, undetected (when she ran the tests and shared them with the public without permission)
  • With the number of cases we see today in countries like the US, Spain, France, Iran, Germany, Japan, Netherlands, Denmark, Sweden or Switzerland, Wuhan was already in lockdown.
  • There are several stages to control an epidemic, starting with anticipation and ending with eradication. But it’s too late for most options today. With this level of cases, the two only options politicians have in front of them are containment and mitigation.
  • Containment is sure all the cases are identified, controlled, and isolated. It’s what Singapore, Hong Kong, Japan or Taiwan are doing so well: They very quickly limit people coming in, identify the sick, immediately isolate them, use heavy protective gear to protect their health workers, track all their contacts, quarantine them… This works extremely well when you’re prepared and you do it early on, and don’t need to grind your economy to a halt to make it happen.
  • Researchers estimate that the Wuhan travel ban only delayed the spread in China by 3-5 days.
  • Mitigation requires heavy social distancing. People need to stop hanging out to drop the transmission rate (R), from the R=~2–3 that the virus follows without measures, to below 1, so that it eventually dies out. These measures require closing companies, shops, mass transit, schools, enforcing lockdowns… The worse your situation, the worse the social distancing. The earlier you impose heavy measures, the less time you need to keep them, the easier it is to identify brewing cases, and the fewer people get infected. This is what Wuhan had to do. This is what Italy was forced to accept. Because when the virus is rampant, the only measure is to lock down all the infected areas to stop spreading it at once. With thousands of official cases — and tens of thousands of true ones — this is what countries like Iran, France, Spain, Germany, Switzerland or the US need to do. But they’re not doing it.
Coronavirus: Why You Must Act Now
Politicians, Community Leaders and Business Leaders: What Should You Do and When?

Tomas Pueyo


Updated on 3/13/2020. Now reflects an update on containment vs. mitigation strategies. 17 translations at the bottom. Send me more existing translations in private notes at the bottom. This article has received 21million views in the last 48h.

With everything that’s happening about the Coronavirus, it might be very hard to make a decision of what to do today. Should you wait for more information? Do something today? What?

Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:

  • How many cases of coronavirus will there be in your area?
  • What will happen when these cases materialize?
  • What should you do?
  • When?
When you’re done reading the article, this is what you’ll take away:

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

As a politician, community leader or business leader, you have the power and the responsibility to prevent this.

You might have fears today: What if I overreact? Will people laugh at me? Will they be angry at me? Will I look stupid? Won’t it be better to wait for others to take steps first? Will I hurt the economy too much?

But in 2–4 weeks, when the entire world is in lockdown, when the few precious days of social distancing you will have enabled will have saved lives, people won’t criticize you anymore: They will thank you for making the right decision.

Ok, let’s do this.

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This is probably the one time in the last decade that sharing an article might save lives. They need to understand this to avert a catastrophe. The moment to act is now.


Below are a few graphics from the link, showing how big of a difference even one day's worth of social distancing can make down the road in daily new cases and eventual cumulative total cases. The article has a ton of other graphics illustrating what happened in many countries and what is expected to happen in selected countries, based on epidemiological models, incorporating what actually happened in countries that handled things similarly.

1*XcXT9eNuHRQMOUEf_gAB9A.png


1*4kOJv8hmd5VFPcBL1mywsw.png

More than a few thought Pueyo's Medium post from 3/14 was way too gloomy. I doubt they think that now. Anyway, he just posted a new, long article on what we can learn from other countries around the world both good (South Korea, Taiwan) and bad (most of Europe and the US) and in-between (Singapore, which started out great, but now has a fast growing outbreak), especially with respect to how best to "go back to normal" where normal isn't the pre-virus normal.

Many of the same people who didn't like social distancing are not going to like major elements of what the most successful countries are doing: very aggressive testing of anyone who came in contact with a new positive result, fairly invasive contact tracing (using phones/tracking) and quarantining and continued modest social distancing and wearing of masks. Don't have time to dive deeply into it, as it's a long read with lots of data/graphics, but it's definitely worth a read.

And while Pueyo is not a medical professional/epidemiologist, he's got an MBA from Stanford and two MS's in eng'g from top European schools and is one of the best data visualization experts out there and numerous other epidemiologists are sending the same message - it's just that he's doing it in a more convincing, data-rich, easy to understand way.

Still having issues linking to Medium posts. Try Googling Medium and TomasPueyo - the article is "Learning to Dance"


 
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I've been following some doctors on twitter and they've been discussing the "asymptomatic" hypoxia observation and implications quite extensively. These patients may not be truly asymptomatic but their symptoms may develop so gradually they don't really notice. They may breathe faster but not reaize it. One of the possible reasons for this (low ox in the 80s or lower with no or minimal symptoms) was briefly mentioned in the article - some think that the damage in the lungs allows much of the co2 in the blood to escape while at the same time not permitting o2 in. I believe the claim was that co2 diffuses out of the blood more readily than o2 diffuses in, though I don't have the medical background to be able to assess the truth of that. The end result would be low o2 but also relatively normal co2 in the blood and it may be the rising co2 that triggers most symptoms.

I did pick up one of those pulse ox meters back in February. They are available on amazon though prices look a bit higher than they were.
 
Interesting letter to the Times from an ER doc and respiratory expert on how important it is for COVID patients to check their blood oxygen levels, since these often drop precipitously well before major breathing symptoms present (something that is almost never seen outside of COVID) and many doctors think treating this "silent hypoxia" early is helpful to avoiding patients going on ventilators, after which most die. Since many infected patients are self-monitoring at home, they all ought to have those little pulse-oximeters for their fingers, which quickly and accurately measure blood oxygen levels.

https://www.nytimes.com/2020/04/20/...M2_aWiOQax2blFi0Kqkq4gpDRy1mGvRpNhZWCXQG4OAnw

A pulse oximeter was instrumental in getting my positive, Covid coworker to the hospital. Oxygen saturations were dropping, his wife is a RN and diagnosed increasing fluid in his lungs with a stethoscope. The final straw was when the O2 sats dropped to 85-86%. He was diagnosed as positive for close to a week and this was the start of his cytokine release syndrome which progressed to storm. As we have discussed, I feel this is THE critical phase (and ideally, as it is in the early stages, not as the patient worsens clinically) to identify if the antivirals, HCQ and/or IL-6 inhibitors stand a chance in helping. That's why the serial markers we discussed the past few days might play a big role in treatment and warding off the storm.

Hypoxia is rarely, if ever, completely asymptomatic. If your O2 sats are low, there will be signs. I'm a little skeptical about the notion of hypoxia that is so utterly benign as to only be detectable by measurement.

You are correct and to add from above, my coworker was getting tachypniec (rapid breathing for those not in the medical field). Some of these patients don't present with extreme tachypnea even though their saturations are dropping BELOW 60% which is very odd. These patients who are not as symptomatic are being treated with aggressive high flow oxygen. Those that are symptomatic are being intubated. This was part of our talk here a couple weeks ago where physicians were altering their oxygen supplementation based on the presentation of the patients and not going by pure oxygen saturation levels and/or partial pressures of oxygen in arterial blood samples. They believed early and unnecessary intubation would cause more harm if the patient could be treated effectively with alternative, less invasive methods.
 
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I think we need to see if their stats balloon soon or not - if they are truly less likely to get it, it wouldn't be HCQ as Lupus patients haven't shown that elsewhere, but the TB vaccine is a possibility but others are skeptical as per the link. Could be lack of testing and reporting.

Also if warm/humid conditions were the key, SG is having a major outbreak right now and Louisiana has the 4th highest death rate per 1MM in the US (and 5th highest case rate). My guess is there are simply other factors as to why India appears to be so low, but who knows really?

https://www.statnews.com/2020/04/14...icism-as-a-potential-weapon-against-covid-19/
I'm not discounting HCQ as a prophylactic treatment based on examples of Lupus patients who got CV19 (which I believe is just anecdotal reporting).
Lupus patients have compromised immune systems by definition. HCQ could be an effective prophylactic treatment for CV-19 in healthy people and not be as effective in those who have compromised immune systems.
 
A pulse oximeter was instrumental in getting my positive, Covid coworker to the hospital. Oxygen saturations were dropping, his wife is a RN and diagnosed increasing fluid in his lungs with a stethoscope. The final straw was when the O2 sats dropped to 85-86%. He was diagnosed as positive for close to a week and this was the start of his cytokine release syndrome which progressed to storm. As we have discussed, I feel this is THE critical phase (and ideally, as it is in the early stages, not as the patient worsens clinically) to identify if the antivirals, HCQ and/or IL-6 inhibitors stand a chance in helping. That's why the serial markers we discussed the past few days might play a big role in treatment and warding off the storm.



You are correct and to add from above, my coworker was getting tachypniec (rapid breathing for those not in the medical field). Some of these patients don't present with extreme tachypnea even though their saturations are dropping BELOW 60% which is very odd. These patients who are not as symptomatic are being treated with aggressive high flow oxygen. Those that are symptomatic are being intubated. This was part of our talk here a couple weeks ago where physicians were altering their oxygen supplementation based on the presentation of the patients and not going by pure oxygen saturation levels and/or partial pressures of oxygen in arterial blood samples. They believed early and unnecessary intubation would cause more harm if the patient could be treated effectively with alternative, less invasive methods.
What are the co2 levels like in these patients? Are they normal despite the low o2 sat? Does the co2 level rise later coincident with rapidly worsening symptoms/need for intubation?
 
What are the co2 levels like in these patients? Are they normal despite the low o2 sat? Does the co2 level rise later coincident with rapidly worsening symptoms/need for intubation?

As patients are getting intubated, their CO2 levels are very high typically. Once vented, it usually comes back down. There is terrible gas exchange as the lungs (alveoli) are getting trashed once the cytokine storm begins.
 
Hypoxia is rarely, if ever, completely asymptomatic. If your O2 sats are low, there will be signs. I'm a little skeptical about the notion of hypoxia that is so utterly benign as to only be detectable by measurement.

I didn't say aymptomatic - said without major breathing symptoms one would normally expect with serious hypoxia. At least that's what this doc said and another doctor friend just said he's seen the same. Some are now starting to think they should try altitude sickness drugs - no idea if that would work.
 
Another study showing no benefits from HCQ with or without azithromycin; yes, it was retrospective and not a controlled study, but it is a fairly comprehensive US study from VA hospitals and the evidence is mounting that this is not particularly beneficial. I imagine there are cases/times where it can help, but perhaps we can stop with the nonsense that this is, in any way, shape or form, a "cure."

CONCLUSIONS: In this study, we found no evidence that use of hydroxychloroquine, either with or without azithromycin, reduced the risk of mechanical ventilation in patients hospitalized with Covid-19. An association of increased overall mortality was identified in patients treated with hydroxychloroquine alone. These findings highlight the importance of awaiting the results of ongoing prospective, randomized, controlled studies before widespread adoption of these drugs.

https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v1
 
Interesting letter to the Times from an ER doc and respiratory expert on how important it is for COVID patients to check their blood oxygen levels, since these often drop precipitously well before major breathing symptoms present (something that is almost never seen outside of COVID) and many doctors think treating this "silent hypoxia" early is helpful to avoiding patients going on ventilators, after which most die. Since many infected patients are self-monitoring at home, they all ought to have those little pulse-oximeters for their fingers, which quickly and accurately measure blood oxygen levels.

https://www.nytimes.com/2020/04/20/...M2_aWiOQax2blFi0Kqkq4gpDRy1mGvRpNhZWCXQG4OAnw

One of the most important information you will find here. IMHO, everyone should get an oxygen meter like yesterday. If you don't have one, I highly suggest you go buy one TODAY. This is the one gadget that could save your life during this pandemic.

Covid symptoms can be very similar to other abnormalities such as anxiety, heart burn or pre-heart attack. Chest pressure, cold sweats, difficulty breathing, etc. But one way you can differentiate is the oxygen level. Normal healthy person should be north of 95%. Low 90s and something is up. Below 90, you need to go to the ER. JMHO, but speaking from experience.
 
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I didn't say aymptomatic - said without major breathing symptoms one would normally expect with serious hypoxia. At least that's what this doc said and another doctor friend just said he's seen the same. Some are now starting to think they should try altitude sickness drugs - no idea if that would work.

I would expect to see, at the very least, some level of tachypnea in a hypoxic patient, as @LETSGORU91 posted above. In the field I would even do a fingernail cap refill test - even though the guidelines say it's only recommended for peds patients, in my experience it's still reasonably effective in adults as well. Early hypoxic patients are also frequently restless or agitated.
 
As patients are getting intubated, their CO2 levels are very high typically. Once vented, it usually comes back down. There is terrible gas exchange as the lungs (alveoli) are getting trashed once the cytokine storm begins.
Got it, but not really what I was asking.

I'm seeing many doctors reporting things like "I had to wait for my patient to get off his cell phone before intubating" or "I've never had a patient with o2 sats that low (50s, 70s, 80s) who could talk to me in complete sentences." So obviously something is very different about covid patients compared to other patients who present with low oxygen levels and/or needing intubation. So, what is it that is different?

The one hypothesis I was referring to was the idea that since co2 diiffuses out of the blood more easily than o2 diffuses in, something was going on at the alveolar level that was impeding o2 entry but not impeding co2 from going out - so patients would have low o2 but relatively normal co2. Is that what is being seen in the patients with low o2 who are still talking and relatively asymptomatic? Are there other blood chemistry irregularities that could explain or at least are consistent with the observations?

Can you even have low o2 with low/normal co2 and how would that present? Is it the lack of o2 or the excess of co2 that would be the primary driver of symptoms such as rapid breathing/high heart rate/headache/exhaustion etc?
 
Got it, but not really what I was asking.

I'm seeing many doctors reporting things like "I had to wait for my patient to get off his cell phone before intubating" or "I've never had a patient with o2 sats that low (50s, 70s, 80s) who could talk to me in complete sentences." So obviously something is very different about covid patients compared to other patients who present with low oxygen levels and/or needing intubation. So, what is it that is different?

The one hypothesis I was referring to was the idea that since co2 diiffuses out of the blood more easily than o2 diffuses in, something was going on at the alveolar level that was impeding o2 entry but not impeding co2 from going out - so patients would have low o2 but relatively normal co2. Is that what is being seen in the patients with low o2 who are still talking and relatively asymptomatic? Are there other blood chemistry irregularities that could explain or at least are consistent with the observations?

Can you even have low o2 with low/normal co2 and how would that present? Is it the lack of o2 or the excess of co2 that would be the primary driver of symptoms such as rapid breathing/high heart rate/headache/exhaustion etc?

It's an interesting theory, but any significant imbalance between O2 in and CO2 out would have to be very temporary, just based on molecular math.
 
It's an interesting theory, but any significant imbalance between O2 in and CO2 out would have to be very temporary, just based on molecular math.
So how does one explain patients with such low o2 values being able to converse in complete sentences? These doctors are all saying they've never seen anything like that before. There has to be an explanation.
 
So how does one explain patients with such low o2 values being able to converse in complete sentences? These doctors are all saying they've never seen anything like that before. There has to be an explanation.

Honestly? I think it's less about some sort of phenomena and more about sample bias. Doctors are seeing a lot more patients moving from mild to moderate to severe hypoxemia than they normally would - and many more in a unit setting. So they're noticing things at a higher rate of occurrence than normal.

Bear in mind that absent this disease, you most often see patients presenting with severe hypoxemia (basically <75% O2 sat) in an emergent setting - and, my gut tells me, most often prior to arrival at the ED.

I did a quick poll of my EMS chat group and it turns out that everyone has seen patients with shockingly low O2 sats who are AOx3.

It also bears considering that your basic pulse oximeter is what you might call a guideline instrument, and isn't guaranteed to tell you exactly what the patient's dissolved oxygen level is.
 
New stay at home test kits. Not sure how many people would be able to swab their own nasal passage if it has to go up as far as they have been doing currently. Will it be accurate if you don’t. If the saliva test could be done as a stay at home test that would be good.

https://www.cnn.com/2020/04/21/health/home-covid-19-test-approved/index.html

I can't see people sticking a swab into their own nasal passage deep enough, which will lead to a ton of false negatives. Also, if you have to send this to a lab, you are probably looking at several days (even with express shipping) before you see results. I'm not sure how beneficial this will be.
 
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