The lockdowns commence. Mass hysteria grips the US

America is going the way of Wuhan very rapidly. Consider:

Lamont issues executive order banning gatherings of more than 250

[Connecticut] Gov. Ned Lamont is using emergency powers to prohibit gatherings of more than 250 people to try to check the spread of coronavirus infection, excluding religious services. […]

The executive order prohibits gatherings of more than 250 people for social and recreational events. The prohibition remains in effect until midnight April 30, unless modified by a subsequent executive order.

The current order covers community, civic, leisure, or sporting events, parades, concerts, festivals, movie screenings, plays, performances, and conventions. It does not apply to any spiritual gathering or worship service. […]

The order also states that violation of the prohibition on large gatherings is a felony offense. The crime carries a maximum prison sentence of five years and a maximum fine of $5,000.

New York Gov. Cuomo bans gatherings of 500 or more amid coronavirus outbreak

New York Gov. Andrew Cuomo on Thursday announced a ban on gatherings of 500 or more people across the state “for the foreseeable future” as public officials try to contain the fast-moving coronavirus outbreak that’s spread across 44 U.S. states and infected at least 127,800 people across the world.

How quickly the freedom to socialize in large groups gets thrown out the window over a respiratory virus that has so far killed [checks notes] two people in New York State and zero people in Connecticut. Does this order cover political protests, i.e. freedom of assembly?

That was Thursday. On Saturday, Hoboken, New Jersey became the first city in America to implement a mass curfew:

Hours after announcing that gyms, health clubs, day cares and movie theaters would join the list of closures in Hoboken, Mayor Ravi S. Bhalla announced the forthcoming curfew and additional restrictions.

The citywide curfew that begins Monday will be in effect from 10 p.m. to 5 a.m. and requires all residents to remain in their homes, barring emergencies. People who are required to report to work are exempted, the statement released late Saturday said.

What public health purpose is served by banning people from going outside between the hours of 10pm and 5am? Especially when bars, move theaters, etc. have already been ordered closed and restaurants have been ordered to stop serving food on the premises? I don’t know, but I do know that people in a state of terror are easier to manipulate and control.

The newspaper of record has a front-page story today with the headline “The Coronavirus Swamps Local Health Departments, Already Crippled by Cuts.” Imagine my surprise to learn that the headline refers to something other than an uncontrollable wave of sick bodies:

CHICAGO — A widespread failure in the United States to invest in public health has left local and state health departments struggling to respond to the coronavirus outbreak and ill-prepared to face the swelling crisis ahead.

Many health departments are suffering from budget and staffing cuts that date to the Great Recession and have never been fully restored. Public health departments across the country manage a vast but often invisible portfolio of duties, including educating the public about smoking cessation; fighting opioid addictions; convincing the reluctant to vaccinate their babies; and inspecting restaurants and tattoo parlors.

Now, these bare-bones staffs of medical and administrative workers are trying to answer a sudden rush of demands — taking phone calls from frightened residents, quarantining people who may be infected, and tracing the known contacts and whereabouts of the ill — that accompany a public health crisis few have seen before. […]

With the virus now consuming all attention, key functions have been put on hold. Some health departments are now making reductions in home health care and education on unwanted teenage pregnancy and other core issues. In Wayne County, Ohio, the health department called off upcoming seminars to vaccinate people in Amish communities, where parents are often reluctant to immunize their children.

I’m not pointing out the glaring discrepancy between headline and news content in order to minimize the problem that our hospitals are probably ill-equipped, maybe severely so, for a major outbreak – an issue I’ve addressed here.

I would, however, like to call attention to the way the media is fanning the flames of mass hysteria over a novel virus that is still not well understand and has still, despite the chain reaction of extreme global dislocations it has triggered, killed fewer than 6,500 people worldwide since its first documented case in either November or December 2019. And yes, I understand exponential growth, but the data is so vague at this point that it’s safe to assume that any “projection” (of death tolls, etc.) is total conjecture. Complacency is not the answer, but neither is fear.

American Hospital Association webinar guesstimates 480,000 deaths

A leaked slide from a presentation given to the American Hospital Association on Feb. 27 estimates that coronavirus could result in 96 million cases, 4.8 million hospitalizations and 480,000 deaths in the US:

The American Hospital Association, which represents thousands of hospitals and health systems, hosted a webinar in February with its member hospitals and health systems. Business Insider obtained a copy of the slides presented.

The presentation, titled “What healthcare leaders need to know: Preparing for the COVID-19” happened February 26, with representatives from the National Ebola Training and Education Center.

As part of the presentation to hospitals, Dr. James Lawler, a professor at the University of Nebraska Medical Center gave his “best guess” estimates of how much the virus might spread in the US.

Here’s the slide:

Note the last point – “Prepare for disease burden roughly 10x severe flu season.” This is the part the “just the flu, bro” idiots are missing. Even with a “low” fatality rate of 0.5% and “only” 5% of cases requiring hospitalization, a surge of coronavirus cases will overwhelm the US hospital system. Flu doesn’t do this.

And this is why, despite my growing skepticism that coronavirus is the global existential threat many fear it is, I am extremely concerned that the US is not properly equipped and prepared to manage the inevitable outbreaks here and is not doing enough to slow the spread of this highly contagious virus.

As usual, John Robb was ahead of the curve on this. See my Feb. 29 summary of his analysis:

The big problem is that there is very little slack in our health care system, as John Robb details in his latest Global Guerrillas Report. He points out that the US had about 1.5 million hospital beds in 1975, whereas now it has about 0.9 million despite the population being 50% higher. Run the numbers – it would only take a surge of as little as 100,000 patients to overwhelm the system.

The flu results in between 140,000 and 960,000 hospitalizations each year (source).

Related: An engineer on why coronavirus will break the US healthcare system.

Exponential growth

I think most people have heard (in one form or another) the old story in which the inventor of chess asks his king to reward him with a quantity of rice, according to the following rule: a single grain of rice is to be placed on the first chess square, doubled on each successive square. The bemused king readily agrees, only to find that he needs to place more than a million grains of rice on the 20th square and more than 18 quintillion (18,000,000,000,000,000,000) grains of rice on the 64th square. D’oh!

And yet, despite the popularity of this fable, it appears that most people really do not understand the awesome power of exponential growth. For example, does the average American grasp the implications of this chart?

The caseload represented by the blue line looks tiny, right? Comment by LZ (Investing in Chinese Stocks):

I’ve been posting the covid-19 case count with two x-axis to show the growth rate more clearly, but for today I put them both on one axis. It shows the rest of the world has a similar number of cases and a similar slope pre-quarantine China.

Even after China initiated a full lockdown on Wuhan, followed by strict nationwide travel restrictions and work closures, it still experienced exponential growth because of cases already in the system. Given the U.S. response to this point, I think it is almost inevitable U.S. cases will soar past China’s.

Note that the full lockdown on Wuhan was implemented January 23.

Here is the same chart with a secondary vertical axis:

In the absence of the kind of brutal containment measures that China has imposed, how widely will coronavirus spread in the US? I’m not sure; I’ve been trying to get a clearer picture of that, but my understanding is that it will likely spread very widely indeed. Harvard epidemiologist Marc Lipsitch predicts, with certain caveats, that the number of infections could reach 40 to 70% of adults worldwide:

Why do I think 40-70% infected? Simple math models with oversimple assumptions would predict far more than that given the R0 estimates in the 2-3 range (80-90%). Making more realistic assumptions about mixing, perhaps a little help from seasonality, brings the numbers down. Pandemic flu in 1968 was estimated to _symptomatically_ infect 40% of the population, and in 1918 30%. Those likely had R0 less than COVID-19.

The next important question is, what is the fatality rate? As far as I can tell, scientists have only a very rough grasp of what that might be, mostly because we have no idea how many people are walking around with undiagnosed infections. One Chinese study published in the Journal of the American Medical Association finds a case fatality rate (CFR) of 2.3%.

Let’s take the lower end of Professor Lipsitch’s estimate and assume that 40% of American adults (209 million x 0.40 = 83.6 million) get infected. With a 2.3% fatality rate, that equates to 1.9 million deaths.

But the fatality rate could be far lower in the US than in China for any number of reasons: perhaps our health care system is better equipped to handle an outbreak, or the far lower incidence of smoking and better air quality in the US mean that patients are less likely to have the kind of underlying respiratory conditions that increase morbidity.

Assuming a lower CFR of 1%, we are talking about 836,000 deaths, or roughly the population of San Francisco.

The incompetence of the CDC

CDC headquarters campusPerhaps there is another explanation for the fact that while South Korea (population: 52 million) has somehow managed to test more than 121,000 people for coronavirus, the US (population: 333 million) had tested only 472 people as March 1 – before deciding to stop disclosing the number of tests.

Perhaps there is an explanation aside from the usual bureaucratic incompetence and/or corruption. If so, I’d like to hear it.

For the record, what I wrote last Monday (Feb 24) is now becoming the conventional wisdom:

It’s easy to mock China, but the US is comically inept. We sat on our hands for a month while China locked down hundreds of millions of people to prevent the spread of a mysterious virus. What is our plan when the pandemic starts claiming victims here? There are probably thousands of undetected cases in major cities already. I hope I’m wrong, but the US will have no one to blame but itself if this thing explodes in our faces.

Then there’s this dumbassery:

San Antonio officials say a patient who was mistakenly released from the Texas Center for Infectious Disease facility spent two hours at a mall after she was let go.

Mayor Ron Nirenberg gave a brief statement on Monday in regard to the incident. During the press conference, he said the patient went to the mall around 5:30 p.m. to 7:30 p.m. and spent most of that time sitting at the food court by herself. Officials add she also went to a local hotel.

At least three people came into contact with her at the hotel, and even with that, the risk factor is low.

On Sunday, when the news broke, Nirenberg said that the patient was released from isolation at a local healthcare facility Saturday because she met the criteria for release, including two negative test results.

However, the patient later returned to isolation after a pending, subsequent lab test came up positive for the virus that causes COVID-19.

“The fact that the CDC allowed the public to be exposed to a patient with a positive COVID-19 reading is unacceptable,” Nirenberg said.

The CDC says they are retesting the individual.

The US has not been taking this situation seriously enough. We will pay the price.

Man in 40s in critical condition

Washington State records another coronavirus case. Curious to know what, if any, preexisting conditions he has, because “in his 40s” is a bit young:

The Snohomish Health District was notified late Sunday afternoon of a new case of COVID-19. The presumptive positive test result came back from the State Public Health Laboratory, bringing the total number of cases in Snohomish County to three. This number is expected to rise as more people are tested and results confirmed.

The new case is a male in his 40s, hospitalized at EvergreenHealth in Kirkland. The man is in critical condition.

The Health District is leading the effort to as quickly as possible identify close contacts of the new confirmed case. At this time, it appears to be another case of community transmission.

And…. New York State announces its first case. Cuomo speaks:

“This evening we learned of the first positive case of novel coronavirus — or COVID-19 — in New York State. The patient, a woman in her late thirties, contracted the virus while traveling abroad in Iran, and is currently isolated in her home. The patient has respiratory symptoms, but is not in serious condition and has been in a controlled situation since arriving to New York.

“The positive test was confirmed by New York’s Wadsworth Lab in Albany, underscoring the importance of the ability for our state to ensure efficient and rapid turnaround, and is exactly why I advocated for the approval from Vice President Pence that New York was granted just yesterday.

“There is no cause for surprise — this was expected. As I said from the beginning, it was a matter of when, not if there would be a positive case of novel coronavirus in New York.

“Last week I called for the Legislature to pass a $40 million emergency management authorization to confront this evolving situation — I look forward to its swift passage.

“There is no reason for undue anxiety — the general risk remains low in New York. We are diligently managing this situation and will continue to provide information as it becomes available.”


As Wuhan goes, so goes the US?

I hope not, but I think the jury is still out on whether the US can successfully deal with what looks like an emerging pandemic:

What we’re seeing in South Korea, Iran and Italy is what exponential disease propagation looks like in the real world. Real world data is spiky. Real world data is messy. Real world exponential growth looks like nothing, nothing, nothing … then cluster, cluster, cluster … then BOOM! My rule of thumb: when a country reports a death from a local COVID-19 infection, then the disease is already endemic in that country. Implementing extreme quarantine measures after that first death – either within that country or by other governments to isolate that country – is closing the barn door after the horse is out … it’s too late. Doesn’t mean you shouldn’t do it for disease minimization or social distancing. But it does mean that a goal of containment is unrealistic.

What we’re seeing today in South Korea, Iran and Italy is the BOOM. Other countries will follow. The United States will follow.

And so now we must fight.

As individuals that means social distancing. As individuals that means doing what we can to stay healthy and prepare for a storm. As a nation that means a war-footing to build dedicated treatment wards before they’re required, to protect healthcare professionals before they get sick, to update our testing and diagnostic capabilities before they are swamped … to do everything possible to bolster our healthcare systems BEFORE the need overwhelms the capacity. […]

A city falls when its healthcare system is overwhelmed. A city falls when its national government fails to prepare and support its doctors and nurses. A city falls when its government is more concerned with maintaining some bullshit narrative of “Yay, Calm and Competent Control!” than in doing what is politically embarrassing but socially necessary.

That’s EXACTLY what happened in Wuhan. More than 30% of doctors and nurses in Wuhan themselves fell victim to COVID-19, so that the healthcare system stopped being a source of healing, but became a source of infection. At which point the Chinese government effectively abandoned the city, shut it off from the rest of the country, placed more than 9 million people under house arrest, and allowed the disease to essentially burn itself out.

And so Wuhan fell.

The disaster that befell the citizens of Wuhan and so many other cities throughout China is not primarily a virus. The disaster is having a political regime that cares more about maintaining a self-serving narrative of control than it cares about saving the lives of its citizens.

“An already substantial outbreak in Washington State”

Report from Trevor Bedford, scientist at the Fred Hutchinson Cancer Research Center in Seattle (emphasis mine):

Trevor Bedford
Replying to
This case, WA2, is on a branch in the evolutionary tree that descends directly from WA1, the first reported case in the USA sampled Jan 19, also from Snohomish County, viewable here:
Trevor Bedford
This strongly suggests that there has been cryptic transmission in Washington State for the past 6 weeks. 3/9
Trevor Bedford
It’s possible that this genetic similarity is a coincidence and these are separate introductions. However, I believe this is highly unlikely. The WA1 case had a variant at site 18060. This variant is only present in 2/59 viruses from China. 4/9
Trevor Bedford
I’d assess the p-value for this coincidence at 2/59=0.03 and so is statistically significant. Additionally, these two cases are geographically proximal, both residing in Snohomish County. 5/9
Trevor Bedford
I believe we’re facing an already substantial outbreak in Washington State that was not detected until now due to narrow case definition requiring direct travel to China. 6/9
Trevor Bedford
We will be working closely with @KCPubHealth
and @WADeptHealth
to investigate the full extent of the outbreak. 7/9
Trevor Bedford
We’re hoping to update soon with better estimates of the number of infections in Washington State using available data. 8/9
Trevor Bedford
Thank you to the @seattleflustudy
team, and particularly to @lea_starita
, for exceptionally fast turnaround from diagnostic assay at @WADeptHealth
to sequenced genome. 9/9
Trevor Bedford
An update, because I see people overly speculating on total outbreak size. Our best current expectation is a few hundred current infections. Expect more analyses tomorrow.

Things are not looking great for the West Coast at this point. On a side note, this tends to suggest that my proposal of January 23, to “shut down international travel until we get this thing firmly under control,” was actually too late.

The hoarding begins

Some people aren’t waiting around to see how bad the current epidemiological situation can get before stocking up on the necessities:

Supermarket shelves are starting to be stripped bare as Americans prepare for the spread of coronavirus by stockpiling on medications and non-perishable items across the country.

People have been panic buying items from stores ever since health authorities warned that Americans should start preparing for domestic acceleration of the virus, which has infected more than 80,000 people worldwide and killed nearly 3,000.

There are now 60 confirmed cases of the coronavirus in the U.S. and the first case where the origin of the disease is unknown was confirmed on Wednesday.

Supplies have been flying off the shelves countrywide this week with people posting photos on social media showing the lack of products available in some stores and pharmacies.

In southern California, some Walgreens stores had been completely depleted of cough medicines, cold and flue medications, vaporizers, masks and thermometers.

Shoppers in Hawaii were buying up flatbeds of canned goods, bottled water, toilet paper and paper towels from a local Costo.

More hoarding behavior:

Here’s how things look at my local Target (note the empty basket of hand sanitizers):

Target hoarding Target hoardingThey’re hoarding in Italy, too. Here, an Italian man reacts to being denied his pasta:

CDC update and Corona math

Daegu, South Korea (Source)

From the CDC website (emphasis added):

Risk Assessment

Outbreaks of novel virus infections among people are always of public health concern. The risk from these outbreaks depends on characteristics of the virus, including how well it spreads between people, the severity of resulting illness, and the medical or other measures available to control the impact of the virus (for example, vaccine or treatment medications). The fact that this disease has caused illness, including illness resulting in death, and sustained person-to-person spread is concerning. These factors meet two of the criteria of a pandemic. As community spread is detected in more and more countries, the world moves closer toward meeting the third criteria, worldwide spread of the new virus.

While there is still much to learn about the unfolding situations in California, Oregon and Washington, preliminary information raises the level of concern about the immediate threat for COVID-19 for certain communities in the United States. The potential public health threat posed by COVID-19 is very high, to the United States and globally.

At this time, however, most people in the United States will have little immediate risk of exposure to this virus. At this time, this virus is NOT currently spreading widely in the United States. However, it is important to note that current global circumstances suggest it is likely that this virus will cause a pandemic. This is a rapidly evolving situation and the risk assessment will be updated as needed.

Current risk assessment:

For the general American public, who are unlikely to be exposed to this virus at this time, the immediate health risk from COVID-19 is considered low.
People in communities where ongoing community spread with the virus that causes COVID-19 has been reported are at elevated though still relatively low risk of exposure.
Healthcare workers caring for patients with COVID-19 are at elevated risk of exposure.
Close contacts of persons with COVID-19 also are at elevated risk of exposure.
Travelers returning from affected locations internationally where community spread is occurring also are at elevated risk of exposure.

CDC has developed guidance to help in the risk assessment and management of people with potential exposures to COVID-19.

What May Happen

More cases of COVID-19 are likely to be identified in the coming days, including more cases in the United States. It’s also likely that person-to-person spread will continue to occur, including in communities in the United States. It’s likely that at some point, widespread transmission of COVID-19 in the United States will occur.

Widespread transmission of COVID-19 would translate into large numbers of people needing medical care at the same time. Schools, childcare centers, workplaces, and other places for mass gatherings may experience more absenteeism. Public health and healthcare systems may become overloaded, with elevated rates of hospitalizations and deaths. Other critical infrastructure, such as law enforcement, emergency medical services, and transportation industry may also be affected. Health care providers and hospitals may be overwhelmed. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it. Nonpharmaceutical interventions would be the most important response strategy.

I found this conversation with Donald G. McNeil Jr., a science and health journalist at the New York Times, most interesting:

donald g. mcneil jr.

OK, this is not like the annual flu. The annual flu, in a bad year, has a death rate of around 0.1 percent. So we’re talking about 20 times as bad.

michael barbaro

That’s very meaningful.

donald g. mcneil jr.

When people were going around saying, oh, not to worry about this. You should get a flu shot because the flu is a bigger threat. Yes. At this moment, the flu is a bigger threat, definitely, in the United States. But don’t think you have nothing to worry about. One thing that might happen is it might not get here in a big wave until the fall. That happened in 1918. There was a spring wave that was scary, and then the virus mostly disappeared in the summer, because a lot of viruses don’t like hot weather. But then when it came back in the fall and winter, that was the real killer wave. And that’s when a lot of people died. But we conventionally say that if the 1918 flu came back today, it wouldn’t be as deadly.

michael barbaro

Because it’s not 1918.

donald g. mcneil jr.

Because in 1918, we didn’t have antibiotics, and a lot of people died of secondary bacterial pneumonias. We didn’t have mechanical ventilators to put people on. We didn’t have the steroids that cuts down on lung inflammation. We have a lot of things in modern medical care that we didn’t have then. But what’s disturbing about what you see happening in China is that a lot of people are going into hospitals and they are getting antibiotics, and they are getting Tamiflu, and they are getting antivirals, and they are getting steroids, and they are getting put on ventilators. And they still die. And that’s unexpected, and it’s quite spooky. […]

donald g. mcneil jr.

Some big chunk of the country — 30, 40, 50 percent — are likely to get a new virus when it blows through. And if you don’t get it in the first wave, you might get it in the second wave.

michael barbaro

And 2 percent lethality rate of 50 percent of the country. I don’t want to do that math. It’s really, really awful.

donald g. mcneil jr.

It’s a lot of people. It means, you know, you don’t die. 80 percent of people have mild cases. But you know somebody who dies.

I’ll do that math. It means, if 30 percent of the country gets infected with coronavirus, and the virus has a 2% mortality rate, that some 2 million people die. But, you know… just the flu, bro.

Now, I don’t know where McNeil Jr. gets those “big chunk of the country” estimates. But a basic reproduction number (R0) of 2.0 to 2.5 for this virus (source) means that it is relatively contagious, much more so than the seasonal flu, which has an R0 of 1.3 (source).

The big problem is that there is very little slack in our health care system, as John Robb details in his latest Global Guerrillas Report. He points out that the US had about 1.5 million hospital beds in 1975, whereas now it has about 0.9 million despite the population being 50% higher. Run the numbers – it would only take a surge of as little as 100,000 patients to overwhelm the system.

The flu results in between 140,000 and 960,000 hospitalizations each year (source).

Presumably, the US healthcare system is better equipped to handle a severe virus outbreak than the Chinese one. A Chinese contact said that her grandmother had a heart attack last week and was taken to the hospital, which told her that she could only be admitted after she tested negative for coronavirus. The hospital give her some pills and told her to go home and wait 14 days. She had a second heart attack this week and the hospital finally agreed to admit her.

More from the NY Times podcast:

donald g. mcneil jr.

Well, in any bad flu season, hospitals put people on all their ventilators. We have a National Strategic Stockpile, which has a lot of stuff in it — masks, gowns, gloves, drugs, even some ventilators. But you can’t stockpile enough ventilators to put — a ventilator is like a cost of a car. It’s $25,000 to $50,000. Hospitals can’t go out and order an extra hundred of those. And if they did order an extra hundred of those —

michael barbaro

It would take awhile.

donald g. mcneil jr.

It would take awhile. And also you need at least three people to staff that ventilator with the patient on it around the clock. And that’s a lot of trained respiratory technicians and things. So if we get hit with a gigantic epidemic of a lot of people with pneumonia needing to be on breathing machines, we’re not prepared for that.

michael barbaro

What about preparations beyond ventilators?

donald g. mcneil jr.

What happened in China, with the shutdown of Wuhan and Hubei province during Tet, during New Year, was the equivalent of shutting down Chicago and most of that surrounding part of the Midwest at Christmas time and telling people, you are now going to stay in Chicago. You can’t leave. You can’t see your families. All the flights are canceled. All the trains are canceled. All the highways are closed. You’re going to stay in there. And you’re locked in with a deadly disease. We can do it.

michael barbaro

Would we do that?

donald g. mcneil jr.

We can do it, but we’re not used to being controlled from the top down the way people have been in China. So I don’t know what’s going to happen in the United States. We’re not mentally prepared to fight a sort of people’s war against an epidemic, which is what happened in China.

The US may have a stockpile, but this message from the US Surgeon General is hardly reassuring: