Covid-19 Two weeks from catastrophe – here – now

Poorest countries likely to be devastated

Even the Wall Street Journal finds it “troubling”:

https://www.wsj.com/articles/coronavirus-is-advancing-on-poor-nations-and-the-prognosis-is-troubling-11585149183?mod=hp_lead_pos10

Ten days till Intensive Care Units full in Australia. Two weeks till more than 20% avoidable death rate in hospitals.

When a system breaks: a queuing theory model for the number of intensive care beds needed during the COVID-19 pandemic
Hamish DD Meares and Michael P Jones
Med J Aust
Published online: 26 March 2020 (preprint)

https://www.mja.com.au/journal/2020/212/10/when-system-breaks-queuing-theory-model-number-intensive-care-beds-needed

The very simple model fits the data from Italy and the current rates of admission to hospital (increasing 23% per day i.e doubling more than twice per week).

Confirms what I’ve been saying, most deaths from unavailable care. Estimates almost a quarter of hospitalized cases will die from unavailable ICU care, not from covid-19, starting 2 weeks from now

“Now, instead of a steady state, imagine the number of total positive cases in the community increases by 20% every day (23% currently in Australia [7]). On the day you have 100 total positive cases, you will have approximately 120 the next. Those 20 new positive cases will require one new ICU admission and a 10-bed ICU to service that rate of admissions.

That implies that the number of ICU beds needed is approximately 10% the Total Positive Cases or 50% of the number of new positive cases. Australia has around 2200 ICU beds, which implies if public health measures fail to curb the rate of growth, Australia’s ICU capacity will be exceeded at around 22 000 COVID-19 cases sometime around the 5 April, 2020. Other sources [8] have suggested that Australia could cope with up to 44,580 COVID-19 cases, but even if this is true it only grants a 3-day extension to the 8 April, 2020. The practical impact on ICU capacity of this scenario is made clear in Figure 1″ [at end of the pdf version]

“Figure 2. ICU admission rate per 100,000 population in Lombardy initially increases exponentially followed by a steep linear increase”

“In Figure 3 we found the mortality rate among hospitalized averaged 8.8% from Day 1 to Day 14 and was essentially steady (p=0.9), but from Day 15, the mortality rate dramatically rises (p<0.001) with an average mortality of 22.7% from Day 15 onwards.”

“The authors’ conjecture is that initially the 8.8% mortality is predominately from COVID-19 patients in ICU but from around Day 15 onwards, the increased demand for ICU beds outstrips the capacity of the system to supply them, and patients perish not from COVID-19 per se but from lack of access to an ICU bed. This is also illustrated in Figure 3 (available in the PDF version) where the ICU admission rate falls as demand increases, with a corresponding increase in the mortality rate.

“These data imply that the eventual mortality rate of COVID-19 may be much higher than currently estimated because once the system reaches breaking point and there are insufficient ICU Beds, mortality rises dramatically.”

Conclusion

“While the specific form of the proposed model can be debated, it does appear to represent a realistic clinical scenario, is consistent with international data and suggests the conclusion that the impending demand for ICU beds could overwhelm capacity in even the largest Australian hospitals in the near future. Australia must immediately take all available measures to rapidly decrease the rate of new cases and radically increase the number of ICU beds otherwise we may face the same fate as Italy, or worse.”

My conclusion is slightly different. Radically increasing the number of ICU beds will only delay catastrophe a few days although that will certainly be a good thing and even more useful for later waves.

The whole focus right now must be on “all available measures to rapidly decrease the rate of new cases“.

That includes Quarantine accommodation which can be rolled out much faster than ICU beds and without diverting any resources from efforts to increase ICU beds.

Hopefully Victoria’s Chief Medical Officer will again “jump the gun” as he did in stress testing the pharmacy supply chains by advising people to stock up for two months lockdown. He should start the full lockdown today and then insist on prompt Quarantine accommodation for ALL cases, and separately for vulnerable people living in households with others, not just household isolation. If he does, others will follow.

Personal refection on above from MJA Editor:

https://www.mja.com.au/journal/2020/212/10/sars-cov-2-medical-profession-ventilator-beds-and-mortality-predictions

Henry Ergas joins the WSJ campaign for more deaths to save the economy

The Australian has reported the above story:

https://www.theaustralian.com.au/nation/tougher-lockdown-key-to-health-system-coping-research-reveals/news-story/4cf57becfbe8165adeb49ebface1902d

But it is still pushing the WSJ’s “pro-death” campaign.

https://www.theaustralian.com.au/commentary/coronavirus-it-will-be-unhealthy-to-ignore-the-cost-of-all-this/news-story/60f5e2f3c1708aa9036aa1778933f15b

As a biosecurity hazard The Australian should also be shut down – now – and stay shut down until it agrees to stop campaigning for more deaths.

Swan Song

Here’s the ABC’s Dr Norman Swan with basically correct advice on what has to happen immediately for “social distancing” but a ludicrous claim that it will result in getting back to normal in say 4 to 6 weeks:

https://www.abc.net.au/news/2020-03-26/how-australia-could-beat-coronavirus-swan-nbk/12091688

He ends with this verbatim quote:

“How long is it going to last before people say ‘stuff this I’m going out’. And then you get the epidemic coming back. Short, sharp, time-limited, get back to our normal life over a period of time.”

It does need to be sharp and stressing “short and time-limited” may help get people to comply with sharp measures more quickly than they otherwise would. Trump seems to be doing that in the USA with his usual posturing against the medical advice while authorizing rapid sharp shutdowns for an initial 15 days and pretending that will be enough.

But 4 to 6 weeks is almost as ludicrous as Trump’s talk of the US economy roaring back after Easter. I think the difference is simply that Trump knows he has a more credulous and reluctant audience than the ABC and is facing either an election or postponement of elections in November. (Presumably the Electoral College mechanism in the US Constitution could still operate without public polling but the US Northern Command Combatant Commander might be just as plausible as either Trump or Biden to maintain a functional national government in that circumstance).

The period cannot be time-limited in advance. It can only be based on testing and a better understanding of how long it takes between triggers for lifting restrictions to increase the rate “R” to a level above 1 that again threatens hospital capacity and triggers for resuming restrictions to get it back below 1 (with increased capacity including ventilators and anti-viral drugs) to again cope. It won’t be “over” (for this season of this strain) until herd immunity via either a vaccine or most of the population having recovered from infection. This is clearly explained (for a technical audience) in Report 9 from the Imperial College covid-19 response team.

As Dr. Anthony Fauci, the USA’s top expert spokesperson says:

“You don’t make the timeline. The virus makes the timeline”

There may be a way to explain that clearly with texts and visualizations, but I don’t know how, and am convinced it urgently needs “Explorable Explanations” with widgets. I doubt that Dr Norman Swan COULD explain it to his ABC audience even if he DOES get it himself (which I also doubt).

Dr Swan is certainly right that people will be saying ‘stuff this I’m going out’ in a short, time-limited period unless they DO understand.
That short, time-limited period should be used to provide clear “Explorable” Explanations that it will NOT just be a single flattened peak and of many other things concerning how society will cope with the actual expected multiple waves.

The other point he stresses is the need for mass testing. That is certainly true and governments certainly do know it now and will get that happening a lot faster than they can possibly roll out ventilators and ICU beds. They simply don’t have enough test-kits yet, not a lack of understanding that they need them. I assume that capabilities to mass produce test-kits fast enough are being rolled out now without need for social mobilization to force them to do so. Like ventilators and ICU beds, test-kits, masks and alcoholic sanitizers cannot replicate themselves as fast as this pandemic virus. But unlike ICUs, they only need to be ramped up at achievable rates to avoid catastrophe.

More important than the tests to confirm who has it (which can be clinically diagnosed reasonably accurately very shortly after symptoms even without tests) are smaller random sample blood tests to see who has recovered from it without being recorded as a case. That data is essential for setting trigger levels for imposing and lifting restrictions in advance of hospitals becoming overloaded. It is a technical matter that does not need to be urgently understood by the general public and unlike Quarantine accommodation I am confident it is already being worked on as fast as possible.

USA likely to be hardest hit modern industrial country

While Spain is closely following the Italian trajetory to catastrophe and major European countries including the UK not far behind, Australia is still a couple of weeks further behind.

I haven’t been following the US situation but this article from Wednesday (25 March) suggests the US will end up worse off than others:

https://www.theatlantic.com/health/archive/2020/03/how-will-coronavirus-end/608719/

It also has some explanation of the protracted nature and multiple waves of the pandemic crisis and speculation about social changes in the aftermath (plus of course some of the usual incomprehension from Never Trumper’s of why Trump’s popularity has not collapsed – but perhaps less dominated by that than usual for “The Atlantic”).

But if you are missing “the usual” from Never Trumper’s, “The Atlantic” is still a good place to find some:
https://www.theatlantic.com/ideas/archive/2020/03/presidents-character-unequal-task/608743/

BTW I’m not following US politics but headlines show Trump’s approval higher than ever in most of the polls. Interestingly Rasmussen poll which usually shows Trump approval significantly higher than others (because it only counts people likely to vote) is relatively static.

For deeper insight into why “Never Trumpers” lost the Republican Party, here’s one whining about his life being in danger as a doctor. The incompetent shortage of Personal Protective Equipment for health workers is very real and serious. But most of them are angry that they risk having to stop working for a few weeks when they get infected, thus further overloading their colleagues and reducing the health system’s capacity to save lives. They aren’t as intensely focussed on themseves as either Trump or this writer for “The Atlantic”:

https://www.theatlantic.com/ideas/archive/2020/03/were-failing-doctors/608662/

On the plus side, at least The Atlantic is strongly opposing the campaign to sacrifice a million or more lives for “the economy” being waged by the Wall Street Journal with a lot of traction on the right (and supported by the NYT’s Thomas Friedman):

https://www.theatlantic.com/ideas/archive/2020/03/national-shutdown-least-bad-option/608683/

I’m only attempting to follow the epidemiology of pandemic disease covid-19, not the virology of the virus responsible, SARS-CoV-2. But for those interested, The Atlantic does have an interesting article on that:

https://www.theatlantic.com/science/archive/2020/03/biography-new-coronavirus/608338/

Also interesting for those trying to follow aspects other than the epidemiology is an account of the dramatic Danish economic response, supported by all parties there:
https://www.theatlantic.com/ideas/archive/2020/03/denmark-freezing-its-economy-should-us/608533/

“Life in a time of Corona”

Here’s a relaxing video from an ABC Foreign Correspondent stuck at home.

https://www.abc.net.au/news/2020-03-24/life-in-the-time-of-corona/12086808 25 minutes Tuesday 24 March.

“Necessity is the mother of invention” so ABC Foreign Correspondent Emma Albericci stuck at home had the bright idea of interviewing her Italian relatives under lockdown. Starts with usual ABC ominous sound track with pictues of deserted Milan, but then shows Italians in near total lockdown coping well now that they know what they have to do and why they have to do it. Less reassuring but appropriately informative on what happened to Italian hospital system because they did not act fast enough to do what they now ARE doing. This is helpful for other countries to do it now instead of “proportionally” and worry less about reactions.

Visualization and Explanation

Quite a good item from the ABC on the actual data for cases, with a reasonably clear message (unlike their previous efforts with “9 charts” and then “13 charts” that were pointless). Worth reading, although I don’t agree with the explanations of differences between countries.

https://www.abc.net.au/news/2020-03-26/coronavirus-covid19-global-spread-data-explained/12089028

What the visualizations actually show is that most countries being tracked are closely bunched together along much the same trajectory of “community transmission” with a common doubling period of known cases of between 2 and 3 days. The outliers are China where containment was sucessful except in Hubei and four other Asian economies (Japan, Singapore, South Korea, Taiwan) that had experience from SARS and MERS. I won’t go into a detailed critique as the central message is good.

But a glance at the numbers makes it glaringly obvious the crisis is nowhere near ending in ANY of these countries. The numbers already infected might be say 10 times larger than the case numbers so far but there is no reason to expect that nearly all of them have recovered and now have at least short term immunity. Even if the numbers infected were 100 times the cases, that would still leave the overwhelming majority susceptible. eg South Korea currently appears to have covid-19 “under control” with total flattening out at around 10,000 cases. Even 100 times that is only 1 million which would still leave 98% of the population susceptible. It isn’t worth arguing about whether the actual numbers infected are closer to 5 or 10 times rather than 100 times as there is no practical difference between 98% susceptible and 100%. That is simply not mentioned.

Nor in my view is there much practical difference depending on what percentage of people infected remain as carriers when restrictions get lifted despite appearing to have either fully recovered or never had symptoms. There will still be a battle using tracking and isolation of cases in small outbreaks with the ongoing potential for eventual “community transmission” and no reason not to expect further peaks after getting the initial outbreak “under control”.

The end of the crisis comes only with a vaccine for herd immunity (followed by regular updated vaccines for new strains of a likely new endemic disease). That is still expected to be 12 to 18 months away.

Tensegrity

On an entirely different note, which somehow feels related to me:

https://tinyurl.com/sthh2fz

That’s all from me on reviewing the media. I’m going back to the technical literature now.

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