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.

covid-19 The “Republic of Letters” Strikes Back

Things in Australia are now moving almost as rapidly towards a less insane policy as in the UK. It is already too late to avoid catastrophe in the UK but Australia has more time in which to at least reduce the scale by a larger factor than the UK can hope to achieve.

Basically scientists have been unleashing a flood of papers that make it pretty clear governments will be held criminally liable for negligence, with proof beyond reasonable doubt. They are more polite about it, but they are “expert witnesses” spelling out the case for prosecution.

The UK Center for Mathematical Modeling of Infectious Diseases has published some prototype “Explorable Explanations” with widgets eg so that anybody can get a “feel” for the UK running out of hospital critical care beds by the end of this month (with the numbers needed doubling every 1-2 days).

https://cmmid.github.io/topics/covid19/

These are still server based Dashboards probably prepared from Jupyter R notebooks using “Shiny”. But they seem to have the server bandwidth to sustain the traffic so far. It won’t be long before easier to understand “Explorables” are available for routine inclusion in any blog post using only browser resources without server support. The difference in impact is roughy comparable to the printing press vs copying out manuscripts by hand. But the prototypes had to come first.

The “Group of Eight” Universities have come out with a group of experts from all relevant fields insisting that the government must “go hard and go now”. Oddly the only google link for that is here:

At the end there is a link to the UK Government’s Scientific Advisory Group for Emergencies – SAGE:

https://www.gov.uk/government/groups/scientific-advisory-group-for-emergencies-sage-coronavirus-covid-19-response

That page is now being updated “on a regular basis with the latest available evidence provided to SAGE.” Note the word “to”, not from. The flood of research is now spilling out of academia onto official government web sites.

There is even a fine grained Agent Based Model for Australia now available via a link from this summary:

https://www.sydney.edu.au/news-opinion/news/2020/03/25/greater-social-distancing-could-curb-covid-19-in-13-weeks.html

I am still studying it, but it does argue that 80% compliance with “social distancing” measure would be needed to get the outbreak under control in 4 months. It does not spell out that 80% compliance is rather implausible without Quarantine accommodation.

Nor does it emphasize that “under control” merely means ending the first outbreak so that it isn’t just doubling every couple of days and there is time to cope. Controls will need to continue on and off until either an effective vaccine has been deployed or most of the population has been infected at a rate the hospitals plus any anti-viral drugs developed can cope with.

I still haven’t seen anybody else advocating a crash program for Quarantine accommodation to isolate infected and vulnerable people from the households they are in. But there is now lots of thinking about how to organize school children during a long shut down.

As explained in my last post in this series that Quarantine accommodation can be arranged much actual new buildings. But it still takes time and needs lots of help from tradies. So it is particularly stupid that the construction industry as being treated as though it was an “essential service” when it obviously isn’t constructing anything essential – like Quarantine accommodation. Most of the construction workers still getting infected on the job will recover in time to help with fitting up Quarantine accommodation for the next few waves if not for the first one. But it suggests there is still no intention to rapidly move into using the establishments and workforce now shutdown to actually do anything to reduce infection rates apart from staying at home.

Still, the complacency is ending. That had to happen for action to begin.

Covid-19 – The Impending Catastrophe and How to Combat It

Introduction

The title of this post in the covid-19 series here is from a pamphlet by Lenin at the end of October 1917. Lenin begins with the words “Famine is Approaching”:

https://www.marxists.org/archive/lenin/works/1917/ichtci/index.htm

We are not in that situation nor anything like it. But there is an impending catastrophe which has been thoroughly documented by the “Imperial College Covid-19 response team” in a series of technical reports:

https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/news–wuhan-coronavirus/#

The current absurd floundering will not result in famine. But it could result in more avoidable deaths from Covid-19 than the total deaths from the “Spanish Flu” which killed more people than the “Geat War” that immediately preceded it – the “War to End All Wars”.

This is very likely in countries ruled by Kleptocracies like many in Africa. But already the failure to prepare is killing large numbers in Italy, with Spain and France close behind and London less than three weeks behind Italy on the same trajectory. Lots of people will also die unnecessarily in countries that are modern industrial democracies with blithering idiots in charge of pretending the owners care about the people.

The potential catastrophe we face is much smaller than the consequences of famine. A Case Fatality Rate of 6% or so instead of less than 1% that could have been achieved if quarantine arrangements were prepared to spread out the peak case load. Say half a million avoidable deaths in the UK, 2 or 3 million in the USA, less than a hundred thousand or so in Australia. Nowhere near as bad as famine…

Most of the deaths will be the result of hospital Intensive Care Units so overwhelmed they cannot provide life saving treatment for the most severe case numbers beyond available capacity.

Figure 3 of this recent authoritative announcement has a clearly labelled graph on “flattening the curve”:

Figure 3 Flattening the Curve – Avoidable DEATHS not prevented

https://www.health.gov.au/news/australian-health-protection-principal-committee-ahppc-coronavirus-covid-19-statement-on-17-march-2020

Instead of just the usual horizontal line showing “Health System Capacity” lower than an early high peak and just above a slower spread out peak it adds a label for the very large shaded region above that line for the high peak and the smaller region still above that line, for spreading out.

The label is “Unmet Need”.

That is clear enough. A sharper version, more easily understood and acted on would be:

“Avoidable DEATHS not prevented”.

But even the milder version is omitted from more recent authoritative announcements.

Australia is on roughly the same trajectory as London, Italy and the United States. “Community Transmission” is already well under way in NSW and Queensland and has just got started in Victoria. It makes sense for the other States and Territories to close their borders to buy some more time just as it made sense internationally.

But it won’t be enough.

Update: If this sounds alarmist check out today’s Australian on what others far more qualified to express an opinion are saying:

https://www.theaustralian.com.au/science/coronavirus-tougher-measures-a-matter-of-life-or-death/news-story/fdde8510d7ebbc5b8e041f668dd6405d

Infectious disease modellers say the current round of restrictions would quarter the number of likely infections at the peak of the epidemic, but even with those social distancing measures in place, unless further measures were taken, Australia could still hit a peak of 125,000 infections a day — a level that would overwhelm the nation’s intensive care units.

Cases of COVID-19 are currently doubling every four days in Australia and heading towards a trajectory of a three-day doubling. If the epidemic were allowed to continue in this manner, University of Melbourne epidemiologist Tony Blakely said infections could climb to as many as 500,000 a day within weeks.

Under that scenario, the reproductive number of the virus is 2.5 — meaning every person infected with the virus would pass it to 2½ others. Social distancing measures are likely to reduce the reproductive number, known as R0.

Professor Blakely has modelled the impact of social distancing measures and predicts the moves to close pubs, clubs, restaurants and sporting facilities could reduce the R0 to 1.2 by the end of May. That would see the epidemic peak at about 125,000 infections a day in late May, with 60 per cent of the population infected.

Based on modelling completed by epidemiologists from Imperial College London, and adapting their model to Australia, Professor Blakely predicts that by the epidemic’s end, 165,000 ­people, or 0.84 per cent of cases, would require intensive care, ­assuming 60 per cent of people of all ages were infected.

Medium Term

Below on “How to Combat It” is mainly about short term measures. Days and weeks of “Impending Catastrophe”.

Fortunately longer term measures are already under way as explained at the end

Scientists and “nerds” are already pushing aside the barriers to effective cooperation from “Intellectual Property” far more rapidly than the rest of society is moving to push aside other forms of private property in the means of production.

The Enlightenment “Republic of Letters” is emerging again in a modern form with rapid mobilization forcing changes in public health policy as documented in earlier articles of this series:

https://c21stleft.com/2020/03/16/covid-19-over-70s-must-self-isolate-for-4-months-scientists-demand-immediate-social-distancing/

https://c21stleft.com/2020/03/13/covid-19-dont-panic-do-self-isolate/

For those who think they already understand and could not even bother to read the links in those posts there are already some excellent animated videos to explain the basics eg:

Why the actual numbers are much larger and growing faster than the statistics catching up:

Estimating actual COVID 19 cases (novel corona virus infections) in an area based on deaths

Some visualizations that are steps towards “Explorable Explanations” with sliders and other widgets to get a “feel” for what is happening and what can be changed can be found here:

https://observablehq.com/collection/@observablehq/coronavirus

Inceasing Healthcare Capacity

It also makes sense to immediately commandeer hotels as well as private hospitals for conversion into Emergency Hospitals and use entirely separate hospital buildings for covid-19 rather than attempting infection control within the same hospital buildings as wards for other patients. No doubt that will all be done along with many other things to raise capacity.

For those interested in the measures for rapidly expanding healthcare capacity a thorough current account of covid-19 for Emergency Medecine Critical Care professionals is here:

https://emcrit.org/ibcc/covid19/ (about 50pp as of 2 March)

Only the first section is likely to be of wider interest to other health workers. I think that first section is adequately summarized for a wider general audience in the public information campaigns now based on accurate advice from Centers for Disease Control etc. Note that the discussion of precautions against possible airborne transmission in above link is only relevant for those actually treating infectious patients.

No doubt surgeons no longer doing elective surgery will be taught how to do intubation procedures to provide ventilation for the vastly increased numbers of severe cases with viral pneumonia including many with further complications such as bacterial pneumonia, even though most of the teaching will be on the job assisting. Inferior split ventilators will be used and supplies will be ramped up.

Supply Chains

Naturally the main focus of the media has been on shopping. The newspapers are printed on the back of ads for shopping and the broadcast news is squeezed between ads for shopping both online and on air.

My view is that the shopping shambles is not of major signifcance and will be sorted out without major impact. Even if 80% of the workforce have mild to moderate illness lasting 2 to 3 weeks over the same relatively short period and there is disruption generally, essential services can be maintained. Most workers are employed to not do anything useful, let alone essential. Workers from large sectors shutting down now can be fairly rapidly mobilised as (unskilled and bewildered) assistants in essential areas while training on the job.

That is what I expect to happen when the blithering idiots in charge notice that funding businesses to continue trading while insolvent does not actually achieve much in the long term for a shutdown that reduces their turnover to near zero. Even the sheer idiocy of disrupting all credit arrangements by not enforcing payment terms so that deliveries will only be for cash will not be catastrophic in itself although the financial system may be fragile enough to come up with a related catastrophe.

Some fumbling and blunders are inevitable. The supply chains for groceries and pharmaceuticals will recover from panic buying without those stuff ups in emergency management causing many unnecessary deaths. The shortage of face masks and alcoholic sanitizers was avoidable but not necessarily catastrophic.

Impending Catastrophe

So what is the “Impending Catastrophe” if the Medium term is looking good, healthcare capacity can be rapidly expanded and supply chain hiccups are not especially catastrophic? Simply this.

There is no reasonable prospect of increasing the capacity of Intensive Care Units rapidly enough for a pandemic that will accelerate to double the case load every 2-3 days. A week after hospitals reach full capacity they will be dealing with a case load more than four times capacity. A fortnight later, more than 16 times. This is happening now in Italy. London is about 3 weeks behind Italy and Australia and the USA not much further behind, all on much the same trajectory that leads to catastrophe.

What cannot be fixed quickly enough for the first peak is the supply of mechanical ventilators etc for Intensive Care Units. Vastly accelerated scale up still cannot possibly keep pace as countries are now entering the period of doubled demand every 2-3 days:

Clin Infect Dis. 2015 May 1; 60(Suppl 1): S52–S57.
Published online 2015 Apr 10. doi: 10.1093/cid/civ089
Estimates of the Demand for Mechanical Ventilation in the United States During an Influenza Pandemic
Martin I. Meltzer,1 Anita Patel,2 Adebola Ajao,3 Scott V. Nystrom,4 and Lisa M. Koonin5
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603361/

The impending catastrophe is lack of preparations for serious quarantine.

Given a shortage of Intensive Care Units and no vaccine, such measures are the ONLY way to prevent or reduce catastrophe.

Quarantine

The measures for people outside the health system to focus on are for “flattening the curve”. Spreading out the infection directly reduces the death rate by directly reducing the number of people with severe cases who cannot be treated when they all arrive at hospital Intensive Care Units at once and equipment is available for only a fraction of those who need it.

That is not something achieved by telling people to stay at home doing nothing. It requires actually building and organizing things.

We need to actively build and organize QUARANTINE facilities. This is not just passive “social distancing”.

The whole point of the “containment” phase of tracking new arrivals for a short period of “self-isolation” and closely tracking the contacts of anybody infected was only to buy time before “Community Transmission” began. Containment merely keeps the numbers of new infections “contained” at a smaller rate to delay the “local transmission” that will inevitably eventually grow at a much larger exponential rate until “herd immunity” is achieved with effective vaccination (expected 12-18 months away). Some cases were bound to get through and eventually result in enough people infected from unknown local contacts that the origin of most new infections is “the community” rather than some tracked or untracked individual cases seeded from outside. Then the pace accelerates from doubling each week to doubling each 2-3 days as in Italy and others that are near the first peak.

The World Health Organization, WHO, has recommended “test, test, test” because the surprise at the Italian hospital system being overwhelmed showed the pandemic was being fought blindfolded. Containment through border control and isolation cannot work when you do not know who to isolate from whom. It was known since late January that most people infected had only mild symtoms or none (with estimates of 86% of cases not reported in the statistics that media have been relentlessly staring at).

Even with an adequate supply of test kits there has to be somewhere to put people who test positive for the couple of weeks or so until most of them recover. Instead they are being told to stay at home and infect the rest of their household who are now (belatedly) being told to also stay at home. That will reduce the acceleration more than if they were told to just keep going out. But three very urgent measures were obviously necessary then.

Their necessity should have been announced loud and clear while rolling out implementation as fast as possible after announcement. So far not even the necessity has been announced. Here is my view of the three most urgent measures that are critically urgent now:

How to Combat It

1. Quarantine Hospitals for the mildly and moderately ill

Also separate facilities for unconfirmed suspected likely cases (eg travellers from areas with more community transmission to those with less).

I don’t know what the correct term is for what I have called “Quarantine Hospital”. People who don’t live by themselves should obviously not be told to just stay at home and infect their household while they wait to see if they are actually infected or while recovering. Nor should they occupy full hospital beds needed for people more severely ill.

The rest of their household can be told to just stay home for a couple of weeks to see if they are already infected or not, but anyone infected should be immediately separated from people who are not known to have been infected. That is blindingly obvious whether they need additonal medical treatment or not and whether any treatment they need is available or not. Any country not doing this is not seriously trying to flatten the curve.

“Quarantine Hospital” sounds better than “Quarantine barracks” but just somewhere to stay and be fed with some nursing staff is all it takes to seriously spread out a peak. It will require an enormous effort but it can be done using space that must be shut down anyway, emergency furnishings and staff from businesses that must be shut down anyway.

Commandeering hotels etc is for full emergency hospitals, not for the larger numbers of beds needed in Quarantine Field Hospitals. Lots of office space unused with people working from home and entertainment venues shut down must be converted to emergency accommodation. The kitchen facilities are available from the cafes and restaurants being shut down. The beds and bedding are available from households in proportion to the numbers moved out of households that will need those beds, and the staff are available from the huge numbers of small businesses trading while insolvent as well as from those already laid off. So far as I can see that has not even been planned, let alone started.

2. Quarantine Accommodation for the vulnerable

Older people and people with various severe health probems are especially vulnerable to being part of the less than 1% who might die before a vaccine is available or part of the additional 5% or so that are killed by government incompetence as a result of intensive care not being available for them when the hospitals are overwhelmed. No doubt local communities will get organized to help those who need help while staying isolated in their own homes but there are others staying in households with less vulnerable people equally susceptible to infection.

“Tough” restrictions on visits to aged care institutions are obviously ludicrous. These can only be intended as justification for very soon saying people had an opportunity to make their last visits immediately before an essential full shutdown until proper procedures for safe visits fully separated by glass barriers etc can be organized.

But vulnerable people currently living in households with others must also be offered accommodation separated from the rest of the susceptible population until the peak has passed and sufficient intensive care facilities are available. That will be hard for many. Many may refuse and many may die. But doing nothing to make viable separate accommodation available is criminal. That seems to be the current “plan”.

Neighborhood support groups are starting to be formed spontaneously through social media:

https://www.abc.net.au/news/science/2020-03-17/coronavirus-online-support-groups/12060530

It is important to keep them entirely separate (although overlapping with) closed small “affinity” groups of households with children discussed in item 3 below.

3. Quarantine Separation of children

Obviously schools will have to be shut at some point except for children of households working in healthcare and other essential activities. Meanwhile schools are vitally important community organizing centers for households with children.

The shutdown won’t just be for a couple of weeks. It will end up lasting for many months.

while still open, and even after closing, schools should be organizing children into small groups, much smaller than class sizes, that will be allowed to interact with each other within school and after the shutdown and prohibited from doing so between groups.

This obviously needs to be coordinated with parents because all the households with children in whatever group any child continues to interact with will tend to get infected together. It will be especially difficult for households with children in different age groups and different schools but every household with children must be assigned to a particular group of households it is permitted (not required) to socially interact with. The kids are not going to just stay at home with their parents for six months, let alone eighteen months! Humans evolved in Hominid bands of a couple of dozen, not as isolated nuclear families.

Hopefully if we move really fast the necessary interaction can be online in Virtual Reality but we don’t know how well that will work, for how long or how quickly. It still ought to be based on non-overlapping groups that should be organized now by schools.

These separate child based groups are likely to continue to mix with and infect each other and must accept that their own group of households will or may end up having the larger risk of earlier infection corresponding to an enlarged single household. They must be confined to small numbers of households who trust each other to maintain isolation from the rest of the world to the same extent as the individual households.

Households with older and more vulnerable people are a major complication as self-isolation within a household is unlikely to be effective for long.

Six months is a rather optimistic estimate of how long this crisis will last. It could “conceivably” be as short as 6 months if all goes perfectly but that is not the period to plan for now. Avoiding overwhelmed hospitals requires dragging things out longer, until an effective vaccine gives “herd” immunity or effective anti-viral drugs reduce the death rate. Even if it could theoretically be even shorter than six months most serious estimates are for 12-18 months of on and off waves.

The current authoritative recommendations are that it is still too early for school closing in Australia:
https://www.health.gov.au/news/australian-health-protection-principal-committee-ahppc-coronavirus-covid-19-statement-on-22-march-2020

But that is based on lack of positive evidence that the time is right. See below on tests.

Evidence

Evidence in support of much of the three proposals above can be found from the experience of South Korea so far:

https://www.wsj.com/articles/how-south-korea-solved-its-acute-hospital-bed-shortage-11584874801?mod=hp_listb_pos1

But even Italy where the hospital overload is currently greatest has only had 0.1% of the population as “cases”.

South Korea has a very long way to go before herd immunity and there is nothing in the lower numbers of new cases after the first peak or the success in dealing with that first peak to suggest that there won’t be many further peaks:

https://www.worldometers.info/coronavirus/country/south-korea/

Likewise for Singapore, another success being hailed as though it were not just success with the first peak.

I don’t know whether anybody has solid evidence of whether and how it may be possible to stop transmission between househods via their children during an extended shutdown. As far as I can make out there is just empty hoping that for some unexplained reason it won’t happen. This mainly takes the form of highlighting the distraction that children have much less severe symptoms (which actually enhances their role as disease vectors).

Current Plans

Compared to Australia and the USA the UK is a model of serious but still unsuccessful efforts to explain public health policy to the public via journalists in a joint effort by the PM, the Chief Science Officer and the Chief Medical Oficer.

It is worth spending the time on these two long videos less than 5 days apart to understand how rapidly the situation is changing and how uncomprehending the journalists covering the “issue” are.

Coronavirus: Boris Johnson holds press conference after Cobra meeting
308,797 views – Streamed live on Mar 12, 2020 – starts at 23’30” of 1:10’57”

Coronavirus: Boris Johnson sets out “drastic action” BBC
292,849 views – Streamed live (Mar 16, 2020)

The pandemic model that now forms the basis for planning in the UK expects multiple waves of infection each time “social distancing” is relaxed after successfully suppressing the peak rates to reduce case loads to hospital capacities. This is in Report 9 from the Imperial College team:

https://time.com/5804555/coronavirus-lockdown-uk/

A shorter Australian attempt at explaining the model to a journalist is this video from the ABC’s Dr Norman Swan on 17 March. (I watched it after having written the rest of this article). In many ways it is better than the UK and Australian official explanations but he still ends up distracted by issues of case tracking from the “Containment” phase rather than the current accelerating exponential growth on entering the “Community Transmission” phase. He simply does not get the fact that spreading out the peak necessarily reduces total deaths from unavailable intensive health care units and instead claims that a spread out peak could still have the same total deaths.

“Explorable Explanations” with widgets for people to actually manipulate the paramaters of the models themselves are really essential instead of literally hand-waving – with or without a background graph:

If any of these people trying to explain had access to such Explorables they would be using them on TV. Instead they are waving their hands.

The primary mechanism for transmission during a long shutdown might well be the overlap between different groups of children from different groups of households interacting to transmit the virus between their otherwise separated groups of households. It will certainly occur with younger children still at school.

Similar transmission will occur from the essential workforce in different workplaces also transmitting between different households, but stringent “social distancing” controls at work can reduce that far more effectively than among younger school children. Likewise smaller households without children will get infected more slowly than extended groups of households whose children infect each other.

Tests

School closure timing and arrangements is the hardest issue to grapple with and the least data is available as to transmission rates through these channels. Currently there have been no adequate systematic random samples of the population generally as test kits are only available for more urgent needs such as border control during the containment period and testing health workers.

In particular there is no blood testing yet to measure the immune system responses of people who have already had the virus without symptoms. Such testing is hoped for soon and could be a game changer for enabling decisions on the optimal timing for imposing and lifting isolation restrictions before and after hospitals are overloaded. It could also shed a lot more light on the transmission between children and between adults and children. At present decisions on how to time for less overloading of peak capacity in successive waves are being taken blindfolded.

The separation of groups of children and their households necessarily involves the widest participation in community decision making and implementation and the most discussion to come up with ideas right now. Explorable explanations with widgets are needed urgently for this.

All UK schools closed last week, very shortly after official announcements that the best “science” showed that overall effects of closing schools could be negative because of:

  1. Large effect on essential workforce diverted back into parenting and child-minding, especially from already overloaded health system. (Private schools closed earlier but essential workforce is generally lower paid with a high proportion depending on schools for childcare while working in health system).
  2. Likelihood that traditional reliance on grandparents to assist will result in more rapid infection of the most vulnerable.
  3. Unlikelihood that school students will remain socially distanced from each other while away from school, short, medium and long term.

https://www.theaustralian.com.au/world/coronavirus-boris-johnson-shuts-down-schools/news-story/b836ff32ea9571630404e563fbaf5bc0

Previous announcements were correct. So is the new decision.

What follows from the correctness of the two opposite decisions of our dearly beloved leaders both 5 days earlier and 5 days later is that urgent mitigation measures can and should be taken for all 3 issues. Others can contribute more to discussion of those measures so I won’t attempt it in this article.

All I can say on it is that school closures will happen soon whether desirable or not.

Here is some confusing advice from USA of the same sort that will dominate discussion here:

https://www.usatoday.com/story/opinion/2020/03/16/schools-closed-but-children-can-still-spread-coronavirus-column/5054108002/

In addition to the advice only now being widely disseminated by authoritative public health information campaigns, households with both children and older and more vulnerable people should carefully consider stronger advice from people who have been campaigning for full social isolation to be implemented sooner.

https://www.endcoronavirus.org/

They also have an interesting critique of the mainstream epidemiological models:
https://static1.squarespace.com/static/5b68a4e4a2772c2a206180a1/t/5e70eb32b16229792eb14836/1584458547530/ReviewOfFergusson.pdf

They cannot be considered “authoritative” but I will be carefully studying the technical background necessary to be able to understand both.

Epidemiology for the Uninitiated

Lots of people, like me, will need to acquire some basic epidemiological concepts to understand what the models are about. Studying this is very good practice for understanding the economics of the capitalist business cycle. (The Explorable Explanations will be more accessible for most people both for pandemics and for the business cycle).

I will be starting here:

https://www.nature.com/articles/nrmicro1845

Book chapters: https://www.bmj.com/about-bmj/resources-readers/publications/epidemiology-uninitiated

Another critique of earlier UK (and current Australian) policy is here:
https://unherd.com/2020/03/the-scientific-case-against-herd-immunity/

If the serious critics are right there won’t be another peak in China and Italy after full social isolation measures are enforced. If the mainstream epidemiological view is correct (as opposed to the government waffle about 6 months) there will be successive waves over 18 months or so until a vaccine is effective, possibly ameliorated by anti-viral drugs. This is because “social distancing” restrictions end up becoming intolerable and therefore ineffective and get relaxed because they cannot be maintained for long when new cases decline to near zero after dealing with each peak in the overloading of ICUs and consequent deaths from unavailable medical treatment. Transmission can be expected to resume gradually and then again suddenly as long as there are large reservoirs of people still susceptible. There will still be large reservoirs susceptible to infection after the first peak overloading the hospitals is shutdown by emergency isolation measures just as there was for the first peak.

The business press is already editorializing about not “over reacting” and the importance of quickly getting people back to work for them. Their views will eventually prevail while the owners are still in charge. Here’s a couple of the Wall Street Journal’s editorials urging that more people be killed quickly to save money:

https://www.wsj.com/articles/rethinking-the-coronavirus-shutdown-11584659154

https://www.wsj.com/articles/the-extreme-state-lockdowns-11584745130

They can rely on help from lots of people who think correct ideas fall from the sky or are inherent in their minds as “just common sense” and are simply not interested in studying the knowledge acquired from social practice and from it alone. The three kinds of social practice include class struggle, the struggle for production and scientific experiment. This is not a good time to be glued to the business channels and ignoring the political class struggle and the struggle for production being waged by workers in the relevant sciences.

Simply assuming the first peak will be the last is as helpful as the Wall Street Journal’s editorials.

The kind of mathematical modeling that is done to help inform public health policy for dealing with this pandemic is closely related to the sort that is needed for understanding the capitalist cycle and the transition from capitalism. So studying the pandemic is not a diversion from other priorities.

Long Term – the “Republic of Letters”

https://en.wikipedia.org/wiki/Republic_of_Letters

The modern form of the “Republic of Letters” is very much based on the communist mode of production and distribution already widespread in the Open Culture (eg Wikipedia) and Open Science offspring of the Free and Open Source Software movement. Such intellectual activity was not enough to produce the Enlightenment, let alone the bourgeois democratic revolution against Feudalism. Nevertheless it was a very important precursor.

Wikipedia has an impressive portal showing the current extent of collaborative effort:

https://en.wikipedia.org/wiki/Portal:Coronavirus_disease_2019

The “pirate” backbone for disseminating scientific and other knowledge from “Library Genesis” and “Sci-Hub” is being hardened against attack and is openly confronting the crisis:

https://www.vice.com/en_us/article/pa7jxb/archivists-are-trying-to-make-sure-a-pirate-bay-of-science-never-goes-down

The main scientific publishers have accepted demands to make all covid-19 research immediately open access (they were being bypassed anyway by pre-prints on community archive sites and by Sci-Hub).

Activists have organized collections of relevant non-current background material. Major Big Tech companies have co-opted the US government to neatly classify what is “Open Access” and what needs to be extracted from behind paywalls and disseminated by activists:

https://www.whitehouse.gov/briefings-statements/call-action-tech-community-new-machine-readable-covid-19-dataset/

https://pages.semanticscholar.org/coronavirus-research

COVID-19 Open Research Dataset (CORD-19). 2020. Version 2020-03-13. Retrieved from https://pages.semanticscholar.org/coronavirus-research. Accessed YYYY-MM-DD. doi:10.5281/zenodo.3715506

Game players with fast Graphics on home PCs are being enlisted for anti-viral drug research:

https://www.vice.com/en_us/article/884djz/scientists-need-your-help-to-find-treatments-for-coronavirus

https://foldingathome.org:

They have vastly more potential computing power than Big Government and Big Data combined:

https://www.wsj.com/articles/in-bid-for-coronavirus-vaccine-u-s-eases-access-to-supercomputers-11584915152?mod=hp_minor_pos4

The 34,000 GPUs mentioned in that article are a drop in the ocean compared to what mobilizing the gamer PCs can deliver.

So anti-viral drugs and vaccines will arrive a lot quicker than usual, as will saner public health policy.

Even before governments started using their powers to commandeer manufacturing resources for ventilators and other hospital supplies, people started organizing to just do it:

https://www.vice.com/en_us/article/5dm4mb/people-are-trying-to-make-diy-ventilators-to-meet-coronavirus-demand see CPAP/

As already mentioned, the Emergency Medecine Critical Care professionals took care well in advance to prepare training materials for their reinforcements before they are overwhelmed:

https://en.wikipedia.org/wiki/EMCrit

A semi-random example of the sort of highly skilled know-how that will need to be increased with extreme acceleration is:

Its interesting that a couple of possibly relevant books listed there have later editions at Library Genesis than the editions mentioned:

Tobin, Principles and Practice of Mechanical Ventilation, 3edn (1500pp)
http://gen.lib.rus.ec/book/index.php?md5=F1730DC52D2BF1A73E857691AF3858FF

The Walls Manual of Emergency Airway Management, 5edn
http://gen.lib.rus.ec/book/index.php?md5=BFA1F68808415E2FA52607AA3F17.

Unfortunately Library Genesis does not have the only book in that list with the word “Intubation” in the title, nor any others in english that look relevant:

The Airway Cam Guide to Intubation and Practical Emergency Airway Management 1st Edition, Richard M. Levitan

Presumably anything relevant wih a doi can be obtained via Sci-Hub or this can rapidly and easily be arranged by the relevant professionals if necessary. Activists are working now to make the relevant materials freely available for people who will find themselves on the front lines along with other health workers quite soon.

Anyway, people are moving way faster than governments.

A new world is being born from the ashes of the old.

Bulk Edit

Arthur

Arthur2 minutes agoUser InfoIn reply to:[…] https://c21stleft.com/2020/03/13/covid-19-dont-panic-do-self-isolate/ […]

Update: Today’s Australian (Tuesday 2020-03-24) also has confirmation from Singapore PM that further waves are expected. I did not notice it last night:

https://www.theaustralian.com.au/inquirer/singapores-prime-minister-says-earning-the-peoples-trust-is-the-key-to-fighting-the-virus/news-story/39bc4f1de8eccbc09982af49ca43d2c7

“We are under no illusions that the problem is over at all,” he says.

“If I made an analogy, it is not that the tide has turned, it is that we put the dykes up. We are watching very carefully to see where water may leak in, and if you take your eyes off it for a ­moment, suddenly I have an outbreak, like what happened in South Korea, and I will be in a perilous situation. It can happen to us at any time.

“Australia is grappling with the same problem. The countries around us in Southeast Asia are also facing the problem. It (the outbreak) is going to catch fire in many countries and is going to take a long time to burn out.”

“I would not say we have successfully prevented it,” Lee says carefully. “I think I would say so far we have reasonably successfully hindered the transmission.”

The key, Lee explains, is checking out all the people any infected person may have unwittingly infected before diagnosis.

“We work very hard to contact-trace,” he says. “Who are the people you have met within the last two weeks, where have you been, what have you done, who may have been exposed to you?

“We make every effort to trace those people down as well and put the immediate contacts either on notice or in quarantine, depending on whether they have symptoms. It is very labour-intensive. We have 300-plus cases now, but we have contact-traced several thousand people already, at least.

“It is labour-intensive but it is helpful in preventing a single case from becoming many hundreds of cases, if you catch it in time.”

“Looking at the behaviour of the disease and the way it is jumping from country to country, you can push it down within a country, but it has not disappeared worldwide,” he says.

“I think this is going to be with us for quite some time.”

“Their population is not immune to it yet, in very large numbers. Because even if a million Chinese have got the virus so far, that still leaves almost 1.4 billion people who have not yet, and are still, in immunological terms, naive and at risk.

“So, what you can hope for is that you control the spread of the disease, you hold the position, and hope and pray that the scientists come up with either a treatment or a vaccine within a year or two — and in time for us to exit this without the doomsday scenario, namely that the disease goes through the whole population, and then eventually we have herd immunity. Either it is going to leave you with huge casualties, or it is going to take forever to lock down.

“I think it is an enormous economic cost, and a human cost too.”

Note: Like South Korea the proportion of the population that remains susceptible to infection in the next wave is even higher than in China where one province, Hubei did have an initially uncontrolled outbreak so are substantial proportion of that province now does have at least short term immunity so there is a fair chance the next wave there will be smaller.

The proportion still fully susceptible in Singapore and South Korea is as close to 100% as makes no difference. So whether the next outbreak is smaller or larger depends largeely on how effectively long term “social distancing” can be maintained until a vaccine. The initial success was “containment” using tracking and quarantine. When actual “Community Transmission” develops rigorous quarantine becomes far more important as then tracking merely confirms that most of the new cases were infected from “the community” rather than from a specific known contact who can be promptly isolated.

Unlike any other statements I have seen from national governments Singapore is clearly stating what the media and pretty well everyone who thinks they don’t need to know more, does not yet understand.

But it still needs “Explorable Explanations” of the model for even a small minority to not be surprised when subsequent waves happen.

[Tried to add this update as a comment but will have to figure that out later]

covid-19 Over 70s must self isolate for 4 months. Scientists demand immediate “social distancing”

 

He said older people would be “shielded for their own protection” and that the plan would be announced, with further details, when the time was right.

 

Don’t wait for the government to get around to this “big ask” in a few weeks. The danger of infection is doubling every few days and the number of Intensive Care Units cannot do so.

Here’s the introduction to the first of two references attached to a statement signed by over 400 scientists demanding immediate “social distancing”.

 
https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca

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.

 

The second link is a:

Warning from Italy

Covid_19: Open letter from Italy to the international scientific community

As you surely know, Italy is suffering a dramatic spreading of the coronavirus.

In just 3 weeks from the beginning of the outbreak, the virus has reached more than 10.000 infected people.

From our data, about 10% of patients require ICU (Intensive Care Unit) or sub ICU assistance and about 5% of patients die.

We are now in the tragic situation that the most efficient health system of the richest area of the country (Lombardy) is almost at its full capacity and will soon be difficult to assist more people with Covid-19.

This is the reason why an almost complete lockdown of the country has been ordered: to slow down and hopefully stop the contagion as soon as possible.

The virus is spreading at maximum speed, doubling the number of infected people in just 2,4 days[1].

As it emerges without a doubt from the data available, all the European countries are in fact experiencing the same rate of contagion speed and that they are just a few days behind on where it is Italy now [2].

The beginning of the outbreak had the exact same number of infections in China, Italy, and other countries. The difference is that China strongly and quickly locked down Wuhan and all of the Hubei region 8 days before Italy [3].

Just 8 days of delay for the Italy lockdown will result in an enormous increase in the number of total deaths in Italy with respect to China.

This exact same initial dynamic in the number of new cases can also be observed in every country outbreak.

It’s hard for non-specialists to intuitively grasp the way an exponential rate increase can get out of control.

So it’s very difficult to realize the tragic consequences that an exponential growth can have in a contagion like this one.

As a scientist, you surely do understand it. You do also understand that, as long as the rate of increase is exponential, no linear solution to contrast it will work (I.e. increasing x times the number of ICU machines, etc.)

Similarly, just imposing a limitation on people from staying together in large groups is not a sufficient solution.

This is an appeal to you, as a member of the scientific community, to urge your government to act now for actively stopping the virus!

In most EU countries you have enough time to make a lockdown similar to China or South Korea to quickly slow down and stop the contagion with much less effort and cost of what is now needed in Italy.

If Italy had strongly acted just 10 days ago, and that is more or less where you are now, there would have been much fewer deaths and economic tumble.

South Korea and China should be taken as the example to follow to stop this epidemic.

There is no other way.

So please, make your best effort to urge your government to act now! Time is our common enemy as the virus is very fast and really lethal.

Every minute is exceptionally important as it means saving lives. Don’t waste it!

Take care.

 

Here’s the statement from scientists:

 

http://maths.qmul.ac.uk/~vnicosia/UK_scientists_statement_on_coronavirus_measures.pdf

Linked from BBC report:

 

Here’s a sympathetic account of the UK government’s case for delay:

I’m not competent to comment on the optimal time for “social distancing”.

The scientists statement is clearly initiated from mathematicians expert at modelling. But the expertise required for these decisions is in epidemiology.

However it seems bloody obvious that whenever the peak should be, or will be, older people (and others with severe health problems) need to avoid infection until AFTER the peak, when there are again intensive care units available. That may be a lot longer than 4 months and many may not be able to do it. But the “time is right” to be told now.

 

covid-19 update Sunday 2020-03-15

Please note the article to pass on is the earliest of the three in this series all tagged covid-19. It highlights the collapse of intensive care in Italy that makes it essential to mobilize for social distancing immediately without waiting for government advice. The links provide authoritative information:

“covid-19 – Don’t Panic – Do Self Isolate”

https://c21stleft.com/2020/03/13/covid-19-dont-panic-do-self-isolate/

Since that article a national information campaign HAS now begun in Australia:

https://www.health.gov.au/news/launch-of-the-coronavirus-covid-19-campaign

Meanwhile:

Spain goes on lockdown; Italy tops 20,000 cases

Spain’s government today announced a lockdown for the whole country, which begins on Mar 16, affecting 46 million, El Pais reported today. The order, slated to last 15 days, allows people to leave their homes to buy food and medicine, to work, and to care for minors, the elderly, and other vulnerable people.

Behind Italy, which is also on lockdown, Spain has the second most cases in Europe and now has 6,391 cases and 195 deaths, according to RTVE, the country’s public broadcasting network. The country’s main hot spots are Madrid, Catalonia, the Basque country, and Andalusia.

Meanwhile, France, stopping short of a lockdown, announced sweeping new measures today, temporarily shuttering all public places except for food stores, pharmacies, and gas stations, and urging people to stay indoors as much as possible, France 24 reported. The country has now reported nearly 4,500 cases, 91 of them fatal.

Elsewhere, Italy’s health ministry today reported 3,497 more cases and 175 more deaths, raising its respective totals to 21,157 cases, 1,441 of them fatal. Germany now has 3,795 cases and 8 deaths, according to the latest numbers from the Robert Koch Institute.

In the United Kingdom, a group of 229 scientists wrote a letter to the government, urging it to take tougher measures to control the spread of the virus, the BBC reported, noting that UK officials were hesitant to take strong steps too early over worries about public frustrations. The scientists are pressing for more social distancing measures, but some government health officials have said the existing approach factors in some herd immunity benefits. Reuters reported today that the government will ban mass gatherings next week.

The second article in this series at c21st left “Interesting Advice” was just speculative and confuses incubation period with infectious period. Unfortunately people may not notice the main article as later articles are displayed first. Be sure to send direct link as above, not just a link to this blog.

BTW some support for my speculation can be found in this paper, which estimates that 48% or more of the infectious period is before symptoms occurred. However it is just a preliminary unreviewed technical report based on studies at two locations and I am not competent to judge its accuracy or to make speculative remarks based on it.

The proportion of pre-symptomatic transmission was 48% (95%CI 32-67%) for Singapore and 62% (95%CI 50-76%) for Tianjin, China. Estimates of the reproduction number based on the generation interval distribution were slightly higher than those based on the serial interval distribution. Conclusions: Estimating generation and serial interval distributions from outbreak data requires careful investigation of the underlying transmission network. Detailed contact tracing information is essential for correctly estimating these quantities.

https://www.medrxiv.org/content/10.1101/2020.03.05.20031815v1

Covid-19 Interesting Advice

It will be interesting to see whether this  advice is correct:

Mr Dutton remains in a Brisbane hospital on Saturday after announcing he had tested positive for the virus on Friday.

Prime Minister Scott Morrison’s office said cabinet ministers who met with Mr Dutton on Tuesday would not be required to self-isolate.

“In advice provided to the Prime Minister this evening, the deputy Chief Medical Officer has reiterated that only people who had close contact with the minister in the preceding 24 hours before he became symptomatic need to self-isolate,” Mr Morrison’s office said.

“That does not include the Prime Minister or any other members of the cabinet.”

https://www.theaustralian.com.au/nation/coronavirus-australia-live-coverage-donald-trump-met-with-infected-staffer-peter-dutton-hospitalised/news-story/d778dcee04f2caeb977b5f42ab0c3df1

The NYT story linked in my previous post had an important link to a recent article in Lancet that suggests to me that it might not be:

http://dx.doi.org/10.1016/S0140-6736(20)30567-5

BTW if you read my post by email, look at the original as the NYT link is not visible in the email.

The Lancet study estimates an infectious incubation period of 5 to 6 days before symptoms and a typical delay between symptoms and isolation of 2 to 7 days. (see appendices).

Dutton reported symptoms promptly and was isolated more quickly after only 1 day of symptoms. But that does not imply he must also have had an usually short incubation period. I don’t see why he could not have been infectious 6 days before. Tuesday to Friday is not 6 days.

It is interesting that a US cabinet member who had contact with  Dutton  a week earlier is not following similar advice:

US President Donald Trump’s daughter Ivanka Trump and US Attorney General William Barr are working from home a week after meeting with Australian Home Affairs Minister Peter Dutton, who on Friday revealed he had tested positive for COVID-19.

The White House said that given Mr Dutton was not showing any symptoms during his US trip Ms Trump and Mr Barr did not need to self-quarantine, but they are working from home “out of an abundance of caution”.

“The Attorney General is feeling great and not showing any symptoms,” a US Department of Justice spokeswoman told Nine newspapers.

Perhaps the US government is more aware of how seriously the medical profession regards politicians as a biosecurity hazard that need to be prevented from interfering with management of pandemic emergencies by any means necessary. The more cabinet Ministers unable to work, the safer the rest of us will be.

Covid-19 – Don’t Panic – Do Self Isolate

It is reasonably certain that Australian governments will take measures for “social distancing” fairly soon.

It is difficult to determine the optimum time as such measures are extremely disruptive and cannot be maintained for very long. The aim is not to contain the outbreak but to spread out the peak to reduce the number of people who die because intensive care such as mechanical ventilators are unavailable during the peak case load.

Italy moved too late according to this article for GPs from their main professional organization, dated 11 March:

6.2% case fatality rate

Italy is now one of the worst-affected nations, with a high elderly population where the virus spread undetected for several weeks.

The entire nation has now been placed into quarantine in an effort to get on top of the virus. All public gatherings are banned, restaurants and bars have restricted hours, and cinemas, theatres, libraries and museums have been ordered to close. Schools, daycare and universities have also been closed.

The national quarantine may be effective, as it was in China, but it will take time to have an effect.

In the interim, large numbers of serious or critical cases have swamped hospitals, leading to top Italian health official Professor Giacomo Grasselli to dub the virus ‘worse than a bomb’.

Dr Daniele Macchini, an intensivist in Lombardy, has described the impact of the virus as an ‘epidemiological disaster’ and a ‘tsunami’ that is threatening the ability of the hospital to offer care.

‘Suddenly the E.R. is collapsing … Every ventilator becomes like gold: those in operating theatres that have now suspended their non-urgent activity become intensive care places that did not exist before,’ he wrote on a Facebook post that has been translated.

The concerning account is echoed by another anonymous Lombardy intensivist, whose comments were posted by UK doctor Jason Van Schoor on Twitter.

The intensivist said that despite Lombardy’s wealth and excellent healthcare system, the virus has overwhelmed hospitals.

‘The current situation is difficult to imagine and numbers do not explain things at all. Our hospitals are overwhelmed by COVID-19, they are running 200% capacity,’ the intensivist wrote.

‘There are hundreds of [patients] with severe [respiratory] failure and many of them do not have access to anything above a reservoir mask.’

Due to the shortage of ventilators – which are essential to keeping critical patients alive through the severe pneumonia – China has now offered to send Italy 1000 ventilators, as well as large supplies of personal protective equipment and testing kits.

The RACGP has more information on coronavirus available on its website.

Going too early might perhaps be as bad as going too late if it merely delays the peak rather than widening it. But the idea of Australian governments moving too rapidly seems implausible.

Here’s a simple journalistic explanation about “flattening the curve”, same date:

China sending ventilators to Italy confirms that social distancing in China has been successful. This is confirmed in a detailed statistical analysis published in British medical journal, The Lancet on the same date:

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30144-4/fulltext

Other medical information can easily be accessed via the links at that site’s resource center, including links to many other resource centers:

https://www.thelancet.com/coronavirus

The absurd delay resulting in the Grand Prix being cancelled only at the last minute suggests that Australian governments will not act too early.

That means the public needs to be mobilized to shut down social contacts and self isolate before official announcements and publicity campaigns.

In particular the more older people self isolate now the more that will surive the shortage of intensive care for severe cases at the peak.

Inevitably triage for access to Intensive Care Units must allocate them to severe cases among younger people more likely to survive than among older people less likely to survive a severe case.

Pretty well everybody will eventually get the flu when it becomes endemic. There is no chance of vaccines being developed quickly enough to prevent this and little likelihood of effective anti-viral drugs being available to help soon. What matters is whether the small minority of mainly older people who get a severe case needing intensive treatment such as mechanical ventilators, need such treatment during the peak or more slowly after the main peak has subsided.

Detailed advice on hygiene, social distancing, self isolation etc has been available from US and EU Centers for Disease Control for some time, although that availability of advice has not been matched by implementation. The Australian equivalent has not yet fully caught up even on advice:

https://www.cdc.gov/coronavirus/2019-ncov/community/

https://www.ecdc.europa.eu/en/publications-data/considerations-relating-social-distancing-measures-response-covid-19-epidemic

https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert