COVID-19 Coronavirus Containment Efforts

[mfb]

You don't take 100 deaths/million and 50 deaths/million and add them to get 150 deaths/million. You just don't.

And no one does. So what's the point of this remark?

Second, those plots are cumulative. They, by construction, integrate out day-to-day effects.

Which is a good thing as the reports have large day-to-day fluctuations no one is interested in.

Norway started its lockdown March 12, Denmark started it the day afterwards, that's at the very beginning of the graph. Nearly the whole graph is impacted by the lockdowns. If you want to take ratios you have to start them March 20 or so. And ideally you also shift the curves to take different starting dates of the outbreak into account, otherwise these ratios will vary a lot simply from the different relative time of the cutoff.

I don't think I'm telling you anything new here. So why do you make such a misleading analysis?

Sweden's reported case count is not helpful since they effectively stopped testing.

 

[atyy]

Also, construction workers tend to be fit (but there is one worrying case from much earlier, a 39 years old construction worker who was (is?) in critical care for months now - his wife in Bangladesh gave birth while he was (is?) still under sedation - all of us really hope he gets to see his baby boy and makes a full recovery).

Some good news - this worker has now been moved out of intensive care

COVID-19: Bangladeshi worker, whose wife gave birth while he was in critical state, moves out of ICU
https://www.channelnewsasia.com/new...19-bangladesh-worker-case-42-recover-12649648

 

[Ygggdrasil]

I picked 15 because it's easy to get off Wikipedia. But that's not a crazy number: 2-3 weeks since shutdoiwns began, and the disease has on average a 5-6 day incubation period, and a couple days for the disease to progress. That leaves time for one or two cycles. So what does the data say? Sweden is at 63%, Denmark 61%, Norway it's impossible to tell, and Germany (for comparison) is 71%.

Scientific publications suggest that the mean time from onset of symptoms to death is 20 days, so combined with a ~5 day delay from infection to onset of symptoms, this gives a figure closer to 4 weeks between infection to death.

In Italy, initial lockdowns began around 21 Feb in the hardest hit regions and expanded to a national lockdown on 9 Mar. The number of deaths per day in Italy don't begin to level off until ~ Mar 28, 5 weeks after the initial lockdowns and 3 weeks after the national lockdown, consistent with a ~4 week delay between infection and death:

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

It is likely still too early to judge the success/failure of Sweden's policy by looking at death data. Data over the next few weeks, however, will likely be informative.

Let's also flip the question on its head. Is there evidence that Sweden's policies have resulted in better economic outlook for that country versus other surrounding countries? Here's what an article from the Guardian says:

Although the longer-term impact is obviously unknown, Sweden’s strategy is not expected to preserve the country’s economy this year any more than those of countries imposing stricter lockdowns: Magdalena Andersson, the finance minister, said on Wednesday GDP could shrink by 10% this year and unemployment rise to 13.5%.

https://www.theguardian.com/world/2020/apr/15/sweden-coronavirus-death-toll-reaches-1000

By comparison, the https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020a -7.5% annual percent change for real GDP for the Euro area (though I don't know if this figure is directly comparable to the figure cited by the Guardian).

 

[Vanadium 50]

You don't take 100 deaths/million and 50 deaths/million and add them to get 150 deaths/million. You just don't.

And no one does.

It says so right in the top right corner of anorlunda's plot.

So why do you make such a misleading analysis?

That comment is beneath you, beneath the Mentorship and beneath PF. You can argue that I am wrong and provide better numbers that make your point without claiming dishonesty on my part.

 

[anorlunda]

You don't take 100 deaths/million and 50 deaths/million and add them to get 150 deaths/million. You just don't.

It says so right in the top right corner of anorlunda's plot.

Aha, now I understand. You misread the plot. The 150 is not a sum, it is the scale, 0, 50, 100, 150 are the tic marks on the scale.

 

[atyy]

This is an interesting comparison among ASEAN COVID-19 cases. Do you agree with this presentation?

The number of total confirmed cases depends a lot on how much testing has been done. It would be more informative if presented along with the number of individuals tested.

Singapore's place at the top with most cases per population is (unfortunately for us) probably right, we've had a huge outbreak among about 20,000 construction workers living in dorms in which social distancing is very hard (total number of workers living in dorms is about 300,000). The government has been increasing testing among these workers and finding temporary housing in military camps and "floating hotels" etc to deal with this.
https://www.reuters.com/article/us-...-workers-as-coronavirus-spreads-idUSKCN21V0FN

I attended a webinar in which one speaker (Dale Fisher) was asked whether Vietnam's apparent success was an artifact of to little testing, and he said no - they had done lots of tests. https://www.worldometers.info/coronavirus/ says 268 cases detected in 135938 tests to date. Also it seems they have very good contact tracing with four layers of contacts under various degrees of quarantine and monitoring. I found a couple of interesting articles by googling:
https://www.npr.org/sections/corona...an-300-covid-19-cases-and-no-deaths-heres-why
https://www.dw.com/en/how-vietnam-is-winning-its-war-on-coronavirus/a-52929967

 

[Keith_McClary]

Postmortem is now on.

Putting aside the politics, how can we scientifically prove human-to-human transmission? Experiments, even with volunteers, would be unacceptable. If you have only a few dozen cases and your testing methods are new and experimental, can you prove it to scientific standards?

 

[mfb]

Hospital staff getting it is quite an obvious sign. Work colleagues who didn't eat the same food? Other people who only visited the same place?

 

[Vanadium 50]

Scientific publications suggest that the mean time from onset of symptoms to death is 20 days,

I see 18.5 days in that study. Mean incubation is 5-6 days, so that's 24 days from infection to death, so we should be seeing effects starting a week ago, perhaps a bit sooner because these are median times.

Also, that seems to be longer than other estimates: https://www.medrxiv.org/content/10.1101/2020.03.09.20033357v1 says infection (not onset)to death is 17.8 days./

The Louisiana governor says it's 11 days. He should know. He's a governor.

But I take your point. "Starting the clock" later gives better data, but there's less of it, so you're more prone to fluctuations. If one goes to the last 7 days (which makes the fluctuations 40% larger - N=74 for Denmark), one gets 24% for Sweden, 24% for Denmark, and 31% for Germany. We will surely get more and better data with time.

All that said, though, the "it's too soon" argument cuts both ways. If it is too soon to tell that Sweden's strategy is no worse than Denmark or Germany's, it's too soon to tell it's worse, which is what the plot that started this discussion was saying.

The "economy is already damaged" is a fair point. Clearly any action should calculate the projected impact taking what has already happened into account. It also needs to take into account what "do nothing" means. "Do nothing" in Sweden means, as far as I can tell, strong encouragement for beneficial behaviors without shutting everything down. But it's not like they are holding handshaking contests. So what we are really seeing is the differential between encouragement and lockdown, not the difference between lockdown and the status quo ante.

 

[Keith_McClary]

Hospital staff getting it is quite an obvious sign. Work colleagues who didn't eat the same food? Other people who only visited the same place?

I mean, suppose you are the district medical officer advising the government, and they are considering mass lockdowns and quarantines. Would you say "There is some anecdotal evidence" or "strong anecdotal evidence", or ... five-sigma confidence?

 

[Ygggdrasil]

Also, that seems to be longer than other estimates: https://www.medrxiv.org/content/10.1101/2020.03.09.20033357v1 says infection (not onset)to death is 17.8 days./

The abstract of that pre-print says "We estimate the mean duration from onset-of-symptoms to death to be 17.8 days (95% credible interval, crI 16.9,19.2 days)" which is consistent with the paper that I cited (18·5 days, CI: 15·0–22·0) (which makes sense because the teams were likely working from similar datasets).

Otherwise, I largely agree with this post. Although we have ~1 week of data, it's probably still too early to judge whether Sweden's policy has led to worse outcomes. Data from Sweden could inform the next steps the US takes in the next few months (e.g. relaxation to Sweden-like rules in some areas of the country).

 

[DennisN]

A bit of fun in all seriousness...
There's a lot of talk of the consequences for millions of people around the world due to disease and lockdowns, but we must remember that there are consequences for animals too:

 

[gmax137]

Here's something I don't understand: The call for widespread testing. All of us who have been seriously staying home, and haven't been sick, we probably have not been infected, right? If we tested everyone who has been staying home, nearly all would be negative, right? What new information do we get from that testing? So, how do the results factor into deciding when to leave the house?

 

[BillTre]

If we tested everyone who has been staying home, nearly all would be negative, right?

Not necessarily.
Since a portion of people can be infected, but show no symptoms, people in a home could spread covid19 from a single infected person in a house (with no symptoms) to others in the home who might also show no symptoms. These secondarily infected people could pop out of their house and infect many others.
There will also always be those who flaunt guidelines and could have picked up or spead an infection.

What new information do we get from that testing?

1. If social distancing guidelines are loosened, then it is expected than incidents of infection will increase. being able to efficiently test people (as has been promised, low these many weeks ago) will allow more rapidly identifying the newly sick and therefore require less re-quarantining of people (which will be politically unacceptable to some.
2. Better understanding of where a particular population is WRT amount of covid19 going around. the appropriate time to loosen things up will be optimized by better information (which is now not so good, IMHO).
3. Effective testing of the effects of different methods of loosening social distancing guidelines will require test results to determine what works. They should have a quick turnaround to limit unintended damage.

Making medical (life and death) decisions in a vacuum of relevant information is not a well thought out approach.
Leadership should realize this and plan for these things BEFORE they are needed.

 

[gmax137]

If social distancing guidelines are loosened, then it is expected than incidents of infection will increase. being able to efficiently test people (as has been promised, low these many weeks ago) will allow more rapidly identifying the newly sick and therefore require less re-quarantining of people (which will be politically unacceptable to some.

yes, but I can test negative today and get infected tomorrow. So is the idea everyone gets tested periodically? Like, every couple of days?

 

[BillTre]

yes, but I can test negative today and get infected tomorrow. So is the idea everyone gets tested periodically? Like, every couple of days?

Could be.
To be determined. More info needed.

 

[DennisN]

About Sweden...

Sweden is called an outlier because it has refused lockdown.
https://www.msn.com/en-us/news/world/swedish-virus-deaths-top-1000-fueling-criticism-over-strategy/ar-BB12C1xU

EU has called on Sweden to revise their anti-Covid measures

Regarding EU: I haven't heard of this. Do you have a source for this`? As far as I know, EU has pretty little to say about (read: enforce) how different member countries handle this.

Further, Sweden has a very high case fatality ratio

Yes, and also few tests being made. And the tests are focused on healthcare workers and incoming patients which could be an explanation for the larger case fatality ratio. But I don't know.

Sweden's reported case count is not helpful since they effectively stopped testing.

I agree with that.

It is likely still too early to judge the success/failure of Sweden's policy by looking at death data.

I think so too. But I am concerned about our policy, more concerned than before.

The major corona hotspot in Sweden is the capital Stockholm and the region associated with it (Stockholm County). Here in South Sweden (Scania) we have been comparatively pretty lucky so far:

(Note: Numbers per 100k population, Date: 16 april 2020)

Stockholm County:
Cases: 219¹
Deaths: 33.4¹

Scania County:
Cases: 36¹
Deaths: 2.7<sup>1

1</sup> per 100k population.

Source: http://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_Sweden#Statistics

Furthermore, recently there has been concern and debate about the high death ratio due to Covid-19 in the eldercare in Sweden (compared to the other Scandinavian countries Denmark and Norway).

Edit:

I should also say that most of the major political parties in Sweden has joined together to help out during this crisis, and recently there was a decision made which gave the government extended abilities to take countermeasures e.g. for local lockdowns if needed.

Edit 2:

Even though it is anecdotal, I also want to add that I have just recently heard from a couple of Swedish friends concerns about experienced diminishing discipline regarding social distancing. And a couple of days ago, while going out late for supplies, I happened to pass by a nightclub in the city which was absolutely packed with people, inside and outside. I did not like seeing that, and I changed my path to keep a good distance from the crowd. So I am a bit concerned about the Swedish policy...

 

[Astronuc]

Data on Gilead Coronavirus drug (remdesivir) suggests patients are responding to treatment
https://www.statnews.com/2020/04/16...uggests-patients-are-responding-to-treatment/

The University of Chicago Medicine recruited 125 people with Covid-19 into Gilead’s two Phase 3 clinical trials. Of those people, 113 had severe disease. All the patients have been treated with daily infusions of remdesivir.

. . .
“The best news is that most of our patients have already been discharged, which is great. We’ve only had two patients perish,” said Kathleen Mullane, the University of Chicago infectious disease specialist overseeing the remdesivir studies for the hospital.

There is another trial in Pennsylvania.

More on different trials from Gilead.
https://www.gilead.com/purpose/advancing-global-health/covid-19/remdesivir-clinical-trials

 

[kyphysics]

Even though it is anecdotal, I also want to add that I have just recently heard from a couple of Swedish friends concerns about experienced diminishing discipline regarding social distancing. And a couple of days ago, while going out late for supplies, I happened to pass by a nightclub in the city which was absolutely packed with people, inside and outside. I did not like seeing that, and I changed my path to keep a good distance from the crowd. So I am a bit concerned about the Swedish policy...

I'm guessing the non-social distancers were young?

I'm annoyed as hell. We have an executive order in my state to social distance. The kids in my neighborhood don't obey at all. They come from all different households to play sports (contact involved).

*tempted to call the police*

 

[DennisN]

I'm guessing the non-social distancers were young?

Hmm... I'd say between 18 and 30 years old circa. And it has a consequence for those who work at the club also of course. I was a bit shocked to see it actually, since I have experienced quite a lot of carefulness among people those times I venture out. My worries about growing complacency/overconfidence which I have mentioned before in the thread remains.

 

[atyy]

yes, but I can test negative today and get infected tomorrow. So is the idea everyone gets tested periodically? Like, every couple of days?

Could be.
To be determined. More info needed.

If some countries manage to get it back to the stage of being manageable by contact tracing and some degree of social distancing that still allows many businesses to operate, then it may be ok to test only symptomatics and those highly at risk (eg. very close contacts of positives). Testing the general population also has a false positive risk. Maybe something like the South Korean testing strategy.

 

[kyphysics]

Perhaps that is from increased testing in the dorms (for construction workers). I think that has been difficult to manage as there hasn't been enough space for social distancing there. Hopefully it will get better as they find at least temporary living space for them in which social distancing is possible.

The health ministry has recently been plotting a new statistic called "community cases". The numbers are much higher than before the school holidays, but the number of new community cases per day has been pretty constant over the last two weeks. Take a look at the last column of the first table (Fig 1.1) in each of these reports, or the orange bar graph in the figure (Fig 1.2) after the table.
https://www.moh.gov.sg/docs/librari...ion-report/situation-report---15-apr-2020.pdf
https://www.moh.gov.sg/docs/librari...port/situation-report---13-apr-2020-2354h.pdf

Yikes.

200's to 400's to now 700's today.
Hoping you stay safe out there!

eta: The reason this is of such interest to me is that Singapore was obviously the world's model nation and there have been questions about what happens if a country relaxes shelter-in-place, social distancing, etc. measures? Will there be a second wave (although, in Singapore, maybe one can argue it's your "first wave," given how you clamped down on the growth curve successfully)?

If this is happening as a "second wave" in Singapore, then I worry about the U.S. and other countries.

 

[Astronuc]

yes, but I can test negative today and get infected tomorrow. So is the idea everyone gets tested periodically? Like, every couple of days?

This is true. However, the idea of widespread testing is to identify those with exposure or asymptomatic/presymptomatic COVID-19 cases and take steps to prevent exposure of others.

There are numerous institutions developing rapid testing. For example,
https://www.raybiotech.com/covid-19-igm-igg-rapid-test-kit/
https://www.confirmbiosciences.com/covid19-instant-coronavirus-test-kit/
https://www.abbott.com/corpnewsroom...etect-covid-19-in-as-little-as-5-minutes.html

I've heard of rapid testing from nasal swabs as well.

If people go back to work in public, folks may need to wear protective masks (and use hand washing and hand sanitizer) to preclude either infecting others or receiving an infection. Physical distancing would probably still apply.

Then it looks like there may be at least one effective anti-viral treatment, and others are being developed.

The long term goal is the development of a vaccine - perhaps a year out, or longer.

With respect to tracking the existing cases, one bit of data that would be useful, primarily in NY City would be the positive cases of folks who use elevators in their dwellings and at work. An elevator is an enclosed space and all it takes is for one infected person to exposure many others. A relative who is a doctor mentioned the longevity of Coronavirus in elevators. Apparently, it's a long time time, as in days. Elevators in high rise office buildings could expose hundreds or thousands of people depending on the number of stories, and there are many high rise buildings around Grand Central Station in NY City.

 

[mfb]

The mean time from infection or onset of symptoms to death for a given person (the ~20 days) is not the mean time of the infection to death for deaths at a given time in a country where cases grow rapidly. If we have 10,000 cases that are 10 days old and 2,000 cases that are 20 days old then the former group can easily lead to more deaths even if a death after 10 days is less likely for each person. If we look at "deaths at day x" then many of them will come from infections that happened more recently.

All of us who have been seriously staying home, and haven't been sick, we probably have not been infected, right? If we tested everyone who has been staying home, nearly all would be negative, right? What new information do we get from that testing? So, how do the results factor into deciding when to leave the house?

If everyone who could potentially be tested is negative then the pandemic wouldn't exist. It keeps spreading mainly from people who don't know they have it, and probably some people who know and don't care. People get infectious before they have symptoms and staying at home 24/7 isn't feasible for many. If you stay at home the whole time, get food delivered and so on you are probably the least concern for widespread testing - but think of the people who deliver that food and do other essential activities outside their home.
Testing will focus on high risk groups and people who had contact to someone infected. The more infected people we can isolate quickly the less likely they can infect others.

Smallpox wasn't eradicated by vaccinating everyone - that approach was viable in developed countries but not elsewhere. It was eradicated by quick reporting of cases and then vaccination of only people close to that case. We don't have a vaccine yet, so we have to rely on tests and isolation instead. If the case count is low enough to test everyone at risk that can work.

 

[atyy]

Yikes.

Yikes indeed!

200's to 400's to now 700's today.
Hoping you stay safe out there!

Thanks!

eta: The reason this is of such interest to me is that Singapore was obviously the world's model nation and there have been questions about what happens if a country relaxes shelter-in-place, social distancing, etc. measures? Will there be a second wave (although, in Singapore, maybe one can argue it's your "first wave," given how you clamped down on the growth curve successfully)?

We haven't had anything like shelter-in-place until last week, and primary and secondary schools were all still running with physical classes, because things seemed to be under control. So I think the Singapore data is still consistent with the idea from South Korea, and the currently good signs from China, that it is possible to manage things well without shutting everything down. The reason I've always cited South Korea (not Singapore) as the model, is that Singapore had not had any spike until now, so Singapore doesn't show what to do after you have a spike. On the other hand, South Korea had a huge spike, and they dealt with it successfully.

The current spike in Singapore is still atypical (at least with respect to Europe and North America), because it is mainly among construction workers living in dorms where social distancing is hard, so the government has had to find new temporary housing for a very large number of people (about 20,000 people) in a short time. I think this has been mostly done now, so hopefully there won't be new infections, we'll find out in a few days. The other thing that has to be done is to take care of the welfare of all the people who suddenly have to live in temporary housing (these are foreign workers, so they don't have family here).

Edit: it seems more temporary housing for the workers in dorms in still being set up.

 

[BillTre]

As things go on, it seems that some kinds of businesses could be set-up to be conducted with a minimal chance of infection.

For example, I just heard of someone who had a load of gravel dumped in her driveway.
No close contact is needed for this to happen. The order could be placed on line and a truck comes and dumps the load in the driveway without any close contact.

This seems fine to me and could happen with a lot of other businesses.
However, making guidelines for things like this would be complex due to the many different kinds of businesses and is probably too complex for some simple minded government regulation.
In addition, there will always be people or businesses that will try to cut corners which can lead to new infections. Some kind of public shaming might work in many cases, but then some of those shamed would probably want to sue those doing the shaming.

 

[atyy]

Interesting positive case with negative nasal swab.

Typical takotsubo syndrome triggered by SARS-CoV-2 infection
Philippe Meyer, Sophie Degrauwe, Christian Van Delden, Jelena-Rima Ghadri, Christian Templin
European Heart Journal, ehaa306, https://doi.org/10.1093/eurheartj/ehaa306

"An 83-year-old lady treated for chronic hypertension was hospitalized for acute chest pain on 18 March 2020, 21 days after the COVID-19 outbreak started in Geneva, Switzerland.
...
At day 3, the patient started developing fever, showing increasing biological signs of inflammation, and clear bilateral lung X-ray opacities (Panel D). Nasopharyngeal swab was negative for SARS-CoV-2, but the initial positive immunoglobin A and negative immunoglobulin G serology pattern proved acute infection."

 

[kadiot]

This is interesting. The Philippines's Department of Health considered the entire Sitio Zapatera, Barangay Luz, Cebu City in the Philippines as infected. The estimated total population of said Sitio is at 10,000. Does this mean they are adding 10k to the official count for COVID-19 positive cases in the Philippines? Because, really, that’s the implication of this decision.

Cebu City will be the country’s New York City, the epicenter of epicenters, dislodging every city in the Capital with over “10k” cases.

https://www.sunstar.com.ph/article/...kiwmX8NJID9kvzjH0jcE2Ao9LtTC7bPvslNgi-MRBiOPI

 

[chirhone]

1. I want to see studies of people with mild symptoms who got well and then immersed themselves as frontlines in hospitals. Can they be reinfected and would it progressed into serious complications or would they continue to have no or mild symptoms? If so, then these immuned people can become invulnerable frontlines?

2. The fatality is 2% and some young people are affected. I want to see studies if the younger victims have insomnia. This is because lack of sleep can make one weak. So do these young people succumbed to Covid because of lack of sleep (even in hospitals)?

 

[kadiot]

1. I want to see studies of people with mild symptoms who got well and then immersed themselves as frontlines in hospitals. Can they be reinfected and would it progressed into serious complications or would they continue to have no or mild symptoms? If so, then these immuned people can become invulnerable frontlines?

I'm not sure if such studies exist because practically we test asymptomatic patients who are contacts of known case.

Have you read the Cebu news report I posted earlier? Amazingly 51 out of 53 tested are asymptomatic meaning their immune system is able to manage the virus. Notably the human body is host to many types of viruses and bacteria with no apparent impact to ones health. It crosses my mind with only 352 official deaths attributed to COVID-19 from January 25 to April 16 or 80 days in a country with more than 108,000,000, we may be reacting disproportionately to this selective pandemic. Bangladesh and many third world populations are not recording the anticipated mortality rates. In the case of the Philippines, were more than 6 weeks past due on the projected surge date... Hopefully it never happens.

 

[kadiot]

Is there a study already of collating criteria based on history and PE that could help determine it is a clinically Covid-19 case over using diagnostic kits?

 

[chirhone]

https://www.washingtonpost.com/heal...f71ee0-7db1-11ea-a3ee-13e1ae0a3571_story.html

Are there other bacteria or viruses that can damage other organs like kidneys or the heart? I know syphilis can. The Covid-19 virus has indications it can.

 

[WWGD]

What should we make of the recent report of 1,290 deaths in China after more than some 3 months when we had a trickle of 3-4 deaths every other day?

 

[TeethWhitener]

What should we make of the recent report of 1,290 deaths in China after more than some 3 months when we had a trickle of 3-4 deaths every other day?

Upward revisions of death tolls are pretty common in pandemics. The initial US death toll from the 2009 swine flu epidemic was around 3,000, later revised upward to around 12,000 as authorities started including people who had died at home, etc.

 

[kadiot]

This is interesting. The Philippines's Department of Health considered the entire Sitio Zapatera, Barangay Luz, Cebu City in the Philippines as infected. The estimated total population of said Sitio is at 10,000. Does this mean they are adding 10k to the official count for COVID-19 positive cases in the Philippines? Because, really, that’s the implication of this decision.

Cebu City will be the country’s New York City, the epicenter of epicenters, dislodging every city in the Capital with over “10k” cases.

https://www.sunstar.com.ph/article/...kiwmX8NJID9kvzjH0jcE2Ao9LtTC7bPvslNgi-MRBiOPI

This is a good case study for herd immunity...lock down that place and let's see who survives...I'm beginning to favor herd immunity, if we can have the old, very young, immunocompromised people protected or secured.