Mar 14 2020
Patient:
There are major take-aways from the information shared with me by a colleague
The 1st cases that show up are the most serious, so initially there appears to be a very high mortality rate (large number of deaths to compared to total cases). Inevitably, the mortality rate declined significantly as more cases are known / reported, and may decline further as many case may never get reported (people with very minor symptoms or who are asymptomatic);
The number of actual cases in an area with known infections 10-20x the reported number;
Here’s the most concerning stat and to caveat it, I have no idea if he’s right or not (his math is correct, but perhaps not the assumptions): By the time there is a reported death in a region, there are likely 800 true cases in the region. This is based on some averages he uses as follows: for those who die from the virus, it’s an average of 17.3 days from infection to death. Assuming a 1% mortality rate, there were already ~100 cases in the area (of which only one ended up in death 17.3 days later). Use the average doubling time for the coronavirus (time it takes to double cases, on average is 6.2 days. That means that, in the 17 days it took this person to die, the cases had to multiply by ~8 (=2^(17/6)). That means that, if you are not diagnosing all cases, one death today means 800 true cases today. Washington state had 22 deaths a few days ago. With that quick calculation, you get ~16,000 true coronavirus cases;
The curve for bad outcomes can be bent significantly toward the better by social distancing and well prepared health care system. Overwhelming the health care system can increase fatalities. Social Distancing works, is on our control, and should be put in place now (really yesterday).
I’d also caveat this that the author does not appear to be a statistician, nor health care policy expert. It doesn’t mean his analysis is wrong. It does mean that commentary for recognized experts would be helpful.
Dr. Why:
I mostly agree with you. I do not agree with the guy. As you indicate, he is not a statistician, epidemiologist, etc. He should not write anything like that. Would you take an investment advice from your financial advisor or from me? I hope not from me because I am an amateur in finance at best, dangerous at worst.
I disagree that the all initial cases were serious. These are cases which come to medical and public attention, but epidemics was developing in a background for weeks and months. Therefore, total mortality from the disease must not be calculated based on the number of severe cases/known cases. It has to be dead/total number of exposed.
At the same time, severe cases, which ended in death, let’s take only those who end up in ICU, will represent ICU mortality. Also, if one did not make it to ICU and died, he should also be added to statistics and counted separately as out of hospital mortality, which is even harder to prove. Only those cases, where presence of the virus was confirmed and there was no other plausible cause of death should be included.
If you read my resent post https://www.doctorwhy.blog/blog/coronaviru24, people who died from “coronavirus” essentially die from ARDS. ARDS is associated with appreciable mortality, with the best estimates from a multicenter, international cohort study of 3022 patients with ARDS, suggesting an overall rate of death in the hospital of approximately 40 percent. Mortality increases with disease severity; unadjusted hospital mortality was reported to be 35 percent among those with mild ARDS, 40 percent for those with moderate disease, and 46 percent for patients with severe ARDS.
Another, common and very serious condition - sepsis - has a high mortality rate. Rates depend upon how the data are collected but estimated range is from 10 to 52 percent. Data derived from death certificates report that sepsis is responsible for 6 percent of all deaths while administrative claims data suggest higher rates. Mortality rates increase linearly according to the disease severity of sepsis. In one study, the mortality rates of Systemic inflammatory response syndrome (SIRS), sepsis, and septic shock were 7, 16, and 46 percent, respectively. In another study, the mortality associated with sepsis was ≥10 percent while that associated with septic shock was ≥40 percent. Mortality appears to be lower in younger patients (<44 years) without comorbidities (<10 percent).
Therefore, if one qualified for ICU admission chances of dying are extremely high regardless of the cause.
If you heard the press-conference at the White House yesterday (the 13th of March), a couple of very good points were made:
Do not test unless symptoms match an algorithm for testing;
Testing of all patients who developed upper respiratory symptoms in Korea yielded number of infected by coronavirus in single digits. 90% of the tested had something else. This is assuming there were no false positive and false negative.
At the same time:
The exposure to a known confirmed case must not be a reason for testing. Trump held the ground quite well for a while saying that he personally does not need to be tested but then caved in said that he might do the test after all. He made a big mistake!
Another mistake made was announcement that anyone in consultation with a physician or even without – just in a Wall-Mart parking lot – can get tested. This is a great business idea for Wall Mart and likes, but will lead to lots of anxiety and may expose people to the virus while standing in line for a “drive in” or other mode of testing. If they wanted to make test available to the masses, it could be done by mail order, in a similar way as consumer genetic testing is done now (23andMe, etc.). So, one orders a kit online, collects the sample and mails it to a lab. No exposure, no hustle.
What was not mentioned is sensitivity and specificity of such tests. If we take influenza as an example, rapid tests are only 62% sensitive, e.g. 38% are false negative. This is at best. Also, there tests are designed to answer YES or NO question and nothing else.
The bottom line, I hope you are buying stocks of Wall Mart, Target, Quest, and whoever else was there yesterday. They just boosted their business by billions of dollars, which will go to waste.
I would like to emphasize the tremendous loss of productivity we suffered. You, for one, spend enormous amount of time researching, reading and trying to educate yourself to become an epidemiologist, while I am spending lots of time trying to debunk misconceptions and myths. At least, I am getting paid for that but I feel that you are semi-paralyzed. I would like to issue a guarantee to you: both you and I will die from something else being much older.
BTW, I flew to London then to my destination outside of the Schengen zone via Frankfurt day before yesterday. The upper class on Virgin Atlantic was sold out. The same was on Lufthansa from London and Frankfurt. There were no checks of any kind anywhere. I did not see dead people laying at the airports and sidewalks. Everything was calm and quiet! I think one of the reasons for calm and quiet is that in socialized healthcare in Europe offers much fewer or no opportunities to make an extra buck on this, other than to sell more toilet paper!
I hope this helps.
BTW: I watched "Contagion” with Matt Damon on the plane. What is playing out right now in the world is scripted in fine detail in this movie. It made to scare people, really! I am wondering, how this movie affected current political and economic decisions in the USA and elsewhere. I suggest NOT to watch this movie without being a physician, or other medical professional. It will ignite panic. It has bats transmitting disease via bananas they eat which are used to feed pigs or stuff them while cooking.