COVID-19: What to Expect

This article was originally posted March 13 and will be updated on a regular basis.  Updates are in reverse order, meaning the latest update is just below.

 

UPDATE:  May 10, 2020

As some of you know, my daughter was in Rome for a semester abroad when the coronavirus breakout occurred in northern Italy. I was able to convince her to return to the US on March 8 – the same day that 16 million in northern Italy were quarantined. Both her US college and the Italian institution waited until March 15 to recommend (not require) that students leave the country.

She wasn’t feeling well and had an obvious, nasty cough, yet passed through customs at both Heathrow and Boston Logan Airport without a single person asking her about her health, taking her temperature, or recording her name, contact information or destination.

She didn’t have a fever, but we decided to quarantine her at home anyway. For her, this meant staying in her room most of the time, washing her hands any time she entered a common area, using a separate bathroom, etc.

For me, it meant getting up early every morning to disinfect everything she had likely touched: every knob on every kitchen cabinet, the refrigerator door handles, bathroom faucets, door handles, stair banisters, etc. We also cooked almost all of her food to minimize her contact with kitchen items/surfaces and administered temp checks daily.

I put an hour or two per day into maintaining the house in this manner, wondering all the while whether it was even necessary.  I also spent another hour or so every day contacting various health care professionals to try and get her tested.  Without a high fever, it wasn’t allowed per the CDC guidelines – even though President Trump had declared two days prior that “anybody who wants a test can get a test.”

Thirty-two days after her return, during one of countless sleepless nights, I happened to notice that CVS had announced drive-through testing at a site only 45 minutes away. I snagged an appointment online moments before they filled up.

Two days later, I watched incredulously as she was handed a swab and told to collect her own specimen by sticking it an inch or so into her nose.

Based on what I had seen, a proper nasopharyngeal specimen requires inserting the swab several inches into someone’s nose, so far back that it reaches the back of their throat. If a person isn’t very uncomfortable, it hasn’t been done correctly.

Her results were negative but, given that the specimen wasn’t collected properly, I assumed that she could easily be one of the 30% of those who were given false negative results.  It’s now a month later, and for better or worse, I’m finally beginning to believe the test results.

But, there are two important takeaways from our experience. First, the US has utterly failed in its efforts thus far. By March 8, it had conducted a total of 1,707 tests. By contrast, Italy and South Korea had each tested hundreds of thousands.

Given that up to 50-60% of all infections are asymptomatic, how many of the current 1,350,000 known cases (1,035,000 of which are still active), 166,000 of whom were hospitalized and 80,000 of whom died could have been spared had widespread testing and contract tracing been more widely available?

My daughter had a persistent cough and arrived from a country with the second highest number of infections in the world, yet no one even jotted her name down for follow up. Nor was she able to get tested until 34 days later – 36 days after Trump insisted tests were available to anybody who wanted one.

The day she returned home, China led the world  with 80,735 reported cases. Italy and South Korea were in a close race for second and the US was far behind. Two months later, the US is very far ahead of the others on both an absolute and relative basis. According to experts, US cases could be 10-20 times greater as the shortage of available testing has contributed to a significant undercount.

Likewise, deaths in the US have multiplied much more rapidly than in Italy or South Korea.

On both an absolute and population-weighted basis, South Korea’s aggressive testing, tracking, and quarantining measures have made a huge difference with 212 cases and 5 deaths respectively per million citizens. There have been many days over the past two weeks when South Korea reported no new cases and no new deaths.

By contrast, the US has incurred 4,079 cases and 36 deaths per million citizens. It has averaged about 29,000 new cases and 2,000 new deaths per day over the last three weeks. The periodic lulls have been just that – lulls, not persistent declines.

Partisan rhetoric and bickering aside, the US has failed its most important public health test of the past 100 years – one measured in millions of illnesses and tens of thousands of deaths.

The second big takeaway is that things will likely get much worse in the coming months. With 1,350,000 known cases, about one of every 245 Americans has been diagnosed as infected. If undercounted by 10-20X as former FDA Commissioner Dr. Scott Gottlieb believes, it could be as many as one in every 12-24 Americans. About one of every 4,111 Americans has been killed by COVID-19 so far. These are numbers that should concern anyone considering whether to dine at a restaurant, attend a football game or send their kid back to school.

My youngest daughter’s high school has 1,500 students, so it’s likely there are at least a few students who have been infected (maybe half of whom are asymptomatic) and will come into contact with at least 100 other students every day. At the end of each day, those students will head home and risk infecting their family members.

Most families can and will exercise caution. But, if my experience is at all typical, it won’t be enough.  Anyone can be hyper-vigilant for a day or two. But, it’s extremely difficult to maintain that same level of caution day after day for weeks at a time.

I’ve been accused of being over-the-top cautious (my daughters prefer “paranoid.”) And, I can’t count the number of times a mistake was made which might have landed one of my family members in the hospital. There were times when my daughter coughed in a common area of the house and we nervously ignored it. Other times, one of us used the same faucet, toilet, door knob, kitchen utensil or remote as she did without first disinfecting it. Several mornings, I forgot to wipe down the banister or the handle of the water pitcher.

Despite the best of intentions and very significant time and effort, each passing day was filled with countless little mistakes – any one of which could have been serious or even fatal. I even knew this to be the case at the time — having recognized very early on that health care professionals with access to superior knowledge and safety equipment were falling ill and dying from COVID-19.

In short, we were as fortunate as we were simply because my daughter was not infected. Had she been infected, our story would be quite different.

A recent study determined that two-thirds of patients hospitalized with COVID-19 in New York had been observing lockdown restrictions. They weren’t eating out, working in a crowded office, riding public transportation, attending political rallies or welcoming their kids home from school every day. They were being careful, yet still became sick.

As more and more states open up, I suspect we’ll see a surge in cases and, after a brief lag, a surge in deaths – particularly in those states which have done inadequate testing, have large numbers of nursing homes, prisons and meat-processing plants, and/or have leadership which has downplayed the coronavirus threat.

There is some good news related to flattening the curve. The daily rate of growth in US cases and deaths continues to slow. The 10-day moving average is about 2.5% for cases and 3% for deaths.  At this rate, cases will reach 1,500,000 around May 14 and deaths will reach 100,000 around May 18.

Global cases should reach the 5 million milestone by May 20 and deaths should reach 300,000 by May 14.  Of course, the progression of global cases will depend largely on the US’ success or lack thereof in reopening the country.

Much has been discussed about the tradeoffs between saving the economy and saving lives. I’m neither a philosopher nor a religious scholar, so I won’t wade into the moral argument. I am troubled, however, by much of what I hear on the economic front.

To a family struggling to buy groceries or pay the rent, reopening the country is a matter of necessity rather than choice. Through no fault of their own, they must bear the economic brunt of their government’s failure to act in a timely manner to forestall the epidemic.

For many, working from home is not an option and buying groceries means exposing oneself and one’s family to serious illness and death. One particular story caught my eye this past week.

Sixty-four year-old Rafael Benjamin worked at a Cargill meat-processing plant in Pennsylvania. Many of his coworkers were falling ill, so on March 25 a daughter gave him a face mask to wear at work. Two days later, a supervisor ordered him to remove it as it made other plant employees nervous. On April 4, Rafael called in sick. The following day, unable to move, he was taken by ambulance to the hospital. He died on April 19.

On April 24, President Trump classified meat plants as critical infrastructure, preventing local and state health authorities from closing them down regardless of health concerns. The business community is working with the White House and Congress to protect companies like Cargill from customer and employee lawsuits related to coronavirus.

If passed, such legislation would allow bad actors to pressure workers to report to work regardless of their health conditions and without providing common sense safeguards. Because it would ultimately result in more illness and death, it would ironically apply additional economic pressures on the very companies seeking liability protection.

Another industry singled out for special treatment is the oil industry. If the White House and Congress were primarily concerned with unemployment in the sector, they could more vigorously subsidize payrolls instead of artificially driving the price of oil and gas higher.  First, artificial price support will do nothing to correct the imbalance between supply and demand. Second, higher fuel prices are a regressive tax on those who can least afford them.

As a disciple of the Cynical School of Economic Thought, I find the entreaties by many major corporations and billionaires (most of which have cheap, ready access to capital markets) to reopen the country now to be self-serving — focused more on inflating excessive equity valuations than ensuring full employment and economic well-being for society’s most vulnerable.

Perhaps quantitative easing and financial engineering have become so effective that the economic well-being of ordinary citizens is no longer relevant.  Things certainly seem to be headed in that direction.

 

UPDATE:  Apr 17, 2020

Word on the street is that the remdesivir story was planted by a rumor-for-hire outfit and that the drug has failed in previous trials in China. Gilead has since walked back the hype.

The other COVID-19 story to hit the wires this morning is that Moderna received $483 million from the government to fast track its vaccine efforts. It’s great news, as is all the other vaccine research going on at an unprecedented pace. In listening to the CEO’s interview, however, it’s obvious that this, like every other vaccine being developed, won’t be widely available until 2021.

I’m as hopeful as anyone else. But, in the absence of a therapeutic or vaccine, I believe opening the country back up will absolutely result in a resurgence of community transmission and a sharp rise in the number of deaths – particularly in those parts of the country which have yet to be affected in great numbers.

The problem continues to be testing. If all of us pack in to a basketball game or concert and even one of us is infected, many of us will become infected. We’ll then head home and infect our loved ones and go in to the office and infect our coworkers. Since 25-50% of infected people have little or no symptoms, there is absolutely no way to prevent this from happening unless we get a vaccine.

In the US, only 13% of the 680,000 diagnosed cases have been closed – meaning either a person got better or died. Of those which were closed, nearly 40% resulted in someone dying – 34,700 of them.The chart below shows that the death rate (the orange line) has remained very steady since March 26, bouncing back and forth between 35% and 43%. This is not progress, and it hardly argues for easing up on efforts to prevent community transmission.

The US remains in 44th place in the world in testing per 1mm people. The chart below, sorted by tests per 1mm, shows some of the countries which have done much more. Not a great argument for opening up the country. The raw number of tests, BTW, is irrelevant. In total cases per 1mm population, the US is in 20th place…

…while in deaths per 1mm, the US is in 14th place. Again, not a great argument for opening up the country. We have had periodic declines in new deaths and cases and the rate of growth in each has definitely subsided. But, both are still occurring at an alarming rate.

If the proportions hold, 1,500 of the 30,000 people diagnosed today will die — and that’s without opening up the country.

Compare the data to a country such as Germany, which imposed a stronger quarantine much earlier than the US. Sixty-two percent of all diagnosed cases have been closed, and deaths account for a mere 4% of those. Remember, the US is running about 40%.

Even though active cases have clearly rolled over…

…Germany is still seeing 3,000 new cases per day… …and deaths are still ticking higher.By comparison, the number of active cases in the US is beginning to flatten, but is far from rolling over.

The most frightening report I’ve seen in the past week was this one from the UN which reveals that 74 million people in the Arab region lack access to a basic handwashing facility (i.e. clean running water.) It’s safe to say that most of those 74 million also don’t have a bottle of Purell handy.

Consider the 1.2 billion people in Africa who have been so susceptible to past epidemics which were much easier to detect. The 2013-2016 Ebola outbreak in West Africa infected 28,646 and killed 11,323. Almost 20,000 cases of COVID-19 have been detected so far, and it’s still early days.

I give President Trump’s political advisors credit for convincing him to give governors the responsibility for deciding when/how to reopen their states. Those who are aggressive about it will pay the price, while those who don’t reopen things quickly will continue to pay an enormous financial price. Without widespread testing and an effective therapeutic/vaccine very soon, there will be no happy ending for either.

 

UPDATE:  Apr 13, 2020

I’ll start with the bad news, just to change things up.  The US now has almost 600,000 cases, 1 out of every 587 people and almost as many as the next 4 countries combined.  Deaths, now 3.9% of all diagnosed cases, total over 23,000.  Sadly, 40% of all closed cases result in someone dying.

Fatal outcomes now account for 4% of all diagnosed cases. Another way of looking at it: for every 100 people who have been diagnosed, 90 are still sick. Of the remaining ten, 6 recovered and 4 died. Were these percentages to hold, we might expect the 26,641 new cases diagnosed just today to result in 1,065 deaths.

But, since deaths lag new diagnoses, it would be 4% of a larger number. And, since the mortality rate is climbing every day (it was 1.2% on March 22) it would probably be a larger percentage of a larger number of people. If one of those were a friend or relative, you’d might disagree with opening up the country just yet – regardless of the trends.

Many countries have had much better outcomes, such as Switzerland where deaths are only 7% of closed cases and testing has been conducted on 22,993 per million citizens versus 8,816 per million (43rd in the world) in the US. Even Italy, to which the US is often compared, has tested 17,315 per million.

Now, for the good news. The daily rate of growth (ROG) in cases has slowed significantly  – presumably as a result of quarantining (aka social distancing.) The 10-day moving average for case growth has slowed from 15% a week ago to about 10%. The 10-day moving average for the daily ROG in deaths has slowed from 22% to about 14%.

More testing and continued quarantining should continue to bring the growth rates down. Opening up the country without more testing, however, will only serve to increase them. At a ROG of 14%, deaths will reach 100,000 by April 24. Slowing the rate to 10% (i.e. flattening the curve) would delay that milestone to Apr 28 and to 5% would delay it to May 13.  This would buy scientists more time to come up with effective therapeutics.

Getting tested?  It’s easier now but, based on my experience, not very accurate. I took my daughter (who returned from Italy with a bad cough) to a drive-through testing site run by CVS. It was fast and free, but they handed my daughter the swab and asked her to collect her own specimen.

She inserted the swab about 1 – 1.5 inches into each nostril, at which point the tech said “good job” and put the sample into a bag for assessment. This was completely inadequate and is probably responsible for the 30%+ false negative results being obtained.

An accurate nasopharyngeal specimen collection means sticking the swab so far back that most people would gag and tear up in the process. Here’s a video of the correct process.  Bottom line, don’t assume that a negative test is correct. Continue to exercise caution – particularly if someone is exhibiting symptoms.

And, even if some politician gives you the all clear, remember that nearly 30,000 new cases will be diagnosed today. Don’t be one of them.

UPDATE:  April 3, 2020

Out of curiosity, I took a look at mortality rate trends in a few other countries. While some are clearly better than others, every single one is rising consistently over the past week.

And, deaths are consistently rising faster than cases. Cases have risen an average of 2x over the past week, while deaths have risen an average of 3.4x.  In the US, the numbers are 2.9x and 4.7x – a ratio of 1.64 deaths per every new case diagnosed. In Germany, deaths are rising over twice as fast as cases.

I have very little medical training, but I believe this is why we’re hearing so much about flattening the curve. The experts know that our hospitals will be overwhelmed if the ROG doesn’t slow dramatically.  Overwhelmed hospitals and shortages of ICU beds and ventilators will translate into higher mortality rates.

In some cases, however, the higher mortality rate can be attributed to a drop in the rate of growth in new cases.  Due to the lag between diagnosis and death, case growth can roll over as deaths are still rising. A good example is Austria.  New cases peaked on March 26 while deaths peaked on March 30.

This has allowed its mortality rate to almost flatten: from 1.3% on March 31 to only 1.5% on April 3. And, its curve is definitely flattening. Note that Austria enacted nationwide restrictions on travel and gatherings on March 16 when there were 1,018 total cases and 3 deaths. This was 18 days after the first community transmission case was detected and two days after the first death.The US, by contrast, has still not enacted a nationwide lockdown despite over 300,000 cases and 8,000 deaths since the virus arrived over two months ago on January 20.

The 10-day moving average of the daily rate of growth in deaths in the US dipped slightly to 27.3%.  But at this rate we would still reach 10,000 deaths this weekend, 100,000 by April 14, and 1 million by April 24.

Some might feel this rate is too pessimistic, that something will happen to change the trajectory. I hope so. But, even if the rate were to plunge to 20%, we would still have over 1 million deaths before the end of April – one in every 323 people in the US.  And, remember, this number is understated – though not as dramatically as the number of cases.

Don’t wait for the government to tell you what we already know: the only way to be completely safe is to stay at home, away from anyone who might be infected (including asymptomatic family members) and to wear a mask if you absolutely must go out – especially around other people. Assume that everything you touch might harbor the virus.

Yes, you might feel like you look really paranoid. But, your family will thank you.  And, God willing, you can all laugh about it some day.

For those staying in this weekend, I just read that HBO is releasing 500 hours of programming for free, including every including every episode of The Sopranos, Veep, The Wire, Barry and Ballers.  You can download the HBO NOW or HBO GO apps or visit HBONOW.com or HBOGO.com. #StayHomeBoxOffice.

Stay safe everyone.

 

UPDATE: March 31, 2020

Italy’s mortality rate continues climbing steadily: from 2.0% on March 1 to 11.4% as of March 30. I never see this data reported anywhere, but believe it’s very important as it confirms what should be obvious: An overwhelmed health system is not as effective in saving the lives of sick COVID-19 patients.

Those in the US who take comfort in its current 2% mortality rate probably shouldn’t. Reported cases – still an understatement of actual cases due to the continuing shortage of test kits – continue to increase at an average (10-day SMA) of 24% per day. But, deaths are climbing at about 30% per day – much faster in some states. Inexplicably, many states have yet to issue stay-at-home orders.

The top 25 states in terms of cases are shown below. Note that Louisiana, a relative newcomer to the top 10, is already at a mortality rate of 4.6% – topping Washington’s 4%. Virginia’s governor finally issued a stay-at-home order yesterday, as that state’s mortality rate reached 2.5%.

Several cities and counties in Georgia, which faces a 3.4% mortality rate, have issued orders; but, the governor has yet to announce a statewide order. Arizona’s governor, who had issued an order restricting the ability of cities and counties to issue their own orders without his approval, finally caved yesterday when cases topped 1,000.

As more hospitals across the nation are overwhelmed by cases that outnumber the available ICU beds and ventilators, the mortality rate is bound to rise. Those that restrict transmissions before cases get out of hand stand the best chance of not being overwhelmed. The rest will suffer the consequences. As Dr. Georges Benjamin, executive director of the American Public Health Association, said: “Waiting until you get a lot of cases is the wrong strategy.”

Currently, about 1/3 of closed cases – someone being either discharged or dying – result in a death. But, only 5% of total reported cases have been closed – again, a factor of the rapid growth in cases.  In Italy, where 26% of all cases have been closed, deaths account for 44% of all closed cases and, as mentioned above, 11.4% of total cases.

Applying the same percentages to US cases would indicate that 2,313 of the 20,297 new cases reported just on March 30 will result in someone dying. At the current daily rate of increase, the US will reach 10,000 deaths by April 4 and 100,000 on or around Easter. My projections indicate total cases could reach 2.4 million by then, swamping the 924,000 beds in the 5,198 community hospitals across the nation.

If even 5% of those cases were serious/critical, the resulting 120,000 cases would far outnumber the 77,000 ICU beds in the US.

Bloomberg pubished an interesting article earlier today citing an Italian study that offered a theory as to why Italy’s mortality rate is so high.  The study suggested that because Italy had such a mild winter, many of the deaths that might ordinarily have occurred due to flu were brought on instead by the coronavirus. The inference is that the mortality rate is much higher than it would otherwise be had the winter been colder.

While I certainly find the premise plausible, it doesn’t do much to move the needle.  The study suggests that “the total number of older Italians spared death directly from the flu this season may have been in the hundreds, based on an annual average of 8,000 nationwide flu deaths cited in the paper.”

Italy has seen over 12,000 deaths. Subtracting 500, for instance, would lower its mortality rate from 11.4% a still very high 10.9%. Having had a daughter in Italy between late January and March 8, I followed the situation very closely. I think the high death rate is much more likely to have been the result of some bad luck (getting hit with the first burst of infections) and a failure to lock down the entire country.

Early on, several small towns in northern Italy were quarantined.  Many who were able to simply left the area, returning to their homes in southern Italy or elsewhere in Europe.  As cases spread, Milan was included in the quarantine. Again, this didn’t stop anyone from returning to their home. As I wrote at the time, 20,000 people were taking a train from Milan to Rome every day.

Eventually, the entire country was put on lockdown. But, by then, the spread had occurred and quickly overwhelmed the available hospital facilities. While cases increased 59X between Mar 1 and Mar 30, deaths increased 341X.

This is why I believe a nationwide lockdown is essential for the US. We all know someone who left a heavily infected area to go someplace “safe” such as a friend or relative’s house, a second home or just a hotel. Unfortunately, some of those people are infected and transmit the disease to people in the other location. It only takes a few to get the community spread ball rolling. This is precisely what happened in Europe.

True, there are some very efficient and tightly controlled countries in Europe with low mortality rates (so far) such as Switzerland (2.7%), Austria (1.4%) and Germany (1.1%).  But, each of these took early, aggressive measures to limit the spread. Many other countries are slightly behind but on the same track as Italy: France (6.8%), Spain (8.9%), UK (7.8%), and Netherlands (8.6%.)

A March 30 study from Imperial College of London researchers draws a direct correlation between the number of deaths and the speed with which various countries took steps to intervene in the virus’ spread.  All but one (Sweden) ultimately ordered a lockdown – typically as each country’s leaders realized they would not be spared.

While identifying and limiting the spread of US cases is incredibly important, note that I have focused mostly on the trend in deaths — which distills all the theories and practices into one defining, indisputable and depressing number every day.  It’s where the rubber meets the road.

I printed a list of the top 25 states in terms of cases as of March 30 above. Mortality rates ranged from 0.5% to 4.6% with a median of 1.7% and a mean of 1.9%.

At the end of today, March 31, the range was from 1.1% to 4.6% with a median of 2.1% and a mean of 2.2%. While total deaths grew by 31% in that one 24-hour period, the average daily rate of increase among the 25 states was a stunning 47%.

Note that the order of the top 25 has changed. Florida has moved into the #5 slot, Illinois has moved ahead of Washington to #7, Louisiana moved from #10 to #9, Georgia moved ahead of Texas to #11, etc. I’ll continue to track these same 25 so we can stay abreast of the trend.

The important thing to realize is that deaths continue to rise sharply. As in Europe, the growth has tended to accelerate faster in states which were late to start testing, close schools and businesses, and issue stay-at-home orders. Those that have not restricted movement should expect to see deaths continue to outpace those that have.

With a total of 4,053 deaths as we goes to press, rising at a 10-day moving average of 29.8% per day, total US deaths should reach 10,000 by Saturday April 4, 100,000 by April 13, 500,000 by April 19 and 1 million by April 22.

I believe that this fate can be avoided only if: (a) everyone who should be tested is tested, (b) the entire nation is locked down, and (c) scientists can develop effective treatments in the next week or so. I hope to God I’m wrong.

A few reminders that I haven’t seen circulated nearly enough: Studies indicate that up to 50% of transmissions are from people who have little or no symptoms. Your kid or your neighbor who appears perfectly healthy can give you the virus.

And, studies now indicate that the coronavirus can remain aerosolized for up to three hours. You could be walking down a deserted aisle at the grocery store and stroll right through the viral mist emitted by someone who sneezed there 20 minutes ago. Wear a mask when out in public places and assume that everything you touch is infected.

 *  *  *

UPDATE:  March 22, 2020

Italy’s mortality rate increased to 9.3% on March 22, a steady increase from 2.0% on Mar 1.  Though, on a positive note, the daily rate of growth in cases and deaths has ebbed somewhat: Neither has exceeded 20% since March 13.  On a not so positive note, both are still doubling every 6-7 days.The daily ROG in US deaths ticked lower on March 20-21, but pushed back up to 39% on March 22.   At this rate, the 419 US deaths as of March 22 would exceed 1,000 by March 25, 10,000 by April 1, and 100,000 by April 8. Take a moment and let those numbers sink in.

Italy still has many active cases, 80% of the total. Fortunately, most are resolving as “recovered/discharged.” But, the 9.3% mortality rate – up from only 2% on March 1 – means that nearly as many die as are discharged/recovered.

Only a very small fraction of US cases are closed. Unfortunately, about 73% of closed cases have resulted in death rather than recovery.

This is up from 60% of cases just 4 days ago. Serious/critical cases as a percentage of active cases have more than quadrupled in that time. In other words, things are getting worse at an accelerating rate.

I regret to report that our original models posted on March 13-14 have not kept up with the actual results. The model which used the then 10-DMAs of daily rates of growth for cases and deaths (34% and 18%) had forecast 23,410 cases and 247 deaths for March 22.

The model which borrowed the 10-DMA of Italy’s daily ROG with an 11-day lag had forecast 23,410 cases and 481 deaths.

As of last night, total acknowledged US cases totaled 33,546 (still undercounted) and deaths totaled 419.

  *  *  *

UPDATE: Mar 17, 2020

For those interested, here is an update on the current case and death data for Italy and the US as of Mar 16.

In Italy, the current mortality rate has ticked up even higher to 7.7%. The 10-day moving average for mortality rate has increased to 6.3%. The 10-DMA for the ROG in cases and deaths has eased slightly to 21% and 28%.

   Italy
   date    cases    deaths
21-Feb                21                  1
22-Feb                79                  2
23-Feb              152                  2
24-Feb              229                  6
25-Feb              322                11
26-Feb              400                12
27-Feb              655                17
28-Feb              889                21
29-Feb           1,128                29
1-Mar           1,701                34
2-Mar           2,036                52
3-Mar           2,502                79
4-Mar           3,089              107
5-Mar           3,858              148
6-Mar           4,636              197
7-Mar           5,883              233
8-Mar           7,375              366
9-Mar           9,172              463
10-Mar         10,149              631
11-Mar         12,462              827
12-Mar         15,113           1,016
13-Mar         17,660           1,266
14-Mar         21,157           1,441
15-Mar         24,747           1,809
16-Mar         27,980           2,158
17-Mar
18-Mar
19-Mar

 

This is largely due to a “good” day on March 16 where cases increased by only 13% and deaths by 19%.  We’ll pray that the decline lasts more than a day.

The US, unfortunately, has managed to keep pace with our forecast from March 13 which was based on a moving average of growth rates. On March 13, our model predicted 5,444 cases and 80 deaths for March 16. Actual results were 4,663 cases and 86 deaths.

Again, the continuing lack of testing kits renders the number of cases essentially meaningless. Many experts feel it could be off by a factor of at least 10X, possibly much more.

The number of deaths, unfortunately, is probably accurate. The 10-DMA for daily ROG in deaths has risen from 18% on March 13 to 19.2%. The chart below reflects these data and uses the most recent 10-DMA in daily ROG for each category to forecast future results (in italics.)

US: 10-DMA
    date     cases    deaths
3-Mar              124                  9
4-Mar              158                11
5-Mar              221                12
6-Mar              319                15
7-Mar              435                19
8-Mar              541                22
9-Mar              704                26
10-Mar              994                30
11-Mar           1,301                38
12-Mar           1,697                41
13-Mar           2,269                48
14-Mar           2,943                57
15-Mar           3,680                68
16-Mar           4,663                86
17-Mar          6,102             103
18-Mar          7,984             122
19-Mar        10,448             146
20-Mar        13,672             174
21-Mar        17,890             207
22-Mar        23,410             247
23-Mar        30,632             294
24-Mar        40,084             351
25-Mar        52,451             418
26-Mar        68,635             499
27-Mar        89,812             595
28-Mar      117,523             709
29-Mar      153,784             845
30-Mar      201,232          1,008

If we were to use the daily ROG exhibited by Italy on an 11-day lag as originally theorized, we’d see the following results in deaths (cases are the same as above, as this is a poor estimate anyway):

US: It ROG
     date      cases     deaths
3-Mar              124                  9
4-Mar              158                11
5-Mar              221                12
6-Mar              319                15
7-Mar              435                19
8-Mar              541                22
9-Mar              704                26
10-Mar              994                30
11-Mar           1,301                38
12-Mar           1,697                41
13-Mar           2,269                48
14-Mar           2,943                57
15-Mar           3,680                68
16-Mar           4,663                86
17-Mar          6,102             114
18-Mar          7,984             135
19-Mar        10,448             213
20-Mar        13,672             269
21-Mar        17,890             367
22-Mar        23,410             481
23-Mar        30,632             590
24-Mar        40,084             736
25-Mar        52,451             837
26-Mar        68,635          1,051
27-Mar        89,812          1,254
28-Mar
29-Mar
30-Mar

As mentioned above, the mortality rate in Italy has risen to 7.7% from only 2.0% on March 1. This was no doubt impacted by the shortage of hospital beds, ventilators and medical personnel.

The US’ relative readiness in this regard has been the subject of many studies and articles. But, I have yet to find a credible source suggesting that the US is better prepared. According to the OECD, the US has 2.8 hospital beds per 1,000 people. China has 4.3, South Korea has 12.3, and Italy has 3.2.

If the number of current US cases were accurate, the current mortality rate would be about 1.8%. We know the number of cases reported is too low.  So, hopefully, the mortality rate is too high. But, even if it were accurate, an escalation in the mortality rate to Italy’s current level would result in over 15,000 deaths by the end of March.

This is why flattening the curve is so vital and why the current growth in cases and deaths is so troubling.

As in Italy, once hospital beds and ventilators are impacted the mortality rate will go up. By slowing admissions, we can reduce overcrowded conditions and keep the mortality rate lower. At least, that’s the theory.

It’s important to note that even a slight increase has a huge impact on resulting cases and deaths.  The chart below shows deaths at Day 5, 10 and 30 for different daily rates of growth.

ROG           Day 1           Day 5          Day 10              Day 30
5%                86              110               140                    372
10%                86              139               223                 1,501
15%                86              173               348                 5,694
20%                86              214               532               20,414
25%                86              262               801               69,470
30%                86              319            1,186             225,320

 

According to the American Hospital Association, the United States has 98,000 total intensive care beds, but 51,000 of those are for specialized use such as cardiology, pediatrics, neonatal, etc.  The difference between a 20% daily growth rate and a 30% growth rate, then, would make all the difference in terms of being able to handle the number of cases. But, that’s looking only 30 days out.

According to a Johns Hopkins Center for Health Security report conducted last month, a moderate pandemic would mean 1 million people needing hospitalization and 200,000 needing intensive care. A severe pandemic would require 9.6 million hospitalizations and 2.9 million ICU beds.

The even more serious problem is ventilators.  According to Johns Hopkins, the US has 160,000 in total, 98,000 of which “are not full-featured but can still provide basic function in an emergency during crisis standards of care.” Another 8,900 mechanical ventilators of uncertain capability are in a national stockpile. Any way you slice it, it’s woefully short of what will likely be needed and will, like Italy, result in a much higher mortality rate.

One last comment on an article which hasn’t received much air time: Stay away from your kids. Seriously. In this article from CNN, several studies are cited which indicate that infected but asymptomatic people might be more contagious than those with obvious symptoms.

In other words, your 20 year-old who just got back from a semester abroad but only has a cough could very well give you the virus that kills you – something to think about as you’re waiting for tests we’ve been promised to finally become available.  Bottom line, keep your distance but follow them around with a spray bottle of bleach. God willing, you’ll both laugh about it some day.

 

 

 

 

 *  *  *

March 13, 2020

I saw something quite stunning this morning: Treasury Secretary Mnuchin describing the COVID-19 pandemic as “a great investment opportunity.” Tone deaf as ever, but no surprise there.  He then went on to draw comparisons to South Korea’s experience where 200,000 people have been tested – only 4% of which were found to be infected, as though this meant there was nothing to worry about. Let’s unpack this, shall we?

Actually, 222,000 people in South Korea have been tested — about .44%, or one in every 225 people.  In the US, the number of people who have been tested was recently removed from the CDC website. But, many academics put it at approximately 13,600, about .0042%, or one in every 24,200 Americans.

In South Korea, the government can access data – CCTV footage, GPS tracking data from phones and cars, credit cards transactions, immigration records and other data to deduce who might be at risk of contracting the disease or passing it to others. Anyone who wants testing can get it, with drive-through testing in place since March 2.

The names of those Koreans found to be infected are made public so friends and relatives who might have been exposed can get themselves tested. Anyone who tests positive is self-quarantined and monitored through an app or by phone until a bed is available, at which point an ambulance delivers them to a hospital with air-sealed isolation rooms.

In the US, an acquaintance recently told me of arriving from an extended trip to Italy and breezing through customs with a noticeable, persistent cough. No one took their temperature, asked their health status or jotted their name down for follow-up. When they called their US doctor, they were told they couldn’t be tested unless their fever topped 100.4 degrees due to a shortage of test kits. The drive-through idea was just announced today.

All things considered, I consider South Korea a very poor comparison. For the past several weeks, I have focused instead on Italy. Like the US, they have a modern health care system, but were caught completely off guard when COVID-19 arrived from China. Italians are also used to a certain degree of autonomy and would presumably bristle at the intrusiveness of South Korea’s response.

About 11,500 Chinese travel to Italy each day compared to 14,000 who travel to the US. The US instituted a travel ban (with some exceptions) from China on February 4.  Foreigners were mostly turned away, but others had their temperature taken and were asked to self-quarantine. Italy instituted a travel ban with no exceptions, and no flights whatsoever, four days earlier.

Italy locked down the northern part of the country, putting 16 million people on lockdown on March 8. The lockdown was extended to the entire country – 60 million people – on Tuesday, with essentially every establishment except grocery stores and pharmacies closed.

In the US, not a single city or state has been quarantined.  Over the past few days, many schools, sporting events, concerts, conventions and the like have made the decision to close or operate online. I am not aware of a single enforced quarantine other than those who returned from a cruise or trip overseas and were clearly infected. Americans are asked to self-quarantine, which is fine in concept but doesn’t work very well given that the incubation period can be two weeks or longer, and few can afford to ditch their jobs for two weeks.

Italy has essentially been shut down, even though its response has arguably been much more robust than America’s.  In my opinion, this doesn’t bode well for the US. I have been making predictions for the past several weeks based upon comparisons between the two: schools closing, stores closing, travel restrictions, runs on cleaning supplies and groceries. Many readers, not to mention friends and family, who initially scoffed are no longer scoffing. I get many texts and emails every day saying something along the lines of “can you believe they just cancelled…?”

I’m a numbers guy, so I’ve been working diligently to come up with a formula that expressed the path the number of cases and deaths was taking. The problem is that only a small number of cases have resolved in both Italy and the US.

Total cases in the US are (supposedly) 2,269. This is no doubt very far short of the actual number due to the lack of available testing. But, the outcome data are telling. Only 79 of these 2,269 are closed: 39% due to the patients’ recovery and 61% due to their death. This leaves 2,190 in limbo, whose fate is as yet undetermined. But, we can make some educated guesses.

While the cases are almost certainly undercounted, the number of deaths is probably fairly accurate.  At 48 total deaths, the current mortality rate is 2.1%. Some might take solace in such a low number. But, that would probably be a mistake. The Italy data are below.

    Italy
   date    cases    deaths
21-Feb                21                  1
22-Feb                79                  2
23-Feb              152                  2
24-Feb              229                  6
25-Feb              322                11
26-Feb              400                12
27-Feb              655                17
28-Feb              889                21
29-Feb           1,128                29
1-Mar           1,701                34
2-Mar           2,036                52
3-Mar           2,502                79
4-Mar           3,089              107
5-Mar           3,858              148
6-Mar           4,636              197
7-Mar           5,883              233
8-Mar           7,375              366
9-Mar           9,172              463
10-Mar         10,149              631
11-Mar         12,462              827
12-Mar         15,113           1,016
13-Mar         17,660           1,266

 

The mortality rate in the 10 days between February 21 and March 2 averaged 2.5%. In the 11 days since, it has averaged 5% – twice as high. It currently stands at 7.2% of total cases.

Other noteworthy data points: the daily rate of growth in total cases has averaged 22% over the past 10 days, and the daily rate of growth in deaths has averaged 32% over the same period.  Again, this is the actual daily rate of growth, not an annualized or theoretical number.

Let’s look at the official US data, flawed as they might be.

    US
   date    cases    deaths
3-Mar              124                  9
4-Mar              158                11
5-Mar              221                12
6-Mar              319                15
7-Mar              435                19
8-Mar              541                22
9-Mar              704                26
10-Mar              994                30
11-Mar           1,301                38
12-Mar           1,697                41
13-Mar           2,269                48

 

First, note that the numbers of US cases and deaths are roughly at the same point that Italy was on March 2 (2,036 and 52.) For this and other reasons, the US data are lagging Italy in most respects. Thus far, assuming a 10-11 day lag has proven to be a very accurate predictor of cases, deaths, closures, and overall social upheaval.

Currently, the mortality rate in the US is considered to be 2.1%. In Italy, it was 2.0% on March 1 – at which point it began its sharp rise to 7.2%. The number of reported cases in the US has averaged a daily rate of growth of 34% – much higher than Italy’s actual ROG of 22%.

On the other hand, the US daily ROG for deaths has been lower – averaging only 18% compared to Italy’s 32%.  This early on, however, the data have been all over the map – from a low of 8% to a high of 27%. So, we’ll examine a number of potential outcomes based on a variety of assumptions.

The first outcome assumes that the number of cases continues to grow at 34% per day and the number of deaths continues to grow at 18% per day.  Under these assumptions, total US cases by March 24 would be over 56,000. Deaths would total 308.

 US – #1
   date     cases    deaths
3-Mar              124                  9
4-Mar              158                11
5-Mar              221                12
6-Mar              319                15
7-Mar              435                19
8-Mar              541                22
9-Mar              704                26
10-Mar              994                30
11-Mar           1,301                38
12-Mar           1,697                41
13-Mar           2,269                48
14-Mar           3,038                57
15-Mar           4,066                67
16-Mar           5,444                80
17-Mar           7,288                94
18-Mar           9,756              112
19-Mar         13,061              132
20-Mar         17,485              157
21-Mar         23,407              185
22-Mar         31,336              219
23-Mar         41,950              260
24-Mar         56,160              308

 

Again, the number of cases is no doubt already much higher than reported, so I have no problem with this forecast. If anything, it is too low. Obviously, we’ll want to revisit this number as time goes by, but keep in mind the US population is 5.5 times that of Italy.

Note that 56,160 cases works out to 1,560 infected people per each city with a population of at least 500,000 or 166 per each city with a population of at least 100,000. My daughter’s high school and all churches in town just closed down after 5 cases were reported in our suburb of 30,000. Yesterday the Boston Marathon, which runs very close to our house, was cancelled for the first time since the outbreak of the Spanish Flu in 1918.

If we had 50-60 cases, I can easily imagine every restaurant, shop, gym and public building being closed. Like Italy, we might well be limited to only groceries and pharmacies (and funeral homes) in another 10 days or so.

Forget about the number of cases for a moment. Let’s focus on deaths – the number that folks of my vintage really care about. If the daily ROG in deaths were to match the 32% Italy has averaged lately, the March 24 tally would be 1,048 instead of 308.

But, remember, Italy’s mortality rate has mushroomed from 2% to 7.2% in the past 11 days. If US cases grew to 56,160 by March 24, a 7.2% mortality rate would equal 4,044 deaths. I wonder how many yogurt shops would remain open.  Oh, and by the way, Italy has more hospital beds per capita than the US.

My point isn’t to scare people or incite a hoarding panic at the local Costco. The coming headlines should do a good enough job of that.  But, I can’t sit idly by and watch the politicians spin this. Tests are not available to anyone who wants one. The mortality rate is not way under 1%. We are not very close to a vaccine.  We are not the most prepared country in the world. And, COVID-19 will unfortunately not disappear one day, like a miracle.

If we’re lucky, the rate of growth will decline and cases and deaths will level off in the not too distant future. If we’re real lucky, a new vaccine or existing medicine will prove effective. But, it probably won’t be in the next 10 days, despite what you might read on Twitter.

At today’s press conference / pep rally, President Trump insisted on shaking hands with nearly every one of the corporate executives who got up to tout his company’s efforts – each of whom also reached out and adjusted the potentially infected microphone.

Trump then refused to admit he had shaken hands with or palled around with several individuals who were known to have tested positive, and was nonchalant about getting tested himself.  Not a great example, to say the least.  Do yourself a favor: Listen to the scientists and doctors and ignore the politicians.

I’ll continue to update the above numbers as conditions warrant. I hope I’m very, very wrong – but fear I’m not.  Watch this space, and please be careful out there.

 

 

Comments

COVID-19: What to Expect — 1 Comment

  1. It is scary. One week makes a big difference. Just for thought. What will happen 3 months or 6 months from now?