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The Math on WuFlu
I’m finding myself in a shrinking minority with respect to my view of the WuFlu. To me, it still appears to be an irrational panic. Heather MacDonald still seems to be on my side, at least as of yesterday (article here). But even the Daily Wire guys have been convinced that there is something serious to fear, other than fear itself. By Monday, MacDonald and I may be the only skeptics left standing. (I would find her to be good company in such an event.)
I’ve done a bit of digging into the facts, and I still can’t understand the cause for alarm. I would particularly value the input of our Ricochet docs and other medical professionals, as I certainly realize that I could be wrong.
I. The Severity of the Symptoms
In round numbers, based on the Chinese experience thus far, it appears that about 80% of WuFlu cases are mild, about 15% are “serious,” and about 5% are “critical.” The main problem with the WuFlu seems to be pneumonia. My impression is that “serious” cases might require hospitalization and oxygen treatment, while “critical” cases might require ICU treatment such as intubation. My source is here, from the same Worldometer site that our friend Rodin is relying upon for his daily posts. These estimates are based on information from China through Feb. 11.
Even these figures seem too high to me. Rodin’s daily post today (here) generally shows lower rates of serious/critical cases than the 20% combined figure noted above. In Italy, it is less than 10% (1,518 serious/critical out of 17,750 active). In South Korea, it is less than 1% (59 serious/critical out of 7,300 active). In the US, it is less than 0.5% (10 serious/critical out of 2,395 active).
My suspicion is that the rates of serious or critical illness is much lower, and that the rates appear high because very few people have been tested. This makes sense, as I would expect that initial testing would be limited to people exhibiting WuFlu symptoms. South Korea seems to have done the most extensive testing to date, and its very low rate of serious/critical cases is consistent with the hypothesis that wider testing will show a higher prevalence of the WuFlu, with the vast majority of cases being so mild as to be almost unnoticeable.
II. The Math on the Hospital Bed Crisis
I’ve seen news reports that the WuFlu has overwhelmed the health care system, in Italy in particular. Here is an article from The Atlantic on Wednesday, March 11, stating:
Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.
This NYT article from Thursday, March 12 similarly claims, in its headline:
We don’t have enough ventilators and I.C.U. beds if there’s a significant surge of new cases. As with Italy, the health system could become overwhelmed.
I know that I’m just a country lawyer, though I did once study math through the graduate level, with a focus on probability, statistics, and mathematical modeling. But it doesn’t take grad-level math to question these figures. It takes middle-school algebra.
The NYT article linked above says that Italy has 3.2 hospital beds per 1,000 people (and the US has only 2.8 beds per 1,000 people). Italy has a population of about 60 million, so this implies about 192,000 hospital beds.
As noted above, the number of serious or critical WuFlu cases reported in Italy, according to Rodin’s post today, is 1,518. That is 0.79% of the number of hospital beds in Italy.
Think about that. We’re supposed to believe that an influx of about 1,500 new patients has overwhelmed the medical system of a nation that has 192,000 hospital beds.
Put this in perspective. Let’s round up the Italian number to 1% — that is, assume that the number of serious or critical WuFlu cases in Italy is equal to 1% of the country’s hospital beds. Imagine that you run a hospital with 200 beds. This means that you can expect two (2) extra patients as a result of WuFlu. Are people seriously suggesting that a 200-bed hospital will be “overwhelmed” if it has to take in an additional two patients?
You all can believe anything you like. I’m staying in the skeptic camp with Heather MacDonald, at least for the moment.
Now let’s apply these figures to the US. Recall that, according to the NYT article linked above, the US has 2.8 hospital beds per 1,000 people. With a population of 327 million, that’s about 915,000 beds.
How many serious or critical cases are there in the US? Ten (10), according to Rodin’s post today. But let’s assume that the WuFlu spread rapidly in the US over the next month. How rapidly? Well, China has had 80,000 cases over several months, so let’s make the extreme assumption that the US has 100,000 new cases over the next month — a vastly faster spread than in China. And let’s use the Chinese figures for serious and critical cases, rather than the much lower figures from South Korea (more than 20 times lower).
So if the US has 100,000 new cases over the next month, 15% will be serious (15,000) and 5% will be critical (5,000), for a total of 20,000. This would be about 13 times the number of serious or critical cases currently existing in Italy.
20,000 new cases in the US would represent about 2.2% of the hospital beds in the country. A hypothetical hospital with 200 beds would have to take in about 4 new patients over the next month.
Is the medical profession seriously maintaining that their capabilities are so marginal, their ability to adapt so limited, as to be unable to cope with an increase in their patient load of about 2%?
I fully understand the graph about the capacity of the health system. Here is one example:
I do not dispute this graph in theory. I dispute the dashed red line about the “healthcare system capacity.” Based on my calculations above, the dashed red line is nowhere near as low as indicated. It is far, far higher — literally off the chart, in this graph.
As noted above, I don’t just understand mathematical modeling. I am a lawyer. I know how to mislead — in my case, I endeavor not to mislead myself, but I am ever vigilant about how my opposition can mislead. This is precisely the way that one can generate a panic — with a graph that is correct in theory, with just one small misleading element.
I see no evidence whatsoever of any serious danger that the WuFlu will overwhelm our healthcare system capacity, even with no protective measures.
Another way to mislead, incidentally, is to assume that the number of cases will continue to grow exponentially. The very early stages seem exponential, but the number of cases eventually follows an S-curve. Continuing to project an exponential growth rate — say for an entire month — is contrary to the facts, and will lead to a vast overestimate of the number of cases that we can expect.
III. Expanding capacity
The calculations above assume that we have no ability to increase our capacity to handle patients needing hospitalization. Obviously, we have such capacity. I haven’t looked into the precise figures, but my recollection from the hospitalization of family and friends over the years is that most hospital rooms are either single or double occupancy. In a crisis, it does not seem, to me, that it would be difficult to add an additional bed in each room. This would probably increase the availability of hospital beds by 30-40%.
This would be enough to hospitalize every American needing it, even if the number of cases increased to about 900,000, and even assuming the very high, 20% rate of serious or critical cases based on reporting from China, and not the rate of about 1% in South Korea and 10% in Italy.
This suggests that we could handle, without too much trouble, the health care needs of Americans even if the WuFlu spreads 10 or 20 times faster in the US than it has spread in China.
And we haven’t even talked about setting up emergency medical facilities. You know, schools are closing. Why not set up temporary hospitals in school gyms or auditoriums? How hard could it be? Bring in about 100 beds and some oxygen masks. Have 4 nurses or orderlies monitor the patients, administering oxygen when necessary. They could check each patient every 30 minutes or so. If there aren’t enough pulse oximeters for each patient, have the nurse carry it around. Patients who need critical care could be sent to a hospital.
As I understand it, even the serious WuFlu cases are essentially moderate-grade pneumonia. Patients may need an oxygen mask, but they won’t immediately die without it. They can take the mask off to eat, or to go to the bathroom. They can basically lie there, in relative comfort with an oxygen mask, and watch TV. Except that they can’t watch March Madness.
IV. About That March Madness
Actually, perhaps these hypothetical WuFlu patients will be able to watch March Madness. Because, it seems to me, the term is being redefined.
I was expecting to watch March Madness on CBS Sports and ESPN. It was going to involve a bunch of college basketball players. Now, I seem to be watching a different kind of March Madness on CNN, MSNBC, and Fox News. It involves a bunch of talking heads, politicians, and medical experts telling me that we’re all going to die unless we shut down the world. I find this extremely unlikely.
I would appreciate any corrections to my analysis.
If I turn out to be correct, I am going to prepare a huge plate of crow for everyone who disagreed. :)
Published in Healthcare
Isn’t @iwe a big skeptic?
iWe, if you should see this, I would love to be reminded of the terms of that bet you made.
I don’t know your level of expertise. Do you actually know this? Do you have figures on the percentage of WuFlu serious or critical cases that need to be intubated?
My impression is that this is probably not necessary, even for most critical cases, though it will be necessary for some. I suspect that we’re mostly talking about a small oxygen mask — maybe just a nose-mask, like my CPAP — for most of the serious or critical cases.
It also occurs to me that, if we don’t have enough intubation-type ventilators, some people will have to settle for a regular hospital bed, with an oxygen mask, rather than intubation in the ICU.
Man, it’s Pi day again already? And I missed the fireworks again — they occur at 1:59 am. Get it? On 3/14 at 1:59.
If you really want to dig into Pi day, you can check out my lengthy, celebratory post from last year (here).
Editorial addition: I should add a sampler of my Pi day post from last year:
Yes, because the turnover for critical corona patients out of icu is long. Which means people die while waiting to get a bed and equipment. Plus, there are no beds for any other issues.
And the staff are getting exposed, because there are no masks, leaving the remainder left to make it work.
So, get with the program.
S*!t about to hit our fans, and we can see it coming. If we don’t, we deserve the consequences of this virus.
Last week, a serious radio personality in Spain mentioned that Spain has around 4000 ICU for the whole country, with about 1000 free at any time. He also mentioned that 10% of patients in Italy required IC (which seems to make sense given the proportion of dead to confirmed cases). So, for a country like Spain you will only need about 10000 cases to start to overwhelm the system. Even if we assume that it will take twice or thrice as many cases to overwhelm the system; without limiting transmission drastically, you can reach those numbers in less than 2 weeks (as Spain is demonstrating right now with more that 5500 new cases in 6 days)… and then, what do you do?
A good friend of mine works in one of the largest hospitals in northern Spain and he’s told me that they are extremely worried about the situation, with talk of using respirators on operating rooms, with the domino effect that you all can imagine.
In any case, we will soon know here in the UK whether not taking extreme measurements actually works as well as what they have tried elsewhere.
Bravo.
This whole thing is BS.
The current panic is doing more harm than the disease.
But I will say no more, as the post says it all.
it’s political. Is that not obvious?
I think that part of it is political, but I think that it’s also a problem of social media and the disintegrating business model of the news business, which relies increasingly on hysteria to generate interest.
@arizonapatriot I agree with most everything you say, and would like to be on your team.
I’m not.
Well, and there’s my/the conspiracy theory, which is that the more hype and anxiety we are subjected to, the greater the hoped-for effect on Orange Man Bad’s election prospects.
3.14159265358979…
I’ve had that memorized for about 45 years, ever since 9th grade math in a classroom that had pi on a strip of paper that went all the way around the classroom, near the ceiling…
And I’m quite familiar with Octal. The first computer I learned on, was a PDP-8. (Octal actually works better in a lot of current-day situations too, but people use Hex because they think – or at least have been taught – that it’s better.)
Everywhere in the world?
Does it? Is an oxygen mask to assist breathing equivalent to a respirator? Knee and hip replacement surgeries can’t be delayed till this passes? The reporting on this sinks. What does treatment consist off and are there levels of care that aren’t being examined as everyone assumes its an ICU bed and team of doctors & nurses per patient.
Restricting interaction with nursing homes and immunocompromised people makes perfect sense. Travel advisories and restrictions – same. I could see schools and businesses requiring health checks or requiring workers in vulnerable age groups taking time off. What we’ve witnessed seems way overboard.
I’ve been curious regarding the rate of recovery of those over 80 or with compromised immune systems whose respiratory condition required ICU with ventilators for example. I heard a report of one 89 year-old man in Seattle who has recovered, but no others.
I agree that what has happened in certain states already should be instituted nationwide – restricting access to nursing homes to medical personnel. Probably top priority in preventing spread and overwhelming health care system.
Seattle hospitals have deferred all elective surgery in order to try to create enough capacity.
On the other hand, perhaps over-reacting to a moderately serious outbreak will make us better prepared for the big one. Assuming we don’t do anything really stupid, like hoard toilet paper. Oops.
We will find out.
The problem is, you under react and it is a disaster. Overreacting is a disaster too.
Basically a no win for people I power thanks to armchair quarterbacks.
I have been a CeO making hard choices without enough information. It sucks, because you know people will second guess you.
A cautionary note on this part of your analysis:
This is a very difficult calculation to make because of the temporal aspect as a certain % of those who have died and a certain % of those currently active but not serious/critical will progress to serious/critical at some point. It’s also important to note that there is usually a period of several days between the onset of symptoms and when patients reach a point where they are serious/critical. For instance, in the US, 65% of the current cases have been identified within the past three days so it is possible a certain percentage may progress to the serious/critical stage. South Korea may have been helped because a large percentage of its cases are associated with a church group which heavily attracted a younger, and less vulnerable, demographic. 46.4% of the Korean cases are under 40 compared to 11.2% of the Italian, while 41.3% of the Italian cases are at least 70 compared to 8.7% in Korea.
Many of the cases in the serious/critical category will require intubation and often mechanical ventilation. This was one of the issues causing problems in Italy because of the lack of equipment, particularly ventilators. It is also a very hazardous procedure for medical personnel who need faceshields, N95 masks, full body protection to avoid infection themselves.
The idea behind social distancing and cancelling of large attendance events (like those in Madrid which occurred shortly before the recent upsurge in cases there) is to reduce the strain on the system and to buy time to put in place some of the things you have suggested.
The pace of cases will probably also impact another key factor beyond equipment and beds – availability of the healthcare people to do this. COVID-19 has already taken a toll on doctors and nurses, even in the US we have a young doc in critical condition right now in NYC. If we have more patients, more beds, more equipment we will need more people to handle this. And, because of the additional protective equipment required many of the tasks they perform will take more time than usual. Whatever measures healthcare workers take to protect themselves we can expect attrition along the way.
We don’t have such capacity, and it is extremely likely that the published US numbers are at least 2 or 3 orders of magnitude too low. (That means if you read 100, think 10,000 or 100,000)
The critical resource in cases of serious pneumonia is ventilators (“ventilators” in real life actually means
• working pieces of equipment
• qualified therapists to operate them 24/7/365
• qualified technicians to keep the machines working 24/7/365
• the necessary consumables. The machines, while not made in China, contain critical components which are. A lot of the consumables are made in China.
In an epidemic, nurses and respiratory therapists are on the front lines and are at risk to contract whatever the epidemic disease is. So whatever the number of qualified personnel you start with, count on it going down during critical periods. So it actually isn’t obvious that we have the capacity to markedly increase our capacity to handle large numbers of critically ill COVID-19 patients:
Follow this guy. He’s been trying to knock down the hysteria all week.
Tweets by JoeSilverman7
I’ve been wondering about this number too. Most officials in Massachusetts have steered conversations to the flu this year, saying that it is a very bad year for the flu. I think they are using guarded code language to say, “Hey, we’re already pretty full right now.” That’s why officials are more upset about Covid-19 than the numbers would suggest they should be. But I can’t find that information for Massachusetts. Usually this time of year, there’s an article somewhere giving the hospital percentage that is being used during flu season. On Cape Cod, it’s the flu that the officials worry about the most and that our hospital capacity is geared to.
# 52 reminds me of an important point: Thanks to Donald Trump, we’ve all died several times in the last few years. There’s no one left for the coronavirus to kill.
While if I were pedantic I would observe that panic is by definition irrational, it actually seems as though fear of getting hit by Kung Flu is inducing rational thinking and responsible behavior. From the trenches in Los Angeles:
The critical thing is to keep the number of people in the water within the capacity of the rescuers. Underlying the Chinese response is not only centuries of Confucianism, as some like to speculate, but the uneasy awareness that if you really tick off the PRC they will lock you up and sell your organs. True, Democrats and their media sycophants admire China’s BAMN methods of organ procurement and other exercises of force.
Aesop has been right on many other epidemic related subjects; the above quote is where I got the 2-3 orders of magnitude number in #44
I remain a huge skeptic. I bet @Kozak that 1 Feb 2020-1 Feb 2021, the flu (and its complications as normally aggrandized by the CDC) will kill more than the Corona.
I remain certain that I will win this bet.
Just a couple of points.
The issue isn’t hospital beds, it’s ICU beds of which a large, 500 bed hospital has maybe a couple of dozen. The term “ICU bed” encompasses all the highly trained people and special things needed to keep people with very severe illnesses alive. For example, we have about 80,000 ventilators in the USA and most of them are already in use. We are not likely to be able to get more of them quickly.
The numbers of infections in the USA are increasing exponentially as they have been for the last two weeks, from 71 on March the first to 2976 now. I’ve been hoping to see evidence that growth was slowing, but none has materialized so far. How much longer can we expect to see this kind of growth in the numbers of infections? I have no idea. I’m just hoping to see some effect of the measures being taken and of the warming weather.
In North America, right? Or just USA? Or was it worldwide?
Anyway, I hope you and @kozak keep us all informed of how this is going.
As to panic and fear, for all of you who are getting tired of singing Happy Birthday twice even if you change the words, Alma Boykin shamelessly borrowed this from the Rev. Paul of Moose in the Yard
Just usa