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Coronavirus Isn’t a Pandemic
The world is in a full state of panic about the spread and incidence of COVID-19. The latest worldwide tallies, as of 12 p.m. ET March 16, 2020, are:
The most dramatic news of the day has been the sudden spike in the number of Italian cases, totaling 24,747 with 1,809 deaths, which may grow to exceed the 3,099 in China.
Overlooked is the good news coming out of China, where the latest report shows 16 new cases and 14 new deaths, suggesting that the number of deaths in the currently unresolved group will be lower than the 5.3 percent conversion rate in the cases resolved to date. In my view, we will see a similar decline in Italy, for reasons that I shall outline in the remainder of this article.
From this available data, it seems more probable than not that the total number of cases worldwide will peak out at well under 1 million, with the total number of deaths at under 50,000 (up about eightfold). In the United States, if the total death toll increases at about the same rate, the current 67 deaths should translate into about 500 deaths at the end. Of course, every life lost is a tragedy—and the potential loss of 50,000 lives worldwide would be appalling—but those deaths stemming from the coronavirus are not more tragic than others, so that the same social calculus applies here that should apply in other cases.
These are deeply contrarian estimates. In dealing with any future prediction it is necessary to develop some model. Right now, the overwhelming consensus, based upon the most recent reports, is that the rate of infection will continue to increase so that the most severe interventions are needed to control what will under the worst of circumstances turn into a high rate of death. This pessimistic view is well captured in an op-ed by Nicholas Kristof and Stuart Thompson, who offer this graph to stress the importance and the immediacy of the looming crisis.
The model here projects a slow takeoff, a sharp rise, and an equally dramatic decline, with a huge cumulative total of deaths. The authors allow that if moderate precautions are taken, these totals might be reduced by about half. The key assumption of this model is a replication rate of 2.3, whereby each person who is infected then infects two others, seemingly without end. But the model does not specify the periodicity of the replication rate or allow it to vary with any downward changes in viral toxicity or human behavioral responses that delay interaction. Nor does the model recognize that if the most vulnerable people are hit first, subsequent iterations will be slower because the remaining pool of individuals is more resistant to infection. And finally, the model explicitly ignores the possibility that the totals will decline as the weather gets warmer.
The writer Tomas Pueyo has struck a similar chord with his viral post “Coronavirus: Why You Must Act Now.” That article contains graph after graph indicating an exponential expansion of cases in the last several days, and then claims that these infections will translate themselves into a similar number of deaths down the line unless radical countermeasures are taken.
Much of the current analysis does not explain how and why rates of infection and death will spike, so I think that it is important to offer a dissenting voice. In what follows, I look first at the trends in the American data, and then, building on my conclusions there, I construct a theoretical framework to evaluate the evolution of the coronavirus in other places.
Based on the data, I believe that the current dire models radically overestimate the ultimate death toll. There are three reasons for this.
First, they underestimate the rate of adaptive responses, which should slow down the replication rate. Second, the models seem to assume that the vulnerability of infection for the older population—from 70 upward—gives some clue as to the rate of spread over the general population, when it does not. Third, the models rest on a tacit but questionable assumption that the strength of the virus will remain constant throughout this period, when in fact its potency should be expected to decline over time, in part because of temperature increases.
As of March 16, the data from the United States falls short of justifying the draconian measures that are now being implemented. As of two days ago, 39 states have declared states of emergency, and they have been joined at the federal level with President Trump’s recent declaration to the same effect. These declarations are meant to endow governments with the power to impose quarantines and travel bans, close schools, restrict public gatherings, shut down major sporting events, stop public meetings, and close restaurants and bars. Private institutions are imposing similar restrictions. The one-two punch of public and private restrictions has caused a huge jolt to the economy.
The irony here is that even though self-help measures like avoiding crowded spaces make abundant sense, the massive public controls do not. In light of the available raw data, public officials have gone overboard. To begin with, the word pandemic should not be lightly used. Recall that the Spanish influenza pandemic, fully worthy of the name, resulted in perhaps as many as a half-billion infections and between 50 and 100 million deaths, worldwide, of which some 675,000 were Americans, many coming back from Europe in the aftermath of the First World War. The World Health Organization recently declared coronavirus a pandemic at a time when the death count was at 4,000, presently being just over 6,500. It will surely rise no matter what precautions are taken going forward, but what is critical is some estimate of the rate.
By way of comparison, the toll from the flu in the United States since October ran as follows: between 36 to 51 million infections, between 370 thousand to 670 thousand flu hospitalizations, and between 22 thousand to 55 thousand flu deaths. That works out to between roughly between 230,000 to 320,000 new infections per day, and between 140 to 350 deaths per day for an overall mortality rate of between 0.044 percent to 0.152 percent.
As we think about the mortality rate of COVID-19, there are some important pieces of data to consider. The chart below documents the most current numbers reported by the New York Times (as of March 16) for the four hardest-hit states:
Note that Washington state, with 676 reported cases and 42 deaths, has a mortality rate of 6.21 percent, which can be traced to a nursing facility in Kirkland, WA. While only contributing 57 cases, it was the source of 27 of the reported deaths, almost two-thirds of the fatalities. (We should expect, as has been the case, that the mortality rate in Washington will decline as the newer cases will not come exclusively from that high-risk population.) The next three states have 1,577 diagnosed cases and 11 deaths for a mortality rate of 0.69 percent, a number which has trended lower over the last few days. Unlike the deadly exposures in Kirkland, the exposures in New York state produced many documented illnesses, but only two deaths even after two weeks of exposure. And while it is easy to miss latent cases, it is harder to miss any virus-related death. Given that the incubation period is about two weeks, the pool of cases before March 1 should be small.
Many of the dire media accounts do not mention evolution. After the initial outburst in Kirkland, the target population was fitter. It is instructive therefore to look at the total number of cases, which spiked from 70 cases on March 5 to 672 cases on March 15. But those figures do not presage an increase into the thousands of daily cases that would be needed to reach the totals of the flu season. The current numbers are about 3 percent of the rate of new flu cases in the 2019-2020 virus season. Even if there is some undercounting, it is highly unlikely, given the relatively short (two-week) incubation period, that the number of current cases will more than double or triple. It is also unlikely that most of the increase in reported cases (as opposed to deaths) will be in the population over age 70. More importantly, these numbers, as reported by the Centers for Disease Control, do not give any indication of heightened severity.
What, then, does all of this portend for the future of COVID-19 in the United States? Good news is more likely than bad, notwithstanding the models that predict otherwise. The deaths in Washington have risen only slowly, even as the number of infections mount. The New York cases have been identified for long enough that they should have produced more deaths if the coronavirus was as dangerous as is commonly believed.
But why might the dire predictions be wrong? Consider the New York Times graphic below, which catalogs the daily totals of new coronavirus cases:
The theoretical answer to the question of how deadly the virus will turn out lies in part in a strong analytical relationship between the rate of spread and the strength of the virus. Start with the simple assumption that there is some variance in the rate of seriousness of any virus, just as there is in any trait for any species. In the formative stage of any disease, people are typically unaware of the danger. Hence, they take either minimal or no precautions to protect themselves from the virus. In those settings, the virus—which in this instance travels through droplets of moisture from sneezing and bodily contact—will reach its next victim before it kills its host. Hence the powerful viruses will remain dominant only so long as the rate of propagation is rapid. But once people are aware of the disease, they will start to make powerful adaptive responses, including washing their hands and keeping their distance from people known or likely to be carrying the infection. Various institutional measures, both private and public, have also slowed down the transmission rate.
At some tipping point, the most virulent viruses will be more likely to kill their hosts before the virus can spread. In contrast, the milder versions of the virus will wreak less damage to their host and thus will survive over the longer time span needed to spread from one person to another. Hence the rate of transmission will trend downward, as will the severity of the virus. It is a form of natural selection.
One key question is how rapidly this change will take place. There are two factors to consider. One is the age of the exposed population, and the other is the rate of change in the virulence of the virus as the rate of transmission slows, which should continue apace. By way of comparison, the virulent AIDS virus that killed wantonly in the 1980s crested and declined in the 1990s when it gave way to a milder form of virus years later once the condition was recognized and the bathhouses were closed down. Part of the decline was no doubt due to better medicines, but part of it was due to this standard effect for diseases. Given that the coronavirus can spread through droplets and contact, the consequences of selection should manifest themselves more quickly than they did for AIDS.
It is instructive to see how this analysis fares by taking into account the Korean data, which is more complete than the American data. South Korea has been dealing with the coronavirus since January 20. Since that time, the Korean government has administered a total of 261,335 tests to its citizens. In press releases updated every day, the Korean CDC is reporting (as of March 15) 8,162 total infections against 75 deaths for an overall mortality rate of 0.92 percent. But as shown in the table below, the age-disparity in outcome is striking:
Clearly, the impact on elderly and immunocompromised individuals is severe, with nearly 90% of total deaths coming from individuals 60 and over. But these data do not call for shutting down all public and private facilities given the extraordinarily low rates of death in the population under 50. The adaptive responses should reduce the exposures in the high-risk groups, given the tendency for the coronavirus to weaken over time. My own guess is that the percentage of deaths will decline in Korea for the same reasons that they are expected to decline in the United States. It is highly unlikely that there will ever be a repetition of the explosive situation in Wuhan, where air quality is poorer and smoking rates are higher.
So what then should be done?
The first point is to target interventions where needed, toward high-risk populations, including older people and other people with health conditions that render them more susceptible to disease. But the current organized panic in the United States does not seem justified on the best reading of the data. In dealing with this point, it is critical to note that the rapid decline in the incidence of new cases and death in China suggests that cases in Italy will not continue to rise exponentially over the next several weeks. Moreover, it is unlikely that the healthcare system in the United States will be compromised in the same fashion as the Italian healthcare system in the wake of its quick viral spread. The amount of voluntary and forced separation in the United States has gotten very extensive very quickly, which should influence rates of infection sooner rather than later.
Perhaps my analysis is all wrong, even deeply flawed. But the stakes are too high to continue on the current course without reexamining the data and the erroneous models that are predicting doom.
© 2020 by the Board of Trustees of Leland Stanford Junior University.
Published in Healthcare
Mr. Epstein says that the virus might not spread as fast as feared because of adaptive responses we are taking.
Then he says that the adaptive responses we are taking are not necessary. He mentions responses that he regards as prudent, though, and I’m not sure how one can gauge that sort of thing at this point.
He points to the example of China bringing the disease under control without acknowledging the huge differences in the “adaptive responses” that the Chinese took compared to our response. He mentions the example of China in order to claim that the disease probably won’t spread as much as the experts fear in the US, and I think this is completely inappropriate.
He mentions the tendency of a virus to become attenuated with time. There is no evidence so far that COVID-19 is becoming attenuated nor can anyone tell us when this might happen.
Epstein is a very smart man, but I get the impression that he doesn’t understand the concept of exponential growth because he keeps harping on the low numbers of people infected and dying so far in the US. He doesn’t mention the situation in Italy and how quickly that developed at all.
Mr. Epstein should get back to us in about a month so that we can see if his analysis has changed. Unfortunately, there is a good chance that he will regard our adaptive responses as being inadequate at that point. Right now there is no basis for saying that the disease won’t spread rapidly and catastrophically because in the US it hasn’t slowed down much so far. It continues to spread even in the warmer parts of the country.
I dearly hope that Epstein and the others who low ball this crisis can point to the Cassandras and say how silly they were when this is all over. I really do. I fear they won’t have that opportunity.
We do not have the information we need at all. So much is unknown about this virus. If you think you have it figured out for sure, you are wrong. We cannot know because it is novel. I have that from more than one expert in the field.
Though I suppose, since argument from expertise is somehow always a logical error in arguments, it will get dismissed.
The infection rate in China probably slowed due to such things as the quarantining of 100 million people, including such steps as welding shut the doors to apartment buildings and physically blocking, with mounds of earth and concrete, highways out of the Wuhan area. We can’t/won’t do that here.
Yep
Decisions are always made from inadequate information. We have enough to act, and then we need to keep reassessing and adjusting accordingly.
We know who is at risk and who is not. We know what helps heal those who ARE at risk.
Why are you still panicking?
They also used available drugs which worked. We can easily do that.
Instead of rushing to emulate brutal Chinese methods, why not emulate their willingness to improvise with the drugs that show promise?
iWe,
Tell’em iWe. Slammin!!!
Regards,
Jim
I have no objection to improvising with the drugs we have, especially if what’s being reported for chloroquinie is correct. Nor am I advocating that we emulate the ChiComs. Just pointing out that the apparent low infection rate in Red China is most likely due to the brutal methods they employed.
In the focus on national trajectories, one can lose sight of local conditions. And they vary.
When @doctorrobert tells me he has 4 patients and has time to catch up on paperwork and journal reading where he is in the northeast (I gather), I believe him. But I also believe @kozak when he says he’s seeing 40 patients (if I remember correctly) and being careful to exercise his discretion to order tests for those he suspects could have coronavirus, so as not to overwhelm the system given constraints on their testing capability in some county between NC and SC.
In the most affected areas, I’m not going to presume I know better than the people closest to the situation. In Boston, hospitals fear they’re not ready for a deluge. Washington state says they have a shortage of PPE. Though they’ve received more resources from the fed’s national stockpile, they suffice to meet only their critical needs. Through university email chains, I know of someone’s wife, an LA County infectious disease specialist extremely worried about about the situation in LA. The ICU in her hospital and those of others are becoming overwhelmed and she believes it is only going to get worse.
Addendum: Oh. And that’s a big hole in Prof Epstein’s post. He concerns himself with making projections about the eventual number of deaths in the US and says don’t panic. As @mendel pointed out elsewhere, the relevant unit is the locality. The numbers of active cases, serious and critical ones, and those needing hospitalization vs not bump up against different areas’ respective capacities. It’s rather lacking in imagination and foresight to think that the numbers of gravely ill could fail to test local capabilities in particular places.
Ah the nub! I don’t agree with your logical assessment of things, therefore I must be panicking. It cannot be that you have any emotion driving your decision making at all, therefore, you have to be right. I disagree with your assessment, even to say “I don’t know what the right answer is” and you call that panicking.
To put it another way, you want to discredit anything I might have to say be writing it off as panic.
You are no more operating from pure reason than any other human. You bring your bias to the table. I don’t share that bias. Instead of asserting I have things figure out, I am saying I don’t know, but we will find out. As such, I am willing to offer more grace than you are, to the people making the calls.
So, we differ on what calls might need to be made. I allow that you make that call based on your own calculus. You, however, offer me no such respect, and dismiss me as being in a panic.
This is not what I said. You are, by your own statements, planning based on worst-case scenarios regardless of whether or not they are justified by the information we have.
None of us know what the right thing is. But we should use the information we have to make decisions, instead of merely saying “It could be really, really, bad, and we have no idea.” This statement denies any information. I call that panicking.
You are right about this. The people making the calls are clearly making the wrong ones. Their reasons are transparent enough: if they do not react as rashly as the next guy, then they will be open to a lawsuit if anyone gets sick. Quarantining everyone badly instead of just doing a good quarantine on people actually at risk is nonsensical.
I do not respect “experts.” In this realm, there are experts on all sides. We are all called upon to use our minds to figure things out and act accordingly.
I remember the last economic crash when Christina Romer (expert) produced a very impressive chart showing unemployment with and without stimulus. It was way off.
I’ve listened and read to a lot of experts who disagree with each other also. The math is easy, it is figuring out what to input is hard. Visit an engineering board and read through multiple pages of engineers arguing about the cause of the Florida Bridge Collapse. Lots of numbers and calculations.
I’d say, based on previous history, this will follow other epidemics. Fauci has to be very conservative on this because of his reputation. He’s making educated guesses too. I think expert fields overlap concerning any diff equations; social/economic/medical all effect how illnesses play out. Perhaps the best thing is to look at past cases and compare.
How many people die behind the wheel in total is not an assessment of the dangers of death on any particular drive. Driving your car one time is safer than getting the flu one time. Drastically so. But we drive far more often than we get the flu. You can also see another example of this if you compare death by snake bites to death by bee/wasp sting. The venom for a snake is far deadlier than any individual bee or wasp sting. But far more many people get stung and stung repeatedly every year such that death by insect stings out oace death by snake bite nearly 10:1. The snake is more dangerous and if people were bitten by snakes as often as stung by bees you’d have more deaths.
China actually does not have one of the lowest infection rates in the World. The vast majority of all the infected countries have lower rates, though in fairness, they have not had as much time to catch up. I use China as an example because they are the original epicenter causing all the panic (with the guiding hand of our Press). Huh, maybe I just thought of a new meme for our media, “Chinese Collusion.”
As long as you insist to using pejorative lablels, there is no way to have an intelligent discussion with you on this.
I have to think that when Valiuth and I are agreeing in more than one thread. It must be the end of the world. :)
Pretty soon we will have some interesting “intersectionality” between the realization that the buck stops with the President in terms of the “draconian” measures being taken and the fact that those critiquing the measures here are generally strong supporters of the President.
Is “expert” a perjorative for you? If so, I’ll stand down.
Dogs and Cats living together!
Roderic, I’ve addresses this “exponential growth” claim in 2 posts already. The one today (here) is shorter, and should be sufficient to make the point.
I urge you to look at my post. The growth is not exponential, according to the data that we have. My graphs start when each country first reports 200 cases, and tracks the increase.
The tricky part is that the growth looks exponential for the first 12-13 days. Then the growth rate declines substantially, and the exponential forecast gives wildly incorrect results — the exponential prediction is 22 times that actual cases in S. Korea by day 25, and almost 3 times the actual cases in Italy by day 22.
I reviewed the problem in Italy recently. Italy apparently has only around 5,000 ICU beds, compared to 95,000 in the US. About half are available (in Italy), and about 10% of active cases require ICU care. (This is per a Lancet article, here). Italy has 26,062 active cases, so about 2,600 will need ICU care, close to their capacity — except that this assumes that all of the serious cases need ICU care at the same time. I do not have data on how long the typical WuFlu patient needs ICU care.
The US would have to have about 450,000 to 500,000 cases before we began having a problem with ICU beds. If we follow Italy’s path, we’ll probably have 60,000 or so cases.
Time will tell, but the panic seems quite unfounded.
To what would you attribute the decline in exponential growth?
Power.
It was the use of the work Panicky, and that was quite clear what I was talking about.
You really don’t want to discuss what people actually say and mean, do you?
Mass Hysteria!
It’s not. I saw no pejoratives in your post.
Of course I do.
I am trying to understand the position of people who think I am wrong. I don’t want bad outcomes, either.
Risk? everyone out in public is at risk of contracting the virus. We do not fully understand what that risk entails. It might be “just a flu” but “just a flu” doesn’t behave the way that this disease is behaving in some countries and we do not understand why. Are there biological characteristics of a population or the physical environment that lessen the impact? We don’t know.
We do know that social isolation, permitting infected people to recover without spreading it, seems to have contained the spread of the disease in China. We do know that the compulsory means used there are unlikely to fly in the US, so rather than fear of the government, we are using fear of the disease as a motivator.
At risk of contracting the virus or at risk of bad outcomes if they catch it? Most of the latter risks are not healable in the short run, if at all.
There are off label uses drug uses reported as effective though not adequately tested for efficacy. IIUC there are no drugs FDA approved to treat the virus. The prognosis is extremely poor in older patients with multiple risk factors and in any patients of any age who progress to severe pneumonia.
We do know that in the first week of February, the Chinese government mandated that all COVID-19 patients in Wuhan be treated with herbal medicine using the formulary provided by the government. This was for patients with mild illness being treated at home and patients in Western medicine hospitals as well as the ones in TCM hospitals. (Also not going to be replicated in the US.) Wuhan seems to have turned the corner.
I’m not. The local health departments have started a mandatory three week self isolation/shelter in place program that has stopped non-urgent medical appointments, closed restaurants except for delivery and takeout, and basically stopped all group assemblies. There have been several community acquired cases reported in my area.
Violation is a misdemeanor. The local shul has consulted its poskim and suspended its minyan for the duration.
Let’s break this into pieces. Do you believe that most everyone will exposed, sooner or later? Or do you believe we can stop it from spreading?
I think either way it is reasonable to point out that where we have good data (South Korea), we know the at-risk population is older, that kids under 10 are asymptomatic, and that in-between looks like a cold or flu.
I don’t see radical outliers. We can reasonably explain why Italy was exposed, why they got it worse, and what could have been done better.
But we can make educated guesses, and have. Hotter and colder weather seem to help, for example. There IS data!
Perhaps.
The reports from China and South Korea tell us otherwise.
There is no such thing as perfect knowledge.
In part because the FDA approves almost nothing. By some estimates, half the prescription drug use in America is OFF LABEL because it simply does not pay to work the FDA process.
The same as with flu. But the anti-malarials and immuno-suppresants seem to work well. Nevertheless, we can (and should!) worry about those who are actually AT RISK. It is far more sensible and effective (not to mention less destructive) to quarantine the at-risk, then to shut everything down.
And I think they, too, have lost their minds. Many shuls here have closed. I attend one that has not. I refuse to be complicit in what is tantamount to mass-insanity.
No you are not trying, because you accuse someone who thinks differently of panicking. That is not trying to understand someone’s position at all, but ascribing to them a state of total unreason.
You have not made an argument. You have not explained what the current directions are trying to do, and what they will achieve, and why we must do them. Why it is better than simply quarantining the at-risk and letting the virus pass through the rest of population.
Absent that, then you are indeed in a state of unreason.