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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
“Everything” is not shut down. No one is suggesting that “everything” shut down.
As to worrying about those AT RISK, the best thing to help them is to break the vectors. “Vectors” – plural. Quarantining the AT RISK breaks a vector (singular). Taking prudent steps to accomplish social isolation and slow down the spread is breaking the “vectors” – plural.
Today, not everyone will be exposed in the next month. In a month, or two, or three, more will be.
We missed the “close the borders” boat. We missed the “contact tracing” boat. Both are standard epidemic control methods.
What the odds are of any individual being exposed depend on circumstances, some controllable. We do not know what percentage of the population in Wuhan contracted the virus. Probably the best statistics of that sort of thing come from Korea. We cannot stop it from spreading, but we may be able to reduce the number of people an infected person exposes and therefore the smaller number of people who are exposed to the virus and contract the disease per day. I believe that this is a highly desirable thing to do. This virus is going to be endemic in our population when the epidemic ends. It will mutate, probably to a less severe form.
We have plausible hypotheses about why outcomes in different places differ. My opinion is that these are not well enough founded to bet the farm on. My expectation is that we will know more later, but again, we are dealing with today.
We may learn in hindsight that the impact on society was actually no more than a seasonal flu; this is not the way to bet today.
iWe (View Comment):
Cardiovascular disease, diabetes, hypertension and the like, in combination with age and immunosuppression are are the (primary) risk (factors) of bad outcome if people catch the disease. Needless to say, not healable in the short run, if at all.
That’s very nice, but we live in the USA and for the near term, which is what counts, these agents will not be used on a mass basis by physicians in the US, an increasing number of whom work to strict “evidence based” (don’t get me started) algorithms and who don’t do off label prescribing much.
Ditto for Chinese herbs, which the PRC mandated six weeks back for all cases of COVID-19 in Wuhan. Not going to happen here.
Pie in the sky scenarios won’t do anything about people getting sick in the next 2 or 3 months. If and when Trump mandates the use of, say, chloroquine phosphate and the like by executive order tomorrow, that might be different. Until then, it ain’t.
Letting the currently asymptomatic carriers and slightly ill people recover without spreading the illness further does that. It has other advantages that have already been hashed out here.
Breaking the vectors.
Reality check time. Start with the number of cases of COVID-19 today (4000 confirmed, 100,000 extremely plausible) and the doubling steps
And:
“Beds” is shorthand for the whole ball of wax: Doctors, nurses, cleaning crew, supply workers, admin, etc., etc., etc.
I’ll still take the under.
I have clearly said there is not enough information at present, and that people are making the best decisions they can based on the limited information they have. Those decisions are different than what you think they should be. So you throw a tantrum.
But if there really are 100,000 cases now, then it would follow that this virus is far less lethal than people are suggesting.
I am using the JHU website. US Cases = 6420 as of 17 Mar 2020 @ 1900
OK, that’s the number of cases confirmed by inadequate testing. It’s certain to be too low, but how much? Who knows. At ~ 1 week doubling at this stage, that means about 13,000 in a week, 13,0000 in 2 weeks, etc. so
still applies.
We’ll know by June. My take is that the downside to having overreacted now is a whole heckuvalot less than the downside to underreacting now.
The virus does have a slower incubation time than flu maybe up to two weeks to develop any symptoms. So if we have many more undetected cases they might start popping up soon.
I think giving ourselves two weeks of more extreme isolation is not an unreasonable precaution. If we have more testing coming on line now it will give us a chance to get a clearer picture of the spread and allow us to have more targeted isolation with some higher degree of confidence. Then we can go back to a more lenient if still cautious and conscientious form of limiting infectious spread. Much of which we should be practicing anyway out of good hygiene.
I don’t see that anyone has mentioned that smoking is still fairly common in Italy, as well as France. And a lot of the trouble in China was because most men in China smoke, while women do not, and they had a lot more male fatalities. So, how much of possible alarm over Italy is actually because Italy is DIFFERENT from the US, not similar?
Just because someone has a different view and you can’t change their mind doesn’t mean they’re throwing a tantrum.
According to Helen Raleigh’s piece at the Federalist, the common thread between Iran and Italy is that both are all in on One Belt One Road, and that as a result there are 300,000 Chinese living in Italy and a lot of back and forth travel.
Love that line!
Cleveland today was trending toward a Zombie Apocalypse. Rush hour traffic was at half-volume. Street urchins who would normally be in school are wandering the streets. Our restaurants are all shut down. Many churches and other organizations are shut down. Election Primary was cancelled today. Worried-looking people in the grocery stores are buying two-dozen identical items at a time. I managed to score two cartons of eggs this morning when my wife called a local store right as they opened and asked a clerk to put them aside for us. This is a minor victory! Our stores are completely out of eggs, milk, toilet paper, potatoes and onions (don’t know why), many frozen foods and much fresh meat. With all the empty store shelves it’s beginning to look like Bernie Sanders’ wet dream. You have to shop at 8:00 AM as soon as each store opens if you hope to get one of the scarce items. These jewels trickle in at random times and are placed on shelves by the overnight stock-boys, and are swept up by the maddening crowds each morning.
Who is that lady on TV who used to yell “Stop the Insanity!”
http://ricochet.com/732555/susan-powter-open-thread/
Trouble is, no disease just keeps doubling unabated. This is wildly hyperbolic. Corona has not done this in any of the countries to date, even Italy.
I am not an epidemiologist (though my wife actually is!), but I think they just make up some of these numbers out of thin air. I trust things more that you can actually measure.
I agree it’s a SWAG but: the testing so far has been inadequate. So 6 K confirmed cases is very much a lowball estimate not much better than the drunk looking for his keys under a streetlight. 1-2 orders of magnitude greater is highly plausible.
I’d go so far as to say that someone who says “see, it’s only 6,000 cases” is either ignorant or deceitful. I’m not 100% opposed to short term deceit if it’s meant to provide cover for the right plan to take effect, but I don’t think that’s what’s happening.
A lot of Chinese people and back-and-forth with Australia, too. But I don’t think smoking is as common in Australia as in both China and Italy.
Meanwhile, perhaps the stupidest thing I’ve heard in probably at least a month, from a host on a music radio station: “Coming up we’re going to find out what Kamala Harris thinks about coronavirus.”
CNN having Anthony Scaramucci on to share his thoughts about coronavirus seems even stupider.
Prayer?
I actually don’t discount the efficacy of prayer. Any other answer would be quite speculative on my part.
I’m not engaging in sophisticated modeling. It is possible to do so, and I once knew how, but that was about 30 years ago and I’m a bit rusty on my differential equations and mathematical modeling. Not that it would necessarily help, because I have an idea about what the models end up looking like. You have to make assumptions about the underlying equations in the first place, and then there are important numbers that you have to estimate, and the models are often very sensitive to those estimates. And you don’t have enough data to make good estimates, so you have to use some sort of confidence interval — and the result might be that the model predicts anywhere between 50,000 and 100,000,000 cases, which is of no practical help.
When this came up, I did some quick internet research, and the general report seemed to be that these outbreaks follow an S-curve, for whatever reason. Expecting an S-curve, I just started plotting the data to see if it was starting to look like an S-curve, rather than like an exponential. As I’ve noted in other posts, S-curves generally start out looking exponential, but they eventually level out.
I should add that “S-curve” is a generic term for a great many mathematical functions that have the same general shape. It’s not a specific function.
I don’t like this type of generic complaining.
When were we supposed to close the borders? It is very likely that Chinese carriers (or Americans returning from China) had already brought the WuFlu into the country before anyone figured out that there is a problem.
I’d like to understand “contact tracing.” It seems like a fantasy to me. I’ve read that the WuFlu has an incubation period of 2-14 days.
So imagine that it’s you. You have a bit of a fever and a cough, and maybe after a couple of days you go to the doc, and he diagnoses you with WuFlu. This may be 16 days after you were infected, and you’ve been contagious for some time.
So — list everyone that you’ve been in contact with for the past 16 days. Do it right now. Post it, for that matter. For me, that would be a list of dozens, perhaps hundreds, of people, and that doesn’t count every store or restaurant or gas station I’ve been to. Or everyone that my wife and kids has contacted.
And we’re then supposed to somehow track down all of those hundreds of people and then — what? Quarantine all of them?
Don’t we also have to figure out everyone they have been in contact with, and quarantine them, too?
This seems completely unworkable to me. I am open to being educated, but it does not seem remotely plausible.
A more plausible reason for the low spread of the disease in places like Singapore and Taiwan (or so I’ve heard) is that the WuFlu may be quite climate-sensitive, and perhaps those jurisdictions have a favorable climate at the moment. There may be other explanations.
I don’t know whether any of the proposed actions would have been remotely effective. Neither do you, and neither does anybody, so I suggest that we stop pointing fingers in ignorance.
In another thread, @Scott R posted an article by University of Maryland researchers that showed that all major outbreaks of the disease occurred along a narrow temperature band of 41 F – 52 F that encircled the Earth in recent weeks.
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3550308
Here is the critical chart from the paper which was current as of March 5th. It foretells the outbreaks in Spain, France, Germany, Switzerland, and Norway which hadn’t yet started at the time of publishing.
It seems to me that Prof. Epstein’s statistical analysis is quite sound. I’ve read the few potshots at him for not being an expert in medicine or virology, or that he’s complacent but as yet I have not seen a convincing attempt to dismantle any part of his argument or analysis with any specificity.
I think there is an inclination to label anyone a denier, a fool, or reckless who expresses doubts about the more extreme and alarming predictions or projections of how massively deadly this virus may become. Sound familiar? How many computer models about the impending baking of the planet, the disappearance of glaciers, the melting of the ice caps, the extinction of the polar bear have been proven wrong or have had to be extended from a 10- or 25-year period to now in the range of 1,000 years?
Yes, this virus has caused thousands of deaths but the question remains and seems at this point not terribly convincing that it is or even has the potential to exceed more common flu outbreaks of the past. There are unknowns and intangibles particularly with the numbers being reported out of China from the beginning to the present day. Any reports from an authoritarian police state should be looked at very skeptically but if there are indeed fewer cases and fewer deaths being reported in China as the days and weeks go on, then the current, more alarming modeling of deaths may be quite overstated.
On the societal front, the way that Americans are behaving is embarrassing and sad – particularly in the panic and hoarding of toilet paper and food and the fights that are breaking out in stores around the country. Unlike the 1930s, America today is a wealthy country that has no problem producing an overabundance of food and household goods and yet it seems that people feel that a super volcano has erupted somewhere on the planet and 500 years of darkness and freezing temperatures are about to envelope the earth.
At a local target store here in South Orange County, a customer sneezed into his shoulder, another customer accused him of spreading coronavirus and struck the man. Police were called. My son’s day program mentor attempted to break up 3 fights at a large supermarket over the weekend and received a cut on his head for his trouble. Yes, the constant media barrage creates panic but if I were an adversary of the United States, I would be paying very close attention to this widespread panic and the senseless way that Americans are behaving and develop psy-ops programs to create the same effects on the populace and the economy at some point in the future.
As long as the adversary figures out that they’re only seeing the bizarre actions of PART of the country, and the rest – perhaps the majority – will be n their way if they actually try something, they should be smart enough to not try anything.
Maybe it would be like if they think the No Nukes crowd actually runs everything, but they aren’t the people with their finger on the button, so to speak.
This is fantastic. What about the odds of contracting a fatal head injury if you actually drive the car? I’m guessing the probabilities will be super low if I keep the car parked in the garage for eternity.
In your example above: The risk of dying, if contracted, is higher than what? The average risk of fatality from driving a car?
These are two different things. What you want to talk about, is: a) what are the odds of contraction, based on a personal profile (meaning if I’m 30 and healthy and don’t lick bathroom stall door handles)), and then b) what is the survivability rate if contraction occurs.
Again, the numbers are extremely different for both of those 2 things, depending on who you are. It’s not the same thing as saying that once it’s contracted, your odds of dying are much higher than any other thing. That’s like saying if you get cancer your odds of dying are much higher than if you drive a car. Well, obviously, but there are two sets of odds to overcome here – actually getting the cancer, and then survivability.
But happier snakes. Like all transactions, there’s a trade-off.
The fact that identification of the infected is not the same as the infection occurring. That most testing and self-identification is being done does not correlate to the actual spread of the disease.
Something I mentioned earlier in the thread. Again, these are two different things. I’ll give you an analogy:
A massive car crash occurs, involving dozens of vehicles, deaths, and injuries. The hospital has no knowledge of what’s happened, they only see the first one or two victims hit their ER. The numbers go up from 1-2, to 3-4, to 6-8, within the span of hours.
Is the number of victims increasing? No. The growth looks exponential because the hospital is only seeing the incremental increase in identification of the victims. The crash isn’t constantly recurring. It’s done. What the hospital sees is the flood, then the trickle, of identified and transported victims.
It’s a crappy analogy. But the exponential growth thing is ridiculous, generally, on its face, because the underlying calcs are based on the growth in identification, the fact that the fatalities occur almost overwhelmingly in the elderly or those with specific conditions that make them susceptible, and the differing situations in all countries (China is not Italy, Italy is not the US, Australia is not Canada, etc) make apples to oranges comparisons dangerous.
Which is what has happened. The hysteria has been stoked by politicians and the media, for various reasons, and I’m going to go ahead and assume reasons that are most frequently not in the public’s best interests.
Hey, maybe it doesn’t double just 17 times. Maybe it super-duper-extra-pooper googolplex doubles.
The above is a “reality check”?
No it doesn’t. There’s no data that supports infinite doubling of cases. Typing it out in a table doesn’t transform reality.
Ignoring the costs of over-reacting is the same as ignoring the costs of under-reacting. Next year, when the normal flu season happens, please re-post your calculations to let us know that tens of millions will be dying by June 2021 if we don’t just do something.