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Day 72: COVID-19 When Will This Be Over?
I listened intently to the President’s briefing Tuesday. This was the briefing in which the President and his team were outlining the compelling data that persuaded the President that the shuttering of businesses remain important through the end of April. The data presented were basically threefold: The alternative looks of the epidemic with and without aggressive measures, the IHME chart on epidemic projections for the US with aggressive measures, and the contrast in case growth (controlled for population) between states that started early on aggressive measures (Washington and California) with states that did not (New York and New Jersey).
@cliffbrown included the video of the briefing in his post:“I’m a cheerleader for America”
Here are screen grabs of the 3 charts:
Featured prominently in Dr. Birx’s presentation was the IHME model from the University of Washington. No doubt many people watching heard about it for the first time. We on Ricochet have been discussing it since I posted Day 68: COVID-19 Comorbidity. As has been discussed there are questions about its predictive power. But for policymakers (in the absence of a better tool), the question becomes is it plausible? Are the predictions of the IHME model plausible even though it has to be refined as more data becomes available?
The White House press corps continues to be a miserable group of ideologically driven numbskulls. If they were doing their job the IHME model would not be new to them and they would have spotted the obvious question that I pose in the title post: When will this be over? And there were hints in the presentation that the press never picked up on. First hint: in the chart that the White House put up to contrast the non-intervention versus intervention case — flattening the curve — the endpoint for intervention stretches the epidemic out in time. In other words, the epidemic burns out more quickly if you do nothing than if you try to intervene. So why would you intervene? The White House says “to save lives” but here they are being a little cagey.
Will spreading out the epidemic reduce the number of people who will die from COVID-19, all things being equal? The answer is technically “no” but all things are not equal. If you had an epidemic for which we were fully prepared with whatever efficacious treatments could be applied, then the death rate would be whatever it would be regardless of how long it went on. What was missing for this epidemic was preparation. On day one there was no universal testing protocol, no vaccine, insufficient PPE for both health workers and the public, and no maximally efficacious treatment protocol. So spreading the epidemic out in time buys us weeks to catch up as best we can. No vaccine, but better treatment protocols and improved PPE for the health workers (and the public at some point).
But in another sense the White House is completely accurate when it says spreading the epidemic out in time will save lives: It will save the lives of people in need of treatment for trauma and from diseases other than COVID-19. If the health system is broken by the demands of the epidemic, then more people die from all causes, not just the epidemic disease. What President Trump, then, was persuaded about was that we need the month of April to save the health care system. And that saving the health system was sufficiently important that the economy should be sacrificed for another couple of weeks.
The second hint about how long the epidemic will go on was in the IHME death data. Again, the chart showed the tail going out into July. Maybe today the press is digging into the data and seeing what I inserted at the top of this post: the IMHE projection of when the last death from COVID-19 will be recorded from this current outbreak.
Will the economy be shut down until no more deaths are recorded? No. The irony is that the state with the worst epidemic response will be the lead indicator that it is OK to start re-opening the economy. New York is projected to record its last death from COVID-19 on May 10; California is projected to record its last death from COVID-19 on July 1. In order to record that last death, there will be a decline in the daily growth of cases and death. For New York, it will be as pronounced in the decline as in the rise because its slope is closer to the non-intervention model. Therefore, the signal for decline will be stronger and sooner. Places like California the signal will be weaker and later.
Whether it is the IHME model specifically that the White House is looking to, or simply its plausibility that is useful, is unknown. But the model has to get better as more data is gathered. In the meantime, the shelter-in-place orders will continue. Locally our County order has been updated and extended to May 3. But…and this is a big but…the clarifications they have made as to what are ESSENTIAL BUSINESSES and what are permitted MINIMUM BASIC OPERATIONS for non-essential businesses portend broader economic activity than what the initial order envisioned.
[Note: Links to all my CoVID-19 posts can be found here.]
Published in General
I watched the press conference yesterday, and was not reassured. Even if the IHME projections are reasonably accurate, no one seems to be asking the key question: won’t it just happen again when we end the lockdown?
I get the impression that the authorities are reacting to short-term projections which only account for the “first wave” of the epidemic, and which may or may not be accurate anyway.
Here is a very troublesome explanation from the IHME FAQ page:
Close to 50% of the burden on medical facilities has been in NYC so far. My sense is that avoiding a breakdown of medical response capability has been a high priority thus far. With regard to the above question, we are in the process of bolstering all the factors of the medical capability that fall in the supply category. Staffing is a separate issue that I won’t comment on. I think we will figure out how to respond medically. We need to work more on the economy.
I am skeptical of this last point. Per Wikipedia, various California counties rolled out shelter-in-place orders between March 16 and 19. Again per Wikipedia, New York did so on March 20. It’s hard to believe that 1-4 days made that much of a difference.
The big increase in reported deaths in the NYC area started on March 22. We’d expect deaths to lag infection by about 10-14 days, maybe more. So there was no one proposing such serious measures at a time when it might have made a difference.
NJ imposed a statewide stay-at-home order on March 21. Washington acted on March 23.
So I don’t see any obvious correlation between supposedly aggressive early measures and the outbreak.
The more plausible explanation, to me, is the far greater population density in the NY metro area, which includes a big part of the population of NJ as well.
I’ve been wondering this for quite some time. Won’t the rates start climbing again? If they do, are the experts going to start recommending lockdowns again? If that happens, will governors, mayors, etc. start issuing them again? When will we decide that as sad the deaths will be, we have to continue on and let the chips fall where they may. Life simply can’t continue on if we don’t.
I was going to ask the question, ‘When will the last coronavirus case be identified?’ but after realizing from earlier comment that only 5% of cases are serious, I’m now thinking that the models would likely project the last coronavirus case from the current outbreak be identified after the last death, making the timeline for last death more significant. That said, the last death will have been identified as a case some period of time prior to the death, it will have been identified well past the point of the critical crunch for the one medical region of interest, and therefore well within its capacity to handle the demand along with other demands for lifesaving services. Other medical regions will be further past their periods of peak demand, so I think the real question to ask is not when the last death or infection will occur, but when the demand will subside to the point where the medical industry and its helpers can manage without special intervention by government. The point of lockdowns and shutdowns wasn’t to reduce the total number of cases and deaths in the short run but to create a buffer in serious cases to reduce the overload on the medical industry to help prevent it from breaking worse than it has been. Now, this approach before implementing demands an assessment of what the after effect of ending the stay at home restrictions will be — will a spike in cases occur, a significant blip that will resume overloading of the medical industry, or will it be a speed bump, or will it be barely noticeable? The return analysis can’t have the same assumptions as the initial outbreak. It would be true that people never exposed might have the same vulnerability as before, we have no vaccine, but we do have widespread exposure and a major variable is the unknown population exposed who dealt with it in course, were never identified or tested positive, who could well have become resistant to further exposure (excepting in higher concentrations that really would overtax their immune response). To get a handle on this, I recommend widespread random antibody testing of people within California, which has comparatively low numbers of deaths for its population. This might be a key bit of information for governors to know, i.e., how susceptible their residents might be to recurrence of outbreak after the controls come off.
Unless antibody testing reveals that this was the second wave. And… unless they don’t have any major breakthroughs in the meantime. Fingers crossed.
@jerrygiordano, I think the answer is based on what “it” means. I do believe there will be an uptick when lockdowns are ended. As stated in my OP I think the primary goal as always been protecting the health care system to provide care for traumas and all diseases. If the data suggests that even with some additional cases the health care system can meet the demands on it, then the economy should be loosened. At the same time the expectation should be communicated to the public that case numbers will head up again but is manageable both by continued distancing practices by the public and the capabilities of health care.
@jerrygiordano, a counterfactual is never falsifiable so we will never know what would have happened if people (and governments) had acted differently. But I do think you have put your finger on a major difference if we had more granular data. What was California doing when New York health officials were publicly encouraging residents to go out to the Chinese New Year events? How are neighborhoods with similar densities in both locations comparing with regard to cases there? I am told there are “several” cases (no number specified) in my locality (which is a suburban (mostly) single detached home development). Without detailed case tracking data it hard to compare experience in different parts of the country.
I pray that this is how things will work out. I fear that the media will take the opportunity to start stoking fears again, and we’ll find ourselves right back where we currently are. I would love to be wrong about that.
Better is “when do we start to see the response to Hydroxychloroquine and Azithromycin?”
That will really shift the curve but the press is ideologically opposed because it make Trump look good.
Tremendous pressure on Brix and Fauci to over estimate deaths. Doctors learned this 2000 years ago if not more.
Again… even the press would be happy to see us (and themselves!) out of this thing. They’ll blame Trump for whatever they wish to blame him for (see Morning Joe), but if people in NYC suddenly start recovering, that will be a story worth covering. I’m hoping that this happens.
Absolutely true, I have noticed this among my never Trump friends. They would rather see patients die than admit Trump is right. And Trump himself said “it may work, it may not work” but denying patients access to a relatively safe drug that could fight covid 19 is unethical.
This jibes with what my manager has been saying, his wife is the lead for a nursing unit at one of the local Charlotte hospitals (Charlotte is in Mecklenburg County). They’re actually sending nurses home due to lack of patients. The hospital took a policy to only admit COVID-19 cases (or something close to that, essentially barring emergencies, etc), and they are extremely underwhelmed with cases, even in my relatively dense Charlotte area.
Realizing, again, that there’s a zillion Ricochetti in the Carolinas.
Our local news is talking about the measures they are making for a “surge” of COVID cases in the Bay Area. But Contra Costa County only has 249 confirmed cases of which less than 10% are hospitalized and only 11 are in the ICU. Other parts of the Bay Area may be more challenged but the planning seems to be based on anticipation not current reality.
#2 sounds to me like a stupid idea. There’s probably a reason the first reports of its usage didn’t recommend taking it on an ongoing basis. The same changes to cell chemistry that mess with the virus protein are likely to mess with other proteins, too. For it to work, you want it to poison the virus more than you poison yourself, analogous to having chemotherapy, though maybe not on such a severe scale. Taking it when you don’t even have the virus in your body doesn’t sound like a good idea to me.
I could be convinced otherwise, but would need data and better explanations of how it works.
For anyone wondering how big the knock on effects of a stressed medical system can be we have the following report from the Wall Street Journal. In the region of Bergamo the number of excess deaths this last march as compared to the average for March in previous years was 4000. But only 2000 of these excess deaths were officially attributed to COVID-19. The other 2000 can safely be assumed to be either unrecorded cases of COVID-19 or deaths due to knock on effects of massive COVID-19 infection in the region. Given this those estimates of 100,000 to 200,000 extra deaths in the US due to this pandemic don’t seems so far fetched…
only if hospitals become overwhelmed. If they’re having to set up makeshift hospitals and all the ICU beds are full of covid patients, that makes it difficult for the guy who has the heart attack… or the person who may have had a life-saving operation but didn’t get it. These stem from an overstretched hospital system, and thankfully, that is something that the US is experiencing much less of than Italy, so I don’t think we can just multiply numbers based on population and expect to repeat their experience. We’ve already seen that this is not the case.
My sister is experiencing the same thing at her hospital in Traverse City, MI. They have redied 1/2 the beds, made a special COVID-19 unit, and have been sitting on a handful of positive tests for 2 weeks. She had to take a vacation day yesterday and two nurses retired who where going to in May. Niece is at Henry Ford and swamped. The hospitals are about 250 mi apart. Same state.
Stephen Smith of the Smith Center for Infectious Disease was on Laura Ingraham tonight. I don’t remember all the numbers but it sounds like he has conducted a test that demonstrates the effectiveness of hydroxychloroquine with azithromycin. He also had some interesting data regarding comorbidity cases relating to BMI. Now we’ll have a new conflict. Anyway, she also had a cardiologist on who pointed out the need to monitor cardiac effects when used prophylactically. The last thing I think I heard was Dr. Smith say he thinks he’s found a cure for covid-19 virus, if I heard him clearly.
Can you imagine what such a result will do to the media and the Democrats?
I’ve also heard privately from a North Carolina nurse reporting something similar. This is why I’m skeptical about a lot of the news reports we’re hearing about doctor’s offices lacking necessary supplies. Why would there be shortages already? I’m not denying that things still could get very bad, but as of right now, I suspect that most health-care facilities are dramatically below capacity, because they’ve canceled appointments and cleared the decks in order to prepare themselves for the tidal wave of COVID-19 cases that hasn’t arrived yet.
Again, I’m not claiming that the tidal wave won’t arrive. But when I see news stories today that claim that medical personnel don’t have the protective gear they need, I can only assume that either a) it isn’t true, or b) the shortages are caused by poor planning, hoarding, inefficient distribution, or something else other than COVID-19.
Except in New York, of course.
I’m skeptical of the cause-effect claims of early intervention as well. Eg, how would that graph claiming to demonstrate its merits look if it included TX?? Relatively late and less-severe interventions, but lower cases/ and deaths/100,000 than most states, including the supposed model of wisdom, CA. The team cherrypicked to make a debatable point appear to be a slam dunk and complexity simple.
Also worth noting that OH, which intervened very early and aggressively, has decent Covid numbers (yay) but the second most unemployment claims in the country (boo). Is the sum total of human suffering likely to have been reduced? Maybe, but again debatable.
I don’t know the best set of tradeoffs for each state, and Trump/Fauci/Birx don’t either, yet presently they’re claiming to.
It is my understanding that the shortage of protective equipment is because China, which supplies most of it, stopped shipping in February. The hospitals didn’t keep on hand a sufficient supply to cover that contingency.
That is part of it, but it was always understood that in the event of a pandemic huge amounts of PPE would be required. That was what the national stockpiles were for. However, they were never maintained at the planned levels and we know certain materials, specifically 75% of the N95 masks, were used in the 2009 H1N1 episode and never replenished. The stockpiles were supposed to allow for time for the supply chain to expand capacity and meet needs for masks, face shields, gloves, ventilators etc.
So if I’m in Provincetown and I have appendicitis or an ectopic pregnancy or an acute myocardial infarction, I have to drive to where? To Falmouth? To Boston?
It’s the same here in the North Texas (generally the Ft Worth/Dallas metroplex area, which covers several counties). According to an update email that I received this evening from the Dallas Morning News, today ended with 1,279 confirmed cases in North Texas and 18 deaths. According to the newspaper, the entire state of Texas has 3,566 cases and 53 deaths. New York City’s hospitals may be currently overwhelmed, but the hospitals here aren’t – or at least shouldn’t be. If they are, they’re running on razor-thin margins.
Edited to Add: Another of those updates came through after I posted this. The numbers now read 1,444 North Texas cases and 23 deaths; 4,146 cases in the state and 66 deaths.
The point is that the number of deaths directly linked to COVID-19 isn’t the whole story of the diseases impact. I bet you will see even in cities that are not overwhelmed, but simply brought to the brink an increase in seasonal mortality rates not fully accounted for by COVID-19 deaths in the US. It isn’t a matter of multiplying Italy’s numbers, but realizing that even their numbers are not telling the whole story of the impact, and that ultimately even our own official numbers may well miss a large chunk of the toll that this disease will have caused.
Probably never.
This is probably going to be with us going forward.
Yeah, as of yesterday there were only 81 hospitalizations in the “Metrolina” region (Meck, Union, Cabbarus, Stanly, Gaston, etc.). Not to say it couldn’t grow massively, but not seeing that now.
Now if the government decided being overweight is a crisis that needs to be fixed by government decisions, do we just accept the idea that a few people can tell us what to do? Government has been a pretty busy busybody in modern times, and sometimes I think they cause us more stress and damage than if they left us alone. I guess people in Oregon can pump their own gas during the crisis. Brother.