Coronavirus

[Guest cherzeca]

my focus has turned from the public health implications of corona (as I have been clear, we are misallocating our resources and needlessly shutting down our economy) to financial, and I must say I have been impressed with the response so far.  very much prefer mnuchin to hank paulson.  https://www.zerohedge.com/political/mnuchin-fed-make-4-trillion-business-loans-send-3000-checks-family-four

[ERICOPOLY]

This is a golden opportunity to work outside, at a 6 ft distance from each other, and repair roads when there is no traffic.  Makes the cost of fixing roads much cheaper if it can just be banged out quickly.

[alwaysdrawing]

I'm also interested in orthopa's point:  For those who believe the US response was "too little, too late" to avoid overloading hospitals a la Italy, by what date (or range of dates) should we start to see overloaded ICUs in the apparently most troubled areas, e.g., Seattle and NYC? 

 

Approx every week cases double, and it takes about a week until people are hospitalized, so once you reach a large enough threshold of cases, each week gets progressively worse.  Going from 1 case to 100 takes around the same amount of time as going from 100 to 100,000 (unmitigated), and the problems become much large in that 100 > 100,000 progression.

 

If the estimates I've seen hold, that threshold is hitting right about now with around 20,000 estimated US cases as of a few days ago. Clusters will become large enough to impact large city health systems once you have a few thousand cases in the area, and I'd expect in less than 7 days you'll start seeing a crush of patients in Seattle and NYC, and the situation will likely get worse each week from there.

 

NYC hospitals have started to become overwhelmed, as well as many cities in Europe.

 

 

I have now revised my expectations that the US will have much worse spread outcomes than Italy, as the US has been much less proactive, and spread is likely continuing in an exponential way further along the curve.  Italy was starting to slow by 100,000 cases, however the US is still traveling on an exponential path.  Millions of cases, and incredibly high CFRs are likely.

 

Ben F. Maier

@BenFMaier

 

As a disease modeler, I disagree that the US's curve looks like Italy's. It looks much worse.

 

Italy: sub-exponential growth due to containment measures

 

US: unmitigated exponential growth

 

 

The economic damage will be much larger than I previously thought as well--depression is now my base case.  I am also not convinced the plans currently being written by the GOP will pass, though my confidence is much lower reading the political tea leaves.  I think the struggle to pass the small $8 billion bill indicates there will be a lot of fighting once the numbers get to the trillions. 

 

Moreover, I expect any industry bailouts to work similar to GM in 2008-2009, where within months, the bailed out company finds that it must still declare bankruptcy, as conditions will not become economic for some time, and they require re-structuring.

 

 

[KJP]

Let’s not forget all the stuff behind the scenes being passed.

 

Patriot Act signed again

 

DOJ just asked congress if it could suspend due process.

Never let a good crisis go to waste right?

 

This type of request has never been granted. Absolutely insane. The closes thing was the despicable handling of the Japanese during wwii. Katrina also had some similar stuff happen. Hundreds of law abiding citizens had their guns confiscated leaving their homes, businesses, vulnerable to looting.

 

What exactly is the text of the request that you're saying has never been granted before?  Many district courts, on their own authority, have already suspended all civil and criminal trials and have excluded that time from counting toward the requirements of the Speedy Trial Act, with specific exceptions to be granted on a case-by-case basis.  To my knowledge, however, no district court has suspended proceedings entirely, which would effectively suspend the writ of habeas corpus in that district (but query whether, in the event a federal district court was closed and thus there were no federal habeas venue, a state court could assume jurisdiction to grant a writ even to a federal prisoner, assuming Congress had not suspending the writ).

 

The primary qualm is the request to detain individuals without due process indefinitely without trial.

 

Yes, that would be disturbing, but I haven't seen the actual text.  The references I have seen to such a request would authorize the Chief Judge in each district to close down.  Under that scheme, it would be at the discretion of the judicial branch, not the executive.  In my experience, they would be loathe to use such authority and would exhaust every other possibility first, such as phone and video conference.

[Spekulatius]

Let’s not forget all the stuff behind the scenes being passed.

 

Patriot Act signed again

 

DOJ just asked congress if it could suspend due process.

 

Yes, every time I think about the provisions in the Patriot act, it raises my blood pressure. This thing hands the keys to Big Brother.

[KJP]

I'm also interested in orthopa's point:  For those who believe the US response was "too little, too late" to avoid overloading hospitals a la Italy, by what date (or range of dates) should we start to see overloaded ICUs in the apparently most troubled areas, e.g., Seattle and NYC? 

 

Approx every week cases double, and it takes about a week until people are hospitalized, so once you reach a large enough threshold of cases, each week gets progressively worse.  Going from 1 case to 100 takes around the same amount of time as going from 100 to 100,000 (unmitigated), and the problems become much large in that 100 > 100,000 progression.

 

If the estimates I've seen hold, that threshold is hitting right about now with around 20,000 estimated US cases as of a few days ago. Clusters will become large enough to impact large city health systems once you have a few thousand cases in the area, and I'd expect in less than 7 days you'll start seeing a crush of patients in Seattle and NYC, and the situation will likely get worse each week from there.

 

NYC hospitals have started to become overwhelmed, as well as many cities in Europe.

 

 

I have now revised my expectations that the US will have much worse spread outcomes than Italy, as the US has been much less proactive, and spread is likely continuing in an exponential way further along the curve.  Italy was starting to slow by 100,000 cases, however the US is still traveling on an exponential path.  Millions of cases, and incredibly high CFRs are likely.

 

Ben F. Maier

@BenFMaier

 

As a disease modeler, I disagree that the US's curve looks like Italy's. It looks much worse.

 

Italy: sub-exponential growth due to containment measures

 

US: unmitigated exponential growth

 

 

The economic damage will be much larger than I previously thought as well--depression is now my base case.  I am also not convinced the plans currently being written by the GOP will pass, though my confidence is much lower reading the political tea leaves.  I think the struggle to pass the small $8 billion bill indicates there will be a lot of fighting once the numbers get to the trillions. 

 

Moreover, I expect any industry bailouts to work similar to GM in 2008-2009, where within months, the bailed out company finds that it must still declare bankruptcy, as conditions will not become economic for some time, and they require re-structuring.

 

I was about to go back the timeline you posted and note the first rumblings from NYC that ICUs are filling up.  Unfortunately, I've found reliable reporting about this specific and very important issue (current status and capacity of hospitals/ICUs) very spotty.  I wish we had comprehensive data consistently published about this, which I view as a much more objective marker than testing, which we know is very flawed.

[alwaysdrawing]

I was about to go back the timeline you posted and note the first rumblings from NYC that ICUs are filling up.  Unfortunately, I've found reliable reporting about this specific and very important issue (current status and capacity of hospitals/ICUs) very spotty.  I wish we had comprehensive data consistently published about this, which I view as a much more objective marker than testing, which we know is very flawed.

 

It's still early innings in NY, however what I'm seeing and hearing is getting pretty scary.  The difficulty is that each week will be getting worse--I don't think you need precise data to know what's coming is very bad, and on the worse side of epidemiologist predictions.

 

The NYTimes had a couple helpful pieces on the current situation:

 

https://www.nytimes.com/2020/03/20/nyregion/ny-coronavirus-hospitals.html?

 

This shows three scenarios--I think the "some control measures" outcome is a very "optimistic" case for the US right now.

 

https://www.nytimes.com/interactive/2020/03/20/us/coronavirus-model-us-outbreak.html

[sleepydragon]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

[ukvalueinvestment]

Same in London.  Lots of people (my friends, intelligent) are posting pictures of them cycling in groups, jokingly saying "at a safe distance" when - quite clearly - they are not. 

 

Western world deaths and disruption will be much higher than Asia because people find it much harder to get their heads around acting for the common good and STAYING AT HOME

[KJP]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

Do standard (non-N95) masks aid healthy people avoid infection, prevent sick people from spreading, or both? 

[alwaysdrawing]

Another thing about ICU capacity, is that even during normal times, ICUs are mostly run at capacity:

 

https://www.latimes.com/california/story/2020-03-20/coronavirus-hospital-bed-icu-pandemic?

 

This is a quote from a friend of mine, who is an MD/PhD at a major medical center, from a week ago:

 

NYC is in trouble. They are clearly about to have a ventilator crunch in the next 2 weeks.

 

It is worth pointing out that tertiary/quaternary (academic/referral center) US hospital ICU capacity is almost always near maximum capacity at baseline. At [REMOVED] our MICU is between 90-100% full all the time from September to May. We have NO MICU surge capacity during normal operation, and we routinely surge into surgical ICUs during normal operation. The reason is because we take transfers from lower-level hospitals where specialty care is not available or where ICU level care is "community level" (community level = not as skilled). We know from our data that there is a survival benefit for being transferred from a community ICU to [REMOVED]'s MICU, which we believe is due to superior care and adherence to current best-practices. And this is likely true across the country. My point is: hospitals are NOT equal, and physician ability/best practices implementation is NOT equal across hospital levels of care (community, secondary referral, tertiary/quaternary referral centers). The system is designed to keep the referral centers full (for financial reasons).

 

My concern is that the referral/academic centers are actually using ventilator / ICU resources close to capacity at baseline. And that the reported ventilator capacity in the country exists primarily in community ICUs where ICU volume is lower. That's an unverified theory, and is based only on my personal experience working at both community, secondary and tertiary/quaternary referral centers. Italy has had issues with surge capacity being geographically spread (ie trying to move patients from Lombardy to southern Italy where ventilators were available), and transferring during a crisis is basically not feasible. Also, at many community and rural hospitals often the only provider available to intubate is the ED physician (especially overnight) and respiratory therapists (technicians who operate ventilators) are much less experienced (partly due to low ICU volumes). In a crisis I imagine anesthesiologists etc would be called to provide coverage. But it's worth noting that US hospital / physician distribution is extremely variable geographically in the US both in quality and quantity. In the 'poor' parts of [REMOVED], community hospitals often have moonlighting community doctors (typically community PCPs) covering night shifts etc -- that's scary because I have received transfers from EDs staffed by these types of docs who cannot place central lines or intubate (the patient 'crashes' into our ICU and then I have to do all that stuff which would typically be done in our ED). The experience level of intensivists and respiratory therapists is important because COVID19 causes ARDS, which is incredibly hard to manage and one of the most important parts of ARDS is careful vent management ala the ARDSnet protocol, which minimizes lung trauma.

[ERICOPOLY]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

There is a lot of information put out there that masks don't help unless you are infected (which isn't helpful since we also are told that you can spread it and have no symptoms), and people are being asked to save them for the hospitals.  So they may be doing as they've been told.

[ERICOPOLY]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

Do standard (non-N95) masks aid healthy people avoid infection, prevent sick people from spreading, or both?

 

Nobody knows if they are infected or not according to the idea that people are spreading it without feeling any symptoms.  Here in California, I've been sneezing because everything is blossoming.  So if I have the virus, I'm spreading it.

[EliG]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

Do standard (non-N95) masks aid healthy people avoid infection, prevent sick people from spreading, or both?

 

Standard masks catch coughs and sneezes. They prevent sick people from spreading. They do not protect healthy people from the virus aerosols in the air. The mask fit is not tight enough and the pores are too big.

[ERICOPOLY]

Let’s not forget all the stuff behind the scenes being passed.

 

Patriot Act signed again

 

DOJ just asked congress if it could suspend due process.

 

Yes, every time I think about the provisions in the Patriot act, it raises my blood pressure. This thing hands the keys to Big Brother.

 

The Federal Govt requires Real ID, and California requires that you give them your finger print during the Real ID application process.  So now they can identify every licensed California driver from a photograph showing the underside of your fingertips.  In the UK, they busted a ring of drug dealers from the photo in a WhatsApp message showing a bare hand holding ecstasy (they took the fingerprints off the digital image).  And while WhatsApp messages are secure, they got the message off of a phone they acquired during a prior drug bust.

[LC]

 

 

This table is made up! If you look at England’s numbers they have reported 233 total deaths as of March 21 including 40 on the 19th and 33 on the 20th.  Yes it will get worse but this is a bit of fiction.

 

I saw the table posted elsewhere and did not think to double check it. Thank you for correcting!

[Spekulatius]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

There is a lot of information put out there that masks don't help unless you are infected (which isn't helpful since we also are told that you can spread it and have no symptoms), and people are being asked to save them for the hospitals.  So they may be doing as they've been told.

 

I believe that masks do help, as evidence shows from Asia. Even non N95 masks may help. I don’t have the link right now handy, but a scientist from the German Robert Koch Institut hypothised that the severe cases afflicting young people may be explained by the Virus getting directly into the lung rather than getting from the upper respiratory tract and then spreading into the lung. later. The latter case allows for the body to time stage an immune defense, while the former case may not. It’s all hypothesis right now, but makes some sense to me, and if true, even a crude mask should prevent microscopes from getting into the lung.

 

Seems to me that breathing thought the nose and avoid breathing through the mouth as well as wearing a mask is a good idea. it‘s all conjecture, but downside is limited.

[cobafdek]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

Do standard (non-N95) masks aid healthy people avoid infection, prevent sick people from spreading, or both?

 

Standard masks catch coughs and sneezes. They prevent sick people from spreading. They do not protect healthy people from the virus aerosols in the air. The mask fit is not tight enough and the pores are too big.

 

[LC]

People in NYC are still walking around without mask

A lot of People in grocery stores, none had mask and only some wear gloves.

Home Depot is packed with people.

 

Do standard (non-N95) masks aid healthy people avoid infection, prevent sick people from spreading, or both?

 

YES - both.

 

There is a good video posted under this about 2 weeks ago:

https://m.facebook.com/smartairfilters/

 

This company manufactures air filtration devices and presents the evidence on different masks.

Interestingly, surgical masks are actually slightly better at preventing virus spread than N95 masks. Both are effective.

[merkhet]

This is a golden opportunity to work outside, at a 6 ft distance from each other, and repair roads when there is no traffic.  Makes the cost of fixing roads much cheaper if it can just be banged out quickly.

 

If there's enough political will, we should honestly put an infrastructure bill to work. We missed our chance in the last crisis and the state of our infrastructure is pretty pathetic.

[TwoCitiesCapital]

This is a golden opportunity to work outside, at a 6 ft distance from each other, and repair roads when there is no traffic.  Makes the cost of fixing roads much cheaper if it can just be banged out quickly.

 

If there's enough political will, we should honestly put an infrastructure bill to work. We missed our chance in the last crisis and the state of our infrastructure is pretty pathetic.

 

Honestly - this would be the only deficit spending I would be supportive of as it is a true investment in the long-term productive capacity of the country.

 

[gary17]

Masks help

look at this report.  these countries are life as normal !

 

https://www.cbc.ca/news/business/taiwan-covid-19-lessons-1.5505031

[gary17]

Saying only sick people can wear mask stigmatizes them - this makes those who are mildly sick to not even want to wear a mask! 

If we are like asia where EVERYONE wears mask, then you do both protection of healthy people and prevention of droplets spreading from sick people !

 

https://www.nytimes.com/2020/03/17/opinion/coronavirus-face-masks.html?smid=fb-share&fbclid=IwAR1XxGheyMqYzyDWcAvF3YyNznjJbZBHY4Hsk6tCAg4_WjkJFyR93Pdu97E

[Jurgis]

For people who are saying that everyone should wear mask: where should people get these masks from? Masks are not available for purchasing over a month now. They were out of stock in February and the situation has not improved.

[minten]

Saying only sick people can wear mask stigmatizes them - this makes those who are mildly sick to not even want to wear a mask! 

If we are like asia where EVERYONE wears mask, then you do both protection of healthy people and prevention of droplets spreading from sick people !

 

https://www.nytimes.com/2020/03/17/opinion/coronavirus-face-masks.html?smid=fb-share&fbclid=IwAR1XxGheyMqYzyDWcAvF3YyNznjJbZBHY4Hsk6tCAg4_WjkJFyR93Pdu97E

 

It's nice to have a theoretical debate whether mask work or don't work, but fact is they're in very short supply in virtually every IC, at least in Europe, right now. There was even a report today in which the Czech Republic supposedly confiscated a shipment of hundreds of thousands of masks which were supposed to be send to Italy, only to use it in their own hospitals. Encouraging regular folk to start hoarding them now amid a shortage seems irreponsible to me;  even if they do the job to some extent, hospitals need them more.