Decoding the Pandemic
   17-Mar-2020
 
 

a_1  H x W: 0 x 
 

 The Coronavirus Outbreak that originated in China has exponentially affected over 114 countries. The Government and society should work together to fight this global health emergency

 

 Tomas Pueyo

 
With everything that’s happening about the Coronavirus, it might be very hard to make a decision of what to do today. Should you wait for more information? Do something today? What?
 
 
Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:
 
 
  • How many cases of coronavirus will there be in your area?
  • What will happen when these cases materialise?
  • What should you do?
  • When?
As a politician, community leader or business leader, you have the power and the responsibility to prevent this.
You might have fears today: What if I overreact? Will people laugh at me? Will they be angry at me? Will I look stupid? Won’t it be better to wait for others to take steps first? Will I hurt the economy too much?
 
 
But in 2–4 weeks, when the entire world is in lockdown, when the few precious days of social distancing you will have enabled will have saved lives, people won’t criticize you anymore: They will thank you for making the right decision.
 
 

1. How Many Cases of Coronavirus Will There Be in Your Area?

 
 
The total number of cases grew exponentially until China contained it. But then, it leaked outside, and now it’s a pandemic that nobody can stop. As of today, this is mostly due to Italy, Iran and South Korea:
 
 
There are so many cases in South Korea, Italy and China that it’s hard to see the rest of the countries, but let’s zoom in on that corner at the bottom right. There are dozens of countries with exponential growth rates. As of today, most of them are Western.
 
 
If you keep up with that type of growth rate for just a week, this is what you get:
 
 
If you want to understand what will happen, or how to prevent it, you need to look at the cases that have already gone through this: China, Eastern countries with SARS experience, and Italy.
 
 

China

 
 
The chart shows in orange bars the daily official number of cases in the Hubei province: How many people were diagnosed that day.
 
 
The grey bars show the true daily coronavirus cases. The Chinese CDC found these by asking patients during the diagnostic when their symptoms started.
 
 
Crucially, these true cases weren’t known at the time. We can only figure them out looking backwards: The authorities don’t know that somebody just started having symptoms. They know when somebody goes to the doctor and gets diagnosed.
 
 
What this means is that the orange bars show you what authorities knew, and the grey ones what was really happening.
 
 
On January 21st, the number of new diagnosed cases (orange) is exploding: there are around 100 new cases. In reality, there were 1,500 new cases that day, growing exponentially. But the authorities didn’t know that. What they knew was that suddenly there were 100 new cases of this new illness.
 
 
Two days later, authorities shut down Wuhan. At that point, the number of diagnosed daily new cases was ~400. Note that number: they made a decision to close the city with just 400 new cases in a day. In reality, there were 2,500 new cases that day, but they didn’t know that.
 
The day after, another 15 cities in Hubei shut down. Up until January 23, when Wuhan closes, you can look at the grey graph: it’s growing exponentially. True cases were exploding. As soon as Wuhan shuts down, cases slow down. On Jan 24th, when another 15 cities shut down, the number of true cases (again, grey) grinds to a halt. Two days later, the maximum number of true cases was reached, and it has gone down ever since.
 
 
Note that the orange (official) cases were still growing exponentially: For 12 more days, it looked like this thing was still exploding. But it wasn’t. It’s just that the cases were getting stronger symptoms and going to the doctor more, and the system to identify them was stronger.
 
 
The rest of regions in China were well coordinated by the central government, so they took immediate and drastic measures. This is the result.
 
 

Eastern Countries

 
 
South Korea cases have exploded, but have you wondered why Japan, Taiwan, Singapore, Thailand or Hong Kong haven’t?
 
 
Taiwan didn’t even make it to this graph because it didn’t have the 50 cases threshold that I used.
 
 
All of them were hit by SARS in 2003, and all of them learned from it. They learned how viral and lethal it could be, so they knew to take it seriously. That’s why all of their graphs, despite starting to grow much earlier, still don’t look like exponentials.
 

a_1  H x W: 0 x 
 
 
So far, we have stories of coronavirus exploding, governments realizing the threat, and containing them. For the rest of countries, however, it’s a completely different story. The coronavirus was contained for the first 30 cases. Patient 31 was a super-spreader who passed it to thousands of other people. Because the virus spreads before people show symptoms, by the time the authorities realized the issue, the virus was out there. They’re now paying the consequences of that one instance. Their containment efforts show, however: Italy has already passed it in numbers of cases, and Iran will pass it tomorrow (3/10/2020).
 

 
USA

 
 
Let’s look at a few cases, such as Washington State, the San Francisco Bay Area, Paris and Madrid. Washington State is the US’s Wuhan. The number of cases there is growing exponentially. It’s currently at 140.
 
 
But something interesting happened early on. The death rate was through the roof. At some point, the state had 3 cases and one death. We know from other places that the death rate of the coronavirus is anything between 0.5% and 5% (more on that later). How could the death rate be 33%?
 
 
It turned out that the virus had been spreading undetected for weeks. It’s not like there were only 3 cases. It’s that authorities only knew about 3, and one of them was dead because the more serious the condition, the more likely somebody is to be tested.
 
 
Washington state has today 22 deaths. With that quick calculation, you get ~16,000 true coronavirus cases today. As many as the official cases in Italy and Iran combined.
 
 
If we look into the detail, we realize that 19 of these deaths were from one cluster, which might not have spread the virus widely. So if we consider those 19 deaths as one, the total deaths in the state is four. Updating the model with that number, we still get ~3,000 cases today. The conclusion is that there are likely ~1,100 cases in Washington state right now. We don’t know the number of true cases, but it’s much higher than the official one. It’s not in the hundreds. It’s in the thousands, maybe more.
 
 

France and Paris

 
 
France claims 1,400 cases today and 30 deaths. Using the two methods above, you can have a range of cases: between 24,000 and 140,000.
 
 
The true number of coronavirus cases in France today is likely to be between 24,000 and 140,000.
 
 
If you stack up the orange bars until 1/22, you get 444 cases. Now add up all the grey bars. They add up to ~12,000 cases. So when Wuhan thought it had 444 cases, it had 27 times more. If France thinks it has 1,400 cases, it might well have tens of thousands
 
 
The same math applies to Paris. With ~30 cases inside the city, the true number of cases is likely to be in the hundreds, maybe thousands. With 300 cases in the Ile-de-France region, the total cases in the region might already exceed tens of thousands.
 

 
Spain and Madrid

 
 
Spain has very similar numbers as France (1,200 cases vs. 1,400, and both have 30 deaths). That means the same rules are valid: Spain has probably upwards of 20k true cases already.
 
 
In the Comunidad de Madrid region, with 600 official cases and 17 deaths, the true number of cases is likely between 10,000 and 60,000. If you read these data and tell yourself: “Impossible, this can’t be true”, just think this: With this number of cases, Wuhan was already in lockdown.
 
 
With the number of cases in countries like the US, Spain, France, Iran, Germany, Japan or Switzerland, Wuhan was already in lockdown.
 
 
And if you’re telling yourself: “Well, Hubei is just one region”, let me remind you that it has nearly 60 million people, bigger than Spain and about the size of France.
 
 
 

Govt weighs evacuation of Indians from Iran, Italy’ : S Jaishankar

C-17 Globemaster, a military transport aircraft of the Indian Air Force (IAF) brought back 58 Indians from coronavirus-hit Iran on March 10.
 
 
"The IAF aircraft has landed. Mission completed. On to the next," External Affairs Minister S Jaishankar tweeted. In an earlier tweet, he said, "First batch of 58 Indian pilgrims being brought back from Iran. IAF C-17 taken off from Tehran and expected to land soon in Hindon."
 
 
"Thanks to the efforts of our Embassy @India_in_Iran and Indian medical team there, operating under challenging conditions. Thank you @IAF_MCC. Appreciate cooperation of Iranian authorities. We are working on the return of other Indians stranded there," Jaishankar added.
 
 
According to latest reports, 237 people have died of novel coronavirus in Iran while the number of positive cases stands at around 7,000. On February 27, 76 Indians and 36 foreign nationals were brought back from the Chinese city of Wuhan by the aircraft of the Indian Air Force.
 
 
On March 11, External affairs minister K Jaishankar in the Rajya Sabha that India has brought back its 58 citizens from Iran and was working with Iranian authorities to operate limited commercial flights for facilitating early return of the others. “We are hoping by tomorrow [Thursday] to fly in a medical team to Italy ... We will do testing of those people and try to put them on an early flight,” he said.
 
 
The minister said Iran and Italy were “focal points” for the government as any “worldwide activity” will only add to panic. As many as 529 more samples brought from Iran were being tested at the National Institute of Virolgy, Pune, and those who test negative will be brought back first in the next flights, he said.
 
 
“Whoever tests negative ... will be on the next lot of flights which will come in. Our effort has been to test as many people as quickly we can. The situation in Italy is emerging a cause of great concern. I would like to share with members that steps in this regard have already been initiated,” the minister said.
 
 
The minister said there are over 6,000 Indians in various provinces of Iran, which include 1,100 pilgrims, nearly 300 students and about 1,000 fishermen.
 
“We have to focus, prioritise and look at very extreme situations. At the moment, Iran is an extreme situation. Italy is an extreme situation,” the minister added.
 
 
 

2. What Will Happen When These Coronavirus Cases Materialize?

 
 
So the coronavirus is already here. It’s hidden, and it’s growing exponentially.
 
 
What will happen in our countries when it hits? It’s easy to know, because we already have several places where it’s happening. The best examples are Hubei and Italy.
 
 

Fatality Rates

 
 
The World Health Organization (WHO) quotes 3.4% as the fatality rate (% people who contract the coronavirus and then die). This number is out of context so let me explain it. It really depends on the country and the moment: between 0.6% in South Korea and 4.4% in Iran. So what is it? We can use a trick to figure it out.
 
 
The two ways you can calculate the fatality rate is Deaths/Total Cases and Death/Closed Cases. The first one is likely to be an underestimate, because lots of open cases can still end up in death. The second is an overestimate, because it’s likely that deaths are closed quicker than recoveries.
 

WHO declares Covid-19 outbreak a pandemic

 
The World Health Organization (WHO) has declared the Covid-19 outbreak a global pandemic as the novel coronavirus continues to rapidly spread worldwide.
 

What is a pandemic?

 
According to the World Health Organization, a pandemic is declared when a new disease for which people do not have immunity spreads around the world beyond expectations. The current pandemics are HIV/AIDS and coronavirus disease 2019 (COVID-19). Some of the most severe past pandemics include the 1918 influenza pandemic (Spanish flu) and the 2009 flu pandemic (H1N1).
 
 
“WHO has been assessing this outbreak around the clock and we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction. We have therefore made the assessment that COVID-19 can be characterised as a pandemic,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus at a media briefing on Covind-19 on March 11.
 
 “Pandemic is not a word to use lightly or carelessly. It is a word that, if misused, can cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death,” he said.
 
 
What I did was look at how both evolve over time. Both of these numbers will converge to the same result once all cases are closed, so if you project past trends to the future, you can make a guess on what the final fatality rate will be.
 
 
This is what you see in the data. China’s fatality rate is now between 3.6% and 6.1%. If you project that in the future, it looks like it converges towards ~3.8%-4%. This is double the current estimate, and 30 times worse than the flu.
 
 
Iran’s and Italy’s Deaths / Total Cases are both converging towards the 3%-4% range. My guess is their numbers will end up around that figure too.
 
 
South Korea is the most interesting example, because these two numbers are completely disconnected: deaths / total cases is only 0.6%, but deaths / closed cases is a whopping 48%. My take on it is that the country is just extremely cautious: they’re testing everybody (with so many open cases, the death rate seems low), and leaving the cases open for longer (so they close cases quickly when the patient is dead). What is relevant is that deaths/cases has hovered around 0.5% since the beginning, suggesting it will stay there.
 
 
The last relevant example is the Diamond Princess cruise: with 706 cases, 6 deaths and 100 recoveries, the fatality rate will be between 1% and 6.5%.
 
 
This is what you can conclude:
 
 
  •  Countries that are prepared will see a fatality rate of ~0.5% (South Korea) to 0.9% (rest of China).
  •   Countries that are overwhelmed will have a fatality rate between ~3%-5%
Put in another way: Countries that act fast can reduce the number of deaths by ten. And that’s just counting the fatality rate. Acting fast also drastically reduces the cases, making this even more of a no-brainer.
 
 

What Will Be the Pressure on the System

 
 
Around 20% of cases require hospitalization, 5% of cases require the Intensive Care Unit (ICU), and around 1% require very intensive help, with items such as ventilators or ECMO (extra-corporeal oxygenation).The problem is that items such as ventilators and ECMO can’t be produced or bought easily. A few years ago, the US had a total of 250 ECMO machines, for example.
 
 
So if you suddenly have 100,000 people infected, many of them will want to go get tested. Around 20,000 will require hospitalization, 5,000 will need the ICU, and 1,000 will need machines that we don’t have enough of today. And that’s just with 100,000 cases.
 
 
That is without taking into account issues such as masks. A country like the US has only 1% of the masks it needs to cover the needs of its healthcare workers (12M N95, 30M surgical vs. 3.5B needed). If a lot of cases appear at once, there will be masks for only 2 weeks.
 
 
Countries like Japan, South Korea, Hong Kong or Singapore, as well as Chinese regions outside of Hubei, have been prepared and given the care that patients need.
 
 
But the rest of Western countries are rather going in the direction of Hubei and Italy. So what is happening there?
 
 

What an Overwhelmed Healthcare System Looks Like

 
 
The stories that happened in Hubei and those in Italy are starting to become eerily similar. Hubei built two hospitals in ten days, but even then, it was completely overwhelmed.
 
 
Both complained that patients inundated their hospitals. They had to be taken care of anywhere: in hallways, in waiting rooms…
 
 
Healthcare workers spend hours in a single piece of protective gear, because there’s not enough of them. As a result, they can’t leave the infected areas for hours. When they do, they crumble, dehydrated and exhausted. Shifts don’t exist anymore. People are driven back from retirement to cover needs. People who have no idea about nursing are trained overnight to fulfill critical roles. Everybody is on call, always.
 
 
That is, until they become sick. Which happens a lot, because they’re in constant exposure to the virus, without enough protective gear. When that happens, they need to be in quarantine for 14 days, during which they can’t help. Best case scenario, 2 weeks are lost. Worst case, they’re dead.
 
 
The worst is in the ICUs, when patients need to share ventilators or ECMOs. These are in fact impossible to share, so the healthcare workers must determine what patient will use it. That really means, which one lives and which one dies.
 
 
All of this is what drives a system to have a fatality rate of ~4% instead of ~0.5%. If you want your city or your country to be part of the 4%, don’t do anything today.
 
 

3. What Should You Do?

 
 
This is a pandemic now. It can’t be eliminated. But what we can do is reduce its impact.
 
 
Some countries have been exemplary at this. The best one is Taiwan, which is extremely connected with China and yet still has as of today fewer than 50 cases. This recent paper explain all the measures they took early on, which were focused on containment.
 
 
They have been able to contain it, but most countries lacked this expertise and didn’t. Now, they’re playing a different game: mitigation. They need to make this virus as inoffensive as possible.
 
 
If we reduce the infections as much as possible, our healthcare system will be able to handle cases much better, driving the fatality rate down. And, if we spread this over time, we will reach a point where the rest of society can be vaccinated, eliminating the risk altogether. So our goal is not to eliminate coronavirus contagions. It’s to postpone them. The more we postpone cases, the better the healthcare system can function, the lower the mortality rate, and the higher the share of the population that will be vaccinated before it gets infected.
 
 
There is one very simple thing that we can do and that works: social distancing.
 
 
If you go back to the Wuhan, you will remember that as soon as there was a lockdown, cases went down. That’s because people didn’t interact with each other, and the virus didn’t spread. This has already been proven in the past. Namely, in the 1918 flu pandemic in the US.
 
 

4. When?

 
 
It is very possible that so far you’ve agreed with everything I’ve said, and were just wondering since the beginning when to make each decision. Put in another way, what triggers should we have for each measure. It might feel scary to make a decision today, but you shouldn’t think about it this way.
 
 
This theoretical model shows different communities: one doesn’t take social distancing measures, one takes them on Day n of an outbreak, the other one on Day n+1. All the numbers are completely fictitious (I chose them to resemble what happened in Hubei, with ~6k daily new cases at the worst). They’re just there to illustrate how important a single day can be in something that grows exponentially. You can see that the one-day delay peaks later and higher, but then daily cases converge to zero.
 
 
And remember, these are just cases. Mortality would be much higher, because not only would there be directly 40% more deaths. There would also be a much higher collapse of the healthcare system, leading to a mortality rate up to 10x higher as we saw before. So a one-day difference in social distancing measures can end exploding the number of deaths in your community by multiplying more cases and higher fatality rate.
 
 
This is an exponential threat. Every day counts. When you’re delaying by a single day a decision, you’re not contributing to a few cases maybe. There are probably hundreds or thousands of cases in your community already. Every day that there isn’t social distancing, these cases grow exponentially.
 

(Courtesy: Medium.com)