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I think most people aren’t aware of the risk of systemic healthcare failure due to #COVID19 because they simply haven’t run the numbers yet. Let’s talk math. 1/n
Let’s conservatively assume that there are 2,000 current cases in the US today, March 6th. This is about 8x the number of confirmed (lab-diagnosed) cases. We know there is substantial under-Dx due to lack of test kits; I’ll address implications later of under-/over-estimate. 2/n
We can expect that we’ll continue to see a doubling of cases every 6 days (this is a typical doubling time across several epidemiological studies). Here I mean *actual* cases. Confirmed cases may appear to rise faster in the short term due to new test kit rollouts. 3/n
We’re looking at about 1M US cases by the end of April, 2M by ~May 5, 4M by ~May 11, and so on. Exponentials are hard to grasp, but this is how they go. 4/n
As the healthcare system begins to saturate under this case load, it will become increasingly hard to detect, track, and contain new transmission chains. In absence of extreme interventions, this likely won’t slow significantly until hitting >>1% of susceptible population. 5/n
What does a case load of this size mean for healthcare system? We’ll examine just two factors — hospital beds and masks — among many, many other things that will be impacted. 6/n
The US has about 2.8 hospital beds per 1000 people. With a population of 330M, this is ~1M beds. At any given time, 65% of those beds are already occupied. That leaves about 330k beds available nationwide (perhaps a bit fewer this time of year with regular flu season, etc). 7/n
Let’s trust Italy’s numbers and assume that about 10% of cases are serious enough to require hospitalization. (Keep in mind that for many patients, hospitalization lasts for *weeks* — in other words, turnover will be *very* slow as beds fill with COVID19 patients). 8/n
By this estimate, by about May 8th, all open hospital beds in the US will be filled. (This says nothing, of course, about whether these beds are suitable for isolation of patients with a highly infectious virus.) 9/n
If we’re wrong by a factor of two regarding the fraction of severe cases, that only changes the timeline of bed saturation by 6 days in either direction. If 20% of cases require hospitalization, we run out of beds by ~May 2nd. 10/n
If only 5% of cases require it, we can make it until ~May 14th. 2.5% gets us to May 20th. This, of course, assumes that there is no uptick in demand for beds from *other* (non-COVID19) causes, which seems like a dubious assumption. 11/n
As healthcare system becomes increasingly burdened, Rx shortages, etc, people w/ chronic conditions that are normally well-managed may find themselves slipping into severe states of medical distress requiring intensive care & hospitalization. But let’s ignore that for now. 12/n
Alright, so that’s beds. Now masks. Feds say we have a national stockpile of 12M N95 masks and 30M surgical masks (which are not ideal, but better than nothing). 13/n
There are about 18M healthcare workers in the US. Let’s assume only 6M HCW are working on any given day. (This is likely an underestimate as most people work most days of the week, but again, I’m playing conservative at every turn.) 14/n
As COVID19 cases saturate virtually every state and county, which seems likely to happen any day now, it will soon be irresponsible for all HCWs to not wear a mask. These HCWs would burn through N95 stockpile in 2 days if each HCW only got ONE mask per day. 15/n
One per day would be neither sanitary nor pragmatic, though this is indeed what we saw in Wuhan, with HCWs collapsing on their shift from dehydration because they were trying to avoid changing their PPE suits as they cannot be reused. 16/n
How quickly could we ramp up production of new masks? Not very fast at all. The vast majority are manufactured overseas, almost all in China. Even when manufactured here in US, the raw materials are predominantly from overseas... again, predominantly from China. 17/n
Keep in mind that all countries globally will be going through the exact same crises and shortages simultaneously. We can’t force trade in our favor. 18/n
Now consider how these 2 factors – bed and mask shortages – compound each other’s severity. Full hospitals + few masks + HCWs running around between beds without proper PPE = very bad mix. 19/n
HCWs are already getting infected even w/ access to full PPE. In the face of PPE limitations this severe, it’s only a matter of time. HCWs will start dropping from the workforce for weeks at a time, leading to a shortage of HCWs that then further compounds both issues above. 20/n
We could go on and on about thousands of factors – # of ventilators, or even simple things like saline drip bags. You see where this is going. 21/n
Importantly, I cannot stress this enough: even if I’m wrong – even VERY wrong – about core assumptions like % of severe cases or current case #, it only changes the timeline by days or weeks. This is how exponential growth in an immunologically naïve population works. 22/n
Undeserved panic does no one any good. But neither does ill-informed complacency. It’s wrong to assuage the public by saying “only 2% will die.” People aren’t adequately grasping the national and global systemic burden wrought by this swift-moving of a disease. 23/n
I’m an engineer. This is what my mind does all day: I run back-of-the-envelope calculations to try to estimate order-of-magnitude impacts. I’ve been on high alarm about this disease since ~Jan 19 after reading clinical indicators in the first papers emerging from Wuhan. 24/n
Nothing in the last 6 weeks has dampened my alarm in the slightest. To the contrary, we’re seeing abject refusal of many countries to adequately respond or prepare. Of course some of these estimates will be wrong, even substantially wrong. 25/n
But I have no reason to think they’ll be orders-of-magnitude wrong. Even if your personal risk of death is very, very low, don’t mock decisions like canceling events or closing workplaces as undue “panic”. 26/n
These measures are the bare minimum we should be doing to try to shift the peak – to slow the rise in cases so that healthcare systems are less overwhelmed. Each day that we can delay an extra case is a big win for the HC system. 27/n
And yes, you really should prepare to buckle down for a bit. All services and supply chains will be impacted. Why risk the stress of being ill-prepared? 28/n
Worst case, I’m massively wrong and you now have a huge bag of rice and black beans to burn through over the next few months and enough Robitussin to trip out. 29/n
One more thought: you’ve probably seen multiple respected epidemiologists have estimated that 20-70% of world will be infected within the next year. If you use 6-day doubling rate I mentioned above, we land at ~2-6 billion infected by sometime in July of this year. 30/n
Obviously I think the doubling time will start to slow once a sizeable fraction of the population has been infected, simply because of herd immunity and a smaller susceptible population. 31/n
But take the scenarios above (full beds, no PPE, etc, at just 1% of the US population infected) and stretch them out over just a couple extra months. 32/n
That timeline roughly fits with consensus end-game numbers from these highly esteemed epidemiologists. Again, we’re talking about discrepancies of mere days or weeks one direction or another, but not disagreements in the overall magnitude of the challenge. 33/n
This is not some hypothetical, fear-mongering, worst-case scenario. This is reality, as far as anyone can tell with the current available data. 34/n
That’s all for now. Standard disclaimers apply: I’m a PhD biologist but *not* an epidemiologist. Thoughts my own. Yadda yadda. Stay safe out there. /end
Thread by @LizSpecht: I think most people aren’t aware of the risk of systemic healthcare failure due to #COVID19 because they simply haven’t run the numbers yet.…
Let’s conservatively assume that there are 2,000 current cases in the US today, March 6th. This is about 8x the number of confirmed (lab-diagnosed) cases. We know there is substantial under-Dx due to lack of test kits; I’ll address implications later of under-/over-estimate. 2/n
We can expect that we’ll continue to see a doubling of cases every 6 days (this is a typical doubling time across several epidemiological studies). Here I mean *actual* cases. Confirmed cases may appear to rise faster in the short term due to new test kit rollouts. 3/n
We’re looking at about 1M US cases by the end of April, 2M by ~May 5, 4M by ~May 11, and so on. Exponentials are hard to grasp, but this is how they go. 4/n
As the healthcare system begins to saturate under this case load, it will become increasingly hard to detect, track, and contain new transmission chains. In absence of extreme interventions, this likely won’t slow significantly until hitting >>1% of susceptible population. 5/n
What does a case load of this size mean for healthcare system? We’ll examine just two factors — hospital beds and masks — among many, many other things that will be impacted. 6/n
The US has about 2.8 hospital beds per 1000 people. With a population of 330M, this is ~1M beds. At any given time, 65% of those beds are already occupied. That leaves about 330k beds available nationwide (perhaps a bit fewer this time of year with regular flu season, etc). 7/n
Let’s trust Italy’s numbers and assume that about 10% of cases are serious enough to require hospitalization. (Keep in mind that for many patients, hospitalization lasts for *weeks* — in other words, turnover will be *very* slow as beds fill with COVID19 patients). 8/n
By this estimate, by about May 8th, all open hospital beds in the US will be filled. (This says nothing, of course, about whether these beds are suitable for isolation of patients with a highly infectious virus.) 9/n
If we’re wrong by a factor of two regarding the fraction of severe cases, that only changes the timeline of bed saturation by 6 days in either direction. If 20% of cases require hospitalization, we run out of beds by ~May 2nd. 10/n
If only 5% of cases require it, we can make it until ~May 14th. 2.5% gets us to May 20th. This, of course, assumes that there is no uptick in demand for beds from *other* (non-COVID19) causes, which seems like a dubious assumption. 11/n
As healthcare system becomes increasingly burdened, Rx shortages, etc, people w/ chronic conditions that are normally well-managed may find themselves slipping into severe states of medical distress requiring intensive care & hospitalization. But let’s ignore that for now. 12/n
Alright, so that’s beds. Now masks. Feds say we have a national stockpile of 12M N95 masks and 30M surgical masks (which are not ideal, but better than nothing). 13/n
There are about 18M healthcare workers in the US. Let’s assume only 6M HCW are working on any given day. (This is likely an underestimate as most people work most days of the week, but again, I’m playing conservative at every turn.) 14/n
As COVID19 cases saturate virtually every state and county, which seems likely to happen any day now, it will soon be irresponsible for all HCWs to not wear a mask. These HCWs would burn through N95 stockpile in 2 days if each HCW only got ONE mask per day. 15/n
One per day would be neither sanitary nor pragmatic, though this is indeed what we saw in Wuhan, with HCWs collapsing on their shift from dehydration because they were trying to avoid changing their PPE suits as they cannot be reused. 16/n
How quickly could we ramp up production of new masks? Not very fast at all. The vast majority are manufactured overseas, almost all in China. Even when manufactured here in US, the raw materials are predominantly from overseas... again, predominantly from China. 17/n
Keep in mind that all countries globally will be going through the exact same crises and shortages simultaneously. We can’t force trade in our favor. 18/n
Now consider how these 2 factors – bed and mask shortages – compound each other’s severity. Full hospitals + few masks + HCWs running around between beds without proper PPE = very bad mix. 19/n
HCWs are already getting infected even w/ access to full PPE. In the face of PPE limitations this severe, it’s only a matter of time. HCWs will start dropping from the workforce for weeks at a time, leading to a shortage of HCWs that then further compounds both issues above. 20/n
We could go on and on about thousands of factors – # of ventilators, or even simple things like saline drip bags. You see where this is going. 21/n
Importantly, I cannot stress this enough: even if I’m wrong – even VERY wrong – about core assumptions like % of severe cases or current case #, it only changes the timeline by days or weeks. This is how exponential growth in an immunologically naïve population works. 22/n
Undeserved panic does no one any good. But neither does ill-informed complacency. It’s wrong to assuage the public by saying “only 2% will die.” People aren’t adequately grasping the national and global systemic burden wrought by this swift-moving of a disease. 23/n
I’m an engineer. This is what my mind does all day: I run back-of-the-envelope calculations to try to estimate order-of-magnitude impacts. I’ve been on high alarm about this disease since ~Jan 19 after reading clinical indicators in the first papers emerging from Wuhan. 24/n
Nothing in the last 6 weeks has dampened my alarm in the slightest. To the contrary, we’re seeing abject refusal of many countries to adequately respond or prepare. Of course some of these estimates will be wrong, even substantially wrong. 25/n
But I have no reason to think they’ll be orders-of-magnitude wrong. Even if your personal risk of death is very, very low, don’t mock decisions like canceling events or closing workplaces as undue “panic”. 26/n
These measures are the bare minimum we should be doing to try to shift the peak – to slow the rise in cases so that healthcare systems are less overwhelmed. Each day that we can delay an extra case is a big win for the HC system. 27/n
And yes, you really should prepare to buckle down for a bit. All services and supply chains will be impacted. Why risk the stress of being ill-prepared? 28/n
Worst case, I’m massively wrong and you now have a huge bag of rice and black beans to burn through over the next few months and enough Robitussin to trip out. 29/n
One more thought: you’ve probably seen multiple respected epidemiologists have estimated that 20-70% of world will be infected within the next year. If you use 6-day doubling rate I mentioned above, we land at ~2-6 billion infected by sometime in July of this year. 30/n
Obviously I think the doubling time will start to slow once a sizeable fraction of the population has been infected, simply because of herd immunity and a smaller susceptible population. 31/n
But take the scenarios above (full beds, no PPE, etc, at just 1% of the US population infected) and stretch them out over just a couple extra months. 32/n
That timeline roughly fits with consensus end-game numbers from these highly esteemed epidemiologists. Again, we’re talking about discrepancies of mere days or weeks one direction or another, but not disagreements in the overall magnitude of the challenge. 33/n
This is not some hypothetical, fear-mongering, worst-case scenario. This is reality, as far as anyone can tell with the current available data. 34/n
That’s all for now. Standard disclaimers apply: I’m a PhD biologist but *not* an epidemiologist. Thoughts my own. Yadda yadda. Stay safe out there. /end
Thread by @LizSpecht: I think most people aren’t aware of the risk of systemic healthcare failure due to #COVID19 because they simply haven’t run the numbers yet.…
WASHINGTON — After weeks of conflicting signals from the Trump administration about the coronavirus, the government’s top health officials decided late last month that when President Trump returned from a trip to India, they would tell him they had to be more blunt about the dangers of the outbreak.
If he approved, they would level with the public.
But Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, got a day ahead of the plan. At noon on Feb. 25, just as Mr. Trump was boarding Air Force One in New Delhi for his flight home, she told reporters on a conference call that life in the United States was about to change.
“The disruption to everyday life might be severe,” she said. Schools might have to close, conferences could be canceled, businesses might make employees work from home. She had told her own children, she said, to prepare for “significant disruption to our lives.”
The stock market plummeted, cable news blared apocalyptic headlines and by the time Mr. Trump landed at Joint Base Andrews early the next morning, his critics were accusing him of sowing confusion on an issue of life or death.
...
But from Mr. Trump’s first comments on the virus in January to rambling remarks at the C.D.C. on Friday, health experts say the administration has struggled to strike an effective balance between encouraging calm, providing key information and leading an assertive response. The confused signals from the Trump administration, they say, left Americans unprepared for a public health crisis and delayed their understanding of a virus that has reached at least 28 states, infected more than 300 people and killed at least 17.
KUWAIT CITY — In the weeks since an American drone strike killed Iranian Maj. Gen. Qasem Soleimani, U.S. military leaders have been sprinting to confront a dangerous new reality in the Middle East.
From Saudi Arabia, where troops are setting up the first U.S. presence in more than a decade; to Syria, where small teams of Americans operate near Iranian-linked forces; to Afghanistan, where officials have detected an increase in Iranian aid to the Taliban, the military is bracing for a potentially catastrophic escalation.
In visits to seven countries over the past six weeks, the top U.S. commander for the region, Gen. Kenneth "Frank" McKenzie Jr., cautioned American troops that the ballistic missile strike Iran launched days after Soleimani's death in Baghdad on Jan. 3 was unlikely the final salvo following Iran's loss of a peerless military figure.
"They're under greater pressure, and entities under great pressure can react very aggressively," McKenzie told sailors in the Arabian Sea.
As the number of coronavirus cases mount in the US, experts are warning that the country is unusually vulnerable to the spread of the disease.
There were 149 cases of coronavirus in the US and 10 people had died from the disease, according to the latest bulletin from the CDC, published at noon on Thursday and reflecting the situation on Wednesday afternoon.
If these numbers are correct, the case count has more than doubled in the past 3-4 days. And, from reports adequate testing is not being done.
As of March 08, 2020 at 13:20 GMT, there have been 447 confirmed cases and 19 deaths due to coronavirus COVID-19 in the United States.
Note: There were 149 cases of coronavirus in the US and 10 people had died from the disease, according to the latest bulletin from the CDC, published at noon on Thursday and reflecting the situation on Wednesday afternoon.
WASHINGTON — After weeks of conflicting signals from the Trump administration about the coronavirus, the government’s top health officials decided late last month that when President Trump returned from a trip to India, they would tell him they had to be more blunt about the dangers of the outbreak.
If he approved, they would level with the public.
But Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, got a day ahead of the plan. At noon on Feb. 25, just as Mr. Trump was boarding Air Force One in New Delhi for his flight home, she told reporters on a conference call that life in the United States was about to change.
“The disruption to everyday life might be severe,” she said. Schools might have to close, conferences could be canceled, businesses might make employees work from home. She had told her own children, she said, to prepare for “significant disruption to our lives.”
...
From the beginning, the Trump administration’s attempts to forestall an outbreak of a virus now spreading rapidly across the globe was marked by a raging internal debate about how far to go in telling Americans the truth. Even as the government’s scientists and leading health experts raised the alarm early and pushed for aggressive action, they faced resistance and doubt at the White House — especially from the president — about spooking financial markets and inciting panic.
“It’s going to all work out,” Mr. Trump said as recently as Thursday night. “Everybody has to be calm. It’s going to work out.”
So like many others in my field, I’ve been urging people, in as calm a tone as I can muster, to listen to experts and advising them about concrete steps they can take to keep their families, communities, and businesses safe. Wash your hands. Don’t touch your face. Avoid large gatherings. Don’t panic, and prepare as best you can.
Advice like mine is meant to be empowering, but now I fear it may also be misleading. If Americans conclude that life will continue mostly as normal, they may be wrong. The United States is far less prepared than other democratic nations experiencing outbreaks of the novel coronavirus. Low case counts so far may reflect not an absence of the pathogen but a woeful lack of testing.
Disruptions are almost certain to multiply in the weeks to come. Airlines are scaling back flights. Conferences, including Austin’s signature event, South by Southwest, are being canceled. The drop in imports is hurting global supply chains. Corporations are prohibiting their employees from traveling and attending mass gatherings. Stanford University just canceled its in-person classes for the rest of the winter quarter, and other institutions are likely to take similar steps. Government agencies and private companies alike will activate continuity-of-operations protocols, as they are called in my field. Get used to it.
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