COVID-19 Coronavirus Containment Efforts

[anorlunda]

This post touches on government authority to act. I tried to make it non-partisan, but it may be borderline.

Spoiler: Borderline political.

Wisconsin's Supreme Court struck down the entire state governor's COVID guidelines, and said it can not be enforced.

This is a bit unusual, the case where government did not give the executive branch sufficient emergency powers in advance. The legislature could rush to pass new laws, but they aren't nearly as fast as bars and restaurants which reopened within minutes of the court decision.

Wisconsin Bars Welcome Crowds After Court Strikes Down 'Safer At Home' Bans

Authority is also an issue in the USA. Today, a whistleblower is demanding a single central plan for the whole country. But in reality, state governments that have that authority. The federal government does not have the authority to impose a national plan. It is similar to Europe where the member states have the authority and the EU does not.

Of course the virus knows nothing about political borders. At what scale should COVID plans be made, city? region? nation? continent? global? That's a pointless question because rational planning is not the issue, authority to act is the issue.

 

[Dale]

It may not matter what the government says for the most part. People started staying home on their own well before the state issued stay at home orders. People have information and generally reacted appropriately without waiting for orders from government. I similarly suspect many people will not put themselves at risk simply because a governor says so.

https://fivethirtyeight.com/feature...o-tell-them-to-stay-home-because-of-covid-19/

 

[PAllen]

I would hope it is the false negatives that are really high with the serological tests, that would imply less devastating implications with a lower IFR for the general population.

To make the true IFR significantly lower than the raw measured one for the Spanish data, using an antibody test on sampled total population, you would have to assume a very high false negative rate and a near zero false positive. I don’t know whether that is plausible for an antibody test. For something symmetric, e.g. 3% false negative, 3% false positive, and 5% measured infection rate, you would expect that the true infection rate is around 2.1%, leading to IFR of 2.7%! So I sure hope they considered this in the analysis. I mean it is elementary statistics.

 

[atyy]

It may not matter what the government says for the most part. People started staying home on their own well before the state issued stay at home orders. People have information and generally reacted appropriately without waiting for orders from government. I similarly suspect many people will not put themselves at risk simply because a governor says so.

https://fivethirtyeight.com/feature...o-tell-them-to-stay-home-because-of-covid-19/

But in this case the lack of central (federal) coordination has meant a very suboptimal response, despite the efforts of individuals and corporations. As Trevor Bedford has commented, "However, the main point of the report was that given IFR, we should be pursuing suppression rather than mitigation. This implies a strict lockdown for suppression followed by #TestTraceIsolate to keep epidemic suppressed. Notably, this is exactly what countries like South Korea and New Zealand have been able to achieve. The US was not able to reach suppression with our lockdown and so we're left with agonizing decisions about how to keep society functioning while holding the virus in check. "

Of course it doesn't mean that federal coordination (which is apparent legally impossible) would have been enough (even if it had been legally possible), since there isn't enough police manpower to enforce the stay-at-home if many people simply disregard the law. So an optimal response (eg. South Korea, NZ) needs both central coordination, and trust of the people in their government.

 

[atyy]

To make the true IFR significantly lower than the raw measured one for the Spanish data, using an antibody test on sampled total population, you would have to assume a very high false negative rate and a near zero false positive. I don’t know whether that is plausible for an antibody test. For something symmetric, e.g. 3% false negative, 3% false positive, and 5% measured infection rate, you would expect that the true infection rate is around 2.1%, leading to IFR of 2.7%! So I sure hope they considered this in the analysis. I mean it is elementary statistics.

One possibility for quite a high "false negative" rate is that it takes time for antibodies to develop to a detectable level. I believe some early studies did not find antibodies in about 30% of cases, while later studies are consistent with more of than 90% of cases developing antibodies. https://www.medrxiv.org/content/10.1101/2020.04.30.20085613v1 (see their discussion for the earlier papers with lower estimates)

Another possibility is that the IFR depends on whether the health care system is overwhelmed (which it may have been in some parts of Spain). So if capacity has been built up (eg. hypoxemic people get detected and put on oxygen early to reduce the risk of deterioration), so that might lead to a lower IFR depending on available health care.

 

[mfb]

An overestimated infection fatality rate can come from an overestimated false positive rate: You subtract the fraction of people you expect to be false negative positive, you subtract too many, leaving too few people counted as infected.

 

[PAllen]

An overestimated infection fatality rate can come from an overestimated false positive rate: You subtract the fraction of people you expect to be false negative, you subtract too many, leaving too few people counted as infected.

True, but I think you accidentally used false negative above (second use) when you meant false positive.

 

[mattt]

A little more information about the seroprevalence study in Spain.

https://english.elpais.com/society/...paniards-have-contracted-the-coronavirus.html

 

[BWV]

So much for warm humid weather hindering the virus

https://www.cnn.com/2020/05/07/americas/amazon-manaus-coronavirus-intl/index.html

 

[Tendex]

To make the true IFR significantly lower than the raw measured one for the Spanish data, using an antibody test on sampled total population, you would have to assume a very high false negative rate and a near zero false positive. I don’t know whether that is plausible for an antibody test. For something symmetric, e.g. 3% false negative, 3% false positive, and 5% measured infection rate, you would expect that the true infection rate is around 2.1%, leading to IFR of 2.7%! So I sure hope they considered this in the analysis. I mean it is elementary statistics.

There are diagnostic tests that are not symmetric at all for those rates(they are call either very specific-little sensitive or viceversa) but I would think they have taken this into account. So if the 5% figure is correct maybe it is not as straightforward to obtain a globally valid IFR from the simple proportion of dead from immune. Maybe the strategy to keep healthy people mostly unaffected through confinement while the most susceptible to die like those in nursery homes comparatively less protected is giving a misleadingly high IFR in these first periods of the pandemic?

 

[nsaspook]

Worth watching as an overview of current efforts. And it steers clear of politics.

https://www.pbs.org/video/decoding-covid-19-hrfhb2/

Decoding COVID-19

 

[atyy]

https://www.nbcnews.com/health/health-news/coronavirus-vaccine-week-s-updates-oxford-nih-n1207141
Coronavirus vaccine: This week's updates from Oxford and the NIH

https://www.biorxiv.org/content/10.1101/2020.05.13.093195v1
ChAdOx1 nCoV-19 vaccination prevents SARS-CoV-2 pneumonia in rhesus macaques
Neeltje van Doremalen, Teresa Lambe, Alex Spencer, Sandra Belij-Rammerstorfer, Jyothi Purushotham, Julia Port, Victoria Avanzato, Trenton Bushmaker, Amy Flaxman, Marta Ulaszewska, Friederike Feldmann, Elizabeth Allen, Hannah Sharpe, Jonathan Schulz, Myndi Holbrook, Atsushi Okumura, Kimberly Meade-White, Lizzette Perez-Perez, Cameron Bissett, Ciaran Gilbride, Brandi Williamson, Rebecca Rosenke, Dan Long, Alka Ishwarbhai, Reshma Kailath, Louisa Rose, Susan Morris, Claire Powers, Jamie Lovaglio, Patrick Hanley, Dana Scott, Greg Saturday, Emmie de Wit, Sarah C Gilbert, Vincent Munster

 

[PAllen]

There are diagnostic tests that are not symmetric at all for those rates(they are call either very specific-little sensitive or viceversa) but I would think they have taken this into account. So if the 5% figure is correct maybe it is not as straightforward to obtain a globally valid IFR from the simple proportion of dead from immune. Maybe the strategy to keep healthy people mostly unaffected through confinement while the most susceptible to die like those in nursery homes comparatively less protected is giving a misleadingly high IFR in these first periods of the pandemic?

Yes, I think differing demographics of who is infected in different regions likely plays a role in different apparent IFRs. Also, differences in treatment protocols, and whether healthcare systems are overwhelmed must play a role.

 

[Vanadium 50]

A fast Sweden/Denmark comparison.

Looking at death rates and seeing where the 7-day moving average peaked, it was April 6 for Denmark and April 22 for Sweden. The doubling time before the peak (i.e. the time to get from half the peak to the peak) was 6-8 days for Denmark and 8-10 for Sweden. Error range comes from picking a peak day +/- 1 or 2 days from the dates above.

The time for an additional 50% deaths to come in is ~8 days for both countries.

The time to double the number of deaths is ~15 days for Denmark and ~23 days for Sweden (at which time Denmark is at 2.3x)

My conclusion: the incremental lockdown difference between the two countries buys you very little. If anything, Sweden's curve is a little flatter. I'm willing to believe that -15% (Comparing 2.3x with 2,.0x) is really +10%, but not that's a factor of 10, 20 or even 60 as various decision-makers and thought leaders have claimed. I don't think it's even a factor of 2.

 

[Vanadium 50]

Atty, you often just say "skeptical". Of what? The procedure? Say what you don't like, don't just stick a frowny face on it. The data? It is what it is, and it's out there for everyone.

Or do you just dislike the conclusion?

 

[mfb]

90 deaths per million in Denmark
40 deaths per million in Norway
50 deaths per million in Finland
350 deaths per million in Sweden.
Is there any evidence against the idea that Sweden simply did worse the whole time? You focus on the time of the lockdown, but the countries did way more than just that.

 

[atyy]

Atty, you often just say "skeptical". Of what? The procedure? Say what you don't like, don't just stick a frowny face on it. The data? It is what it is, and it's out there for everyone.

Or do you just dislike the conclusion?

I worry about the combative tone of many of your posts on this topic. Just as I'm not fond of the exaggerated criticisms by some about Sweden's policy, I don't like the possible implicit reading of your posts that lockdown policies are mistaken - both policies could be reasonable, depending on the situation in each country.

I actually think Sweden had a reasonable policy, riskier in some respects, but if people did follow the government's recommendations even though there was no law punishing non-compliance, it is reasonable to think it could work. Part of the reason I think Sweden's policy was reasonable is that Singapore in the early phase (first 1.5 months after onset of community transmission) had a similar policy with no stay-at-home and things were under control (I am pretty sure there were not a lot of undetected cases in the community; we have since had a huge spike in cases needing stay-at-home orders, but that was due a different cause that is maybe quite unique to Singapore).

Although Sweden overall has more COVID-19 deaths per capita than Denmark, that may not be because of the lack of a lockdown-like policy. Some of their officials have attributed it to an implementation failure in other policies meant to protect people in nursing homes (though I haven't seen the numbers), and I recall reading that they have since taken steps to address that (not sure precisely what they've done, will have to look).

 

[PAllen]

One point is that the least damaging policy depends on features of the country, e.g. population density, demographics, culture including trust of government, etc. As a simple point, Denmark has over 6 times the population density of Sweden, so there is no reason to expect the same optimal policy for both. Similarly, Wyoming is rather different from NYC.

 

[PeroK]

90 deaths per million in Denmark
40 deaths per million in Norway
50 deaths per million in Finland
350 deaths per million in Sweden.

420 deaths per million in France.
508 deaths per million in the UK.
525 deaths per million in Italy
590 deaths per million in Spain
770 deaths per million in Belgium

 

[atyy]

As I mentioned above, the higher per capita deaths in Sweden may not be related to a lack of a lockdown-like policy, but may be due to an implementation failure in policy to protect nursing homes, as one of the reports below says "The country said early on that shielding those 70 and older was its top priority."

https://www.thelocal.se/20200504/swedish-health-authorities-examine-high-coronavirus-death-toll
Sweden has been hit much harder by the Coronavirus than the rest of Scandinavia. The country's health authorities are now looking at why the infection swept through elderly care homes so fast.

https://www.france24.com/en/20200510-sweden-admits-failure-to-protect-elderly-in-care-homes
Sweden admits failure to protect elderly in care homes

In Singapore we've also had one outbreak in a nursing home, with 2 deaths (I think) so far from that. Though we did have good news that a 102 year-old female nursing home resident made a good recovery. A rather draconian measure the Singapore government has now taken is that all nursing home workers must be tested and not return home, but stay in either at work or hotels (paid for by the government) for a few weeks, to avoid the workers acquiring the infection at home then bringing it to work. It's supposed to be temporary (a couple of weeks), while they figure out a more sustainable policy, but we don't know what that is yet. Chatting with a friend of mine whose wife works at a nursing home, and he said she was enjoying a vacation at a hotel while he's left with the kids at home (obviously his point of view, not hers ).

 

[DennisN]

An article and a blog post about the reported lingering/prolonged symptoms of Covid-19:

'Weird as hell’: the Covid-19 patients who have symptoms for months (The Guardian, 15 May 2020)

In mid-March Paul Garner developed what he thought was a “bit of a cough”. A professor of infectious diseases, Garner was discussing the new Coronavirus with David Nabarro, the UK’s special envoy on the pandemic. At the end of the Zoom call, Nabarro advised Garner to go home immediately and to self-isolate. Garner did. He felt no more than a “little bit off”.

Days later, he found himself fighting a raging infection. It’s one he likens to being “abused by somebody” or clubbed over the head with a cricket bat. “The symptoms were weird as hell,” he says. They included loss of smell, heaviness, malaise, tight chest and racing heart. At one point Garner thought he was about to die. He tried to Google “fulminating myocarditis” but was too unwell to navigate the screen.

[...]

Paul Garner: For 7 weeks I have been through a roller coaster of ill health, extreme emotions, and utter exhaustion (BMJ, 5 May 2020)

Paul Garner, professor of infectious diseases at Liverpool School of Tropical Medicine, discusses his experience of having covid-19

In mid March I developed covid-19. For almost seven weeks I have been through a roller coaster of ill health, extreme emotions, and utter exhaustion. Although not hospitalised, it has been frightening and long. The illness ebbs and flows, but never goes away. Health professionals, employers, partners, and people with the disease need to know that this illness can last for weeks, and the long tail is not some “post-viral fatigue syndrome”—it is the disease. People who have a more protracted illness need help to understand and cope with the constantly shifting, bizarre symptoms, and their unpredictable course.

[...]

 

[bhobba]

In Singapore we've also had one outbreak in a nursing home, with 2 deaths (I think) so far from that.

It's not just Singapore:
https://www.abc.net.au/news/2020-05-17/coronavirus-rockhampton-nurse-covid-19-test/12256038

It's a very interesting thing. India has had a lower death rate than other places. I do not think anybody knows why for sure, but one theory is older people tend to still stay with their family and not concentrated in nursing homes. When it gets in a elderly care facility it can spread like wildfire and they have a higher death rate.

Thanks
Bill

 

[Vanadium 50]

I do not think anybody knows why for sure, but one theory is older people tend to still stay with their family and not concentrated in nursing homes

This is the same theory as to why Italy had a higher rate. (And Spain higher and Japan lower) I'm willing to believe it makes the rate either higher or lower, but not both.

 

[Vanadium 50]

I don't like the possible implicit reading of your posts that lockdown policies are mistaken

But if the data says that they are, shouldn't that change your mind? Are we scientists or not?

The data show that the post-peak peformence of Sweden is not hugely better or worse than other countries. It is true that Sweden has a 30% high overall death rate than the EU as a whole (and it would be smaller if the UK were still in), but as PeroK points out other countries with harsher lockdown policies have higher rates (up to a factor of 2 more). Further, it's impossible for post-peak policies to influence the size of the peak. In short, if you want to argue Sweden's past policies were mistaken, go ahead, but it is a completely separate issue from how well the present policies are performing.

I will admit the question of "what works" is tangled with the question "who decides". If democracies are going to temporarily cede control to the Experts to make decisions, it is not unreasonable to ask how well these Experts are doing. The insistence that we need to lock down tighter than Sweden seems not to be supported by the facts. The moving of Covid patients into nursing homes in New York seems not to have been a good idea.

 

[mfb]

420 deaths per million in France.
508 deaths per million in the UK.
525 deaths per million in Italy
590 deaths per million in Spain
770 deaths per million in Belgium

100 deaths per million in Germany.
Scandinavian countries are best compared to other Scandinavian countries as they are the most similar.

I looked again how the isolated islands do (treating Australia as island here):
Iceland is at nearly zero - one case last week, two cases the week before that. 6 active cases. They might have a few asymptomatic cases left that they only find if these infect others or if they show up in random testing.
New Zealand found two cases last week and 10 the week before. So far they follow the path of Iceland with a week delay or so.

Australia limited the spread quickly after the peak, but in the last weeks new cases have been roughly constant:



By state, this seems to come mainly from a smaller outbreak in Victoria, but it's not gone elsewhere either. If the goal is regional extinction they'll probably need to do more.

Hawaii has 1-2 cases per day. The trend still seems to go downwards, slowly. They have a mandatory 2 week quarantine for people entering, but no travel restrictions otherwise as far as I understand. I'm still skeptical if they can keep that up, without tourism a main income source is gone.

 

[atyy]

But if the data says that they are, shouldn't that change your mind? Are we scientists or not?

We are both scientists and citizens. The data already shows that lockdown-like policies can work superbly. How well they and other policies work in each context will depend on the past and continuing actions of citizens.

 

[bhobba]

Is Nobel Laureate Peter Doherty being overly optimistic:


Maybe it's because he is not a MD but a vet .

Seriously he and his institute is on the frontlines of this battle.

Thanks
Bill

 

[PAllen]

Is Nobel Laureate Peter Doherty being overly optimistic:


Maybe it because he is not a MD but a vet .

Seriously he and his institute is on the frontlines of this battle.

Thanks
Bill

Interesting - your link complains that one must disable tracking protection in firefox to see the embedded link. Foul behavior, IMO. I found the content anyway, but I despise such behavior by websites. What I see as the text of your tweet link is "Cannot load tweet. Disable your adblocker and tracking protection. " I have no adblocker, but I do accept firefox default tracking blocking. This is the very first time a site has complained about tracking protection in the year since firefox introduced it.

 

[atyy]

It's a very interesting thing. India has had a lower death rate than other places. I do not think anybody knows why for sure, but one theory is older people tend to still stay with their family and not concentrated in nursing homes. When it gets in a elderly care facility it can spread like wildfire and they have a higher death rate.

Various reports on the quite varied situation in India

https://www.npr.org/sections/corona...india-sees-a-drop-in-mortality-under-lockdown

https://www.theguardian.com/world/2...-health-minister-helped-save-it-from-covid-19

https://www.channelnewsasia.com/news/asia/covid-19-packed-morgues-beds-mumbai-hospitals-12738752

 

[PeroK]

Scandinavian countries are best compared to other Scandinavian countries as they are the most similar.

Why? What's the scientific reason for this? Are you sure you don't have a moral objection to what Sweden did, hence are only prepared to compare them to countries with fewer deaths?

Several newspaper articles I've read have done the same: emphasised the deaths in Sweden, with never a mention that there are countries that locked down very hard are have many more deaths.

If we compare Sweden only with countries with fewer deaths, then Sweden is the worst place for COVID-19. If we compare Sweden with all other countries, then it isn't the worst place.

 

[Vanadium 50]

he data already shows that lockdown-like policies can work superbly.

What do you think is the best data for it? I ask only that:

• Sweden is not in the list of countries with "lockdown-like" policies (otherwise why complain about my posts?)
• It be causal - i.e. post-peak policies can't influence an earlier statistic
• It be data - not comparing to a counterfactual model

 

[mfb]

Why? What's the scientific reason for this?

See my previous post.
Why don't we compare Sweden to North Korea with zero reported deaths? Syria with 3 reported deaths? You know why: Because that wouldn't make sense. We need countries that are as similar as possible for a meaningful comparison. Countries with a similar demographics, structure, style of life, overall government policies and so on.

Are you sure you don't have a moral objection to what Sweden did, hence are only prepared to compare them to countries with fewer deaths?

What an odd question. Yes, I am sure.

If we compare Sweden with all other countries, then it isn't the worst place.

No one questioned that, but is that really the best measure? Should we stop trying to get the best result we can because it is worse somewhere in the world?

Is Nobel Laureate Peter Doherty being overly optimistic:

If they start mass production in October we can get something early 2021. A record speed for a record demand, but in line with optimistic predictions we have seen before.

 

[PeroK]

We need countries that are as similar as possible for a meaningful comparison. Countries with a similar demographics, structure, style of life, overall government policies and so on.

We're not talking about N Korea, we're talking about Western Europe. The virus is widespread across all of western Europe. You're comparing Sweden with three small countries with a combined population of less than 20 million. There needs to be a good reason to say that Sweden is fundamentally (or at least significantly) different from the Netherlands, say. And why the rest of western Europe is not a relevant comparison to Sweden.

There's no issue excluding Africa, Asia or N Korea. The problem is excluding the rest of western Europe.

There is no scientific basis I can see for this.

 

[DennisN]

About Sweden and comparing countries...

I wrote previously in this thread briefly about that I think it is difficult to compare countries.
When it comes to Sweden I was thinking that I don't really see the point comparing such a small country with US. I personally wouldn't even try to; just thinking about it gives me a headache.
Maybe one could compare Sweden to a state in the US perhaps, but still I personally wouldn't, because I know too little about US. To me it would seem more straightforward to compare the individual US states with each other, rather than Sweden.

I also wrote that I think it is best to compare Sweden with Denmark, Norway and Finland, because these countries have been, and are often compared to each other in various ways; they are close, with comparable populations and area etc (though Denmark is pretty small). But maybe there are other countries in the EU that would be useful to compare the Nordic countries with, I really don't know. Belgium and Netherlands perhaps?

I understand the desire of and interest in comparing countries, I really do. I did it myself in this thread
before, when I did a couple of graphs and tables. But after I realized that the testing policies in different countries were different, I started to question the validity of the numbers and thus the usefulness in comparing cases (confirmed cases).

After that I started to think about different circumstances for different countries, and soon it gave me headaches . For instance, when it comes to the Nordic countries, I don't know if these countries count the deaths in a similar way. Another thing is that Sweden has a large number of deaths in nursing homes. Now, add the fact that the nursing homes in Sweden have more people in them (they are more dense) than in Norway, and you may understand that comparisons can get quite tricky. Furthermore, if I am not misinformed, Finland was not hit as hard initially with the virus as the other Nordic countries.

My point here is that there seems to be significant difficulties in comparisons even between the Nordic countries.

Personally, I temporarily have given up making comparisons. I see so many variables that may have an influence on the numbers that it gives me headaches, e.g. population, population density, age distribution, initial cases (spreaders), number of hotspots, policies, regulations, testing, population movement, information to the public etc etc. And I realize I know very little about these things in other countries, so I leave it to others to do comparisons if they like to.

Also, I would repeat what Dr Osterholm and others I have quoted in this thread before has said, this pandemic may last for quite a while. But hopefully it will be over sooner than later.

Nevertheless I am pretty certain that this pandemic and the various policies will be heavily researched in the near future. I am also certain I won't do any of that research.

Edit: I could also add that the Swedish policy and the high number of deaths in nursing homes are being debated domestically, but I'm not up to date about it. And I am of the opinion that we have failed with regards to the nursing homes, and I share our chief epidemiologists thoughts that this is likely in part due to inherent/previous problems with our nursing homes (e.g. bad routines, lack of info). This will likely be heavily debated and discussed in Sweden.

 

[mfb]

We're not talking about N Korea, we're talking about Western Europe. The virus is widespread across all of western Europe. You're comparing Sweden with three small countries with a combined population of less than 20 million. There needs to be a good reason to say that Sweden is fundamentally (or at least significantly) different from the Netherlands, say. And why the rest of western Europe is not a relevant comparison to Sweden.

Sweden has a population of 10 million. Norway has 5 million, Finland has 6 million, Denmark has has 6 million. I don't know why you brought up total population, but clearly these countries are closer in population than e.g. Germany with 80 million or France with 70 million?
If you think Scandinavian countries are so similar to Western Europe (and no matter where you look, they are not) you would have to explain why they all had death tolls so much lower than most of Western Europe. Well, all except Sweden.