This is Going to be Bad Ep. 08
We have reached the end of the Beginning
A Review of what we know
We are now six months into the Covid-19 pandemic. I first noticed it last December as a small story about a new virus showing up in a market in Wuhan in http://outbreaknewstoday.com/. My wife and I started paying attention to what was happening in China in January, although we didn’t get seriously worried until they started taking temperature readings of travelers from China at SFO airport in late January. For us, that was the tripwire indicating Covid-19 was SERIOUS and we started preparing. Because we were in Mexico in 2009 for H1N1, we thought we had a fairly good idea of what was probably coming. So, we stocked up and got ready for a siege. Little did we know.
I think we expected a reprise of 2009. That there would be some hysteria, a few months of clampdowns on travel, an outbreak or two in the US that would be quickly dealt with, news of outbreaks and deaths from countries with poor healthcare systems, and a return to normalcy in five or six months. The usual pattern of events for disease outbreaks in the early 21st century. After all, we had seen this before. SARS, MERS, H1N1, H5N1 none of them really touched the US significantly. This would probably be the same, a scary “near miss” with minimal impact. Still, my wife had a “bad feeling” about this one and she ordered stocks of PPE, disinfectants, and canned goods through the month of February, “just in case”.
I thought she was overreacting because she is in poor health now. Since she had ARDS, triggered by septic shock three years ago, she has been paranoid about respiratory illnesses. Even a “regular” flu could kill her, so we are very vigilant about managing our exposure and risk to infections. Once again, her synthesis and gestalt of the situation proved to be right (that’s, why she’s a genius and I’m just “really smart”). Still, we watched in disbelief as the situation deteriorated through the month of March, endured the “half assed” April shutdown, and watched the Republican May “Great Reopening” with horror. Now, June is over, July is here, and C-19 is still raging through the US population worse than ever. We have learned a lot about C-19, and while there are many unanswered questions, this seems like a good point to take stock of what we know and think about what that means for the rest of the year. Here is observation number one:
There is not going to be a vaccine this year. The probability of it happening is so low that no meaningful plan should include it. Life does not work like that movie “Contagion” and some noble CDC doctor is not going to risk their life by injecting themselves with the virus to prove their untested vaccine works. Thereby saving us all and returning life to normal in time for the Christmas shopping season. THERE IS NOT GOING TO BE A VACCINE THIS YEAR.
I write and post on a number of sites and recently got attacked for having no “academic credentials” in any medical field. I do not wish to misrepresent myself as a medical expert to anyone who is reading this or any of my other posts, so let us be clear:
I am not a doctor, epidemiologist, virologist, or public health specialist. I am a motivated individual studying the issue using publicly available datasets and papers. The analysis I am presenting is my own. I make no claim to “insider or hidden knowledge” and all the points I discuss can be verified with only a few minutes of research on the Internet.
Back in the early 90’s I did National Security level analysis and threat assessment reports for a few years. My professional degree is a double major in Electrical Engineering and Computer Science, but it is from the 70’s and has only minor relevance to the world today. I also have a “hobby” degree in Anthropology and a passion for Mesoamerican archeology (see my Tumblr blog if you are interested, The Archeotourist — Mesoamerica) none of which makes me an “expert” on pandemics or infectious diseases.
The analysis and opinion I present, in this and my other pieces, is exactly that: my opinion. I hope anyone reading it finds it useful, informative, and insightful but in the end, it is just my opinion. You have been warned.
So, six months into the pandemic here are what I think are the key things to understand about C-19 and what is likely to happen in the next 6 months:
It’s a “Virgin Field” Disease
Since C-19 is a virgin field pandemic only 5–10% of the population is likely to be immune. That means 90–95% of the population could be infected if the virus spreads through the entire population (in the US that’s about 300 million people). Everyone who is exposed enough to C-19 will get infected. The only way to not get infected is to minimize your exposure to the virus.
It’s a Highly Infectious, easily Transmissible Virus
The earliest case studies out of China have shown that C-19 is highly infectious in enclosed spaces. There was the bus case, the restaurant case, and the call center case all of which indicated that a single infected individual could easily spread the virus to multiple people, without direct face to face contact, in an enclosed indoor environment. Multiple studies of superspreader incidents in the US and Europe have confirmed this. While there was a great deal of concern about the virus’s ability to spread on contaminated surfaces what we have learned is that the primary vector of transmission is small aerosolized particles that individuals exhale through breathing. Although you can get C-19 from a contaminated surface the most likely route of infection is breathing contaminated air.
It’s a “Stealthy” Virus
From the beginning we have known that for each “serious” infection there were many other asymptomatic or mild infections. The earliest population study from the Italian village of Vo, proved the existence of asymptomatic infections. Accumulating evidence suggests that the ratio of asymptomatic and mild infections to “serious” infections is about 80/20. Only about one out of five C-19 infections will require medical attention or hospitalization. The idea that if you don’t feel sick you are not infectious is wrong. Most of the people who get C-19 will never feel “sick”. They are still infectious and can spread the virus though.
Even for those who develop a serious illness, there is a “presymptomatic” period which can range from several days to several weeks. During this period, they will not “feel sick” but they are infectious. Basically, everyone who gets infected can become infectious in about three days whether they have any symptoms or not. Temperature checks for fever aren’t a reliable screen for infection. Many of the infected never have a high fever. If you think entry into an area is “safe” because they are taking people’s temperatures, you are wrong. There is no reliable way to know if someone without obvious illness is infected.
Herd Immunity is a Mirage
75%, that’s the percentage of the population that will probably have to be infected with C-19 before Herd Immunity causes the virus to be starved out and vanish. The more infectious a virus is, the higher the required percentage of infection is required. C-19 is very infectious so 75% is a good estimate. This means that about 225 million Americans would have to get infected for the virus to burn out on its own if we did nothing. Right now, somewhere between 14 to 20 million Americans have had C-19. It will take 18–36 more months before “herd immunity” becomes real. If it is even possible.
There is some emerging research that indicates people who get C-19 may not develop a strong antibody response to it. Particularly the people who have asymptomatic and mild cases. It is very possible that these people may be able to be reinfected with C-19 in six months to a year from now. If this turns out to be the case, then natural herd immunity will never happen in the population. Without a vaccine C-19 will always be in the population waiting to strike whoever is vulnerable.
The Infection Mortality Rate seems to be Around 1%
One percent (1%) is the number that the evidence seems to be coalescing around for the Infection Mortality Rate of C-19. The two earliest population studies in Vo and on the Diamond Princess indicated that the Infection Mortality Rate was about 1%. This was the number used to calculate the 2.2 million US deaths in the Imperial College study that got Trump to agree to the lockdown of April. Every other population study, every bit of experimental data from countries like New Zealand (which have crushed their infections), and the NYC analysis of their data set is pointing at an Infection Mortality Rate of about 1%. This is the number I am using in my analysis.
This number, in early March, has been as high as 4%. The WHO once estimated it in late March as 2.5%, as bad as the “Spanish Flu”. The CDC first estimated it at 0.1%, the same as the flu. This was in late March when they confidently predicted no more than 50K deaths. About a month ago, accepting the reality of 100K dead of C-19 they upgraded to a 0.5% estimate. Almost everyone thinks this is too low. Several studies, based on serological tests, have placed the Infectious Mortality Rate at 0.60–0.65%. I have the most confidence in the 1% estimate and it is the one I am going to keep using.
This means, that if all those 225 million Americans got C-19 you could expect about 2.25 million of them to die. That would be the worst-case scenario if we did nothing to prevent infections or treat the infected.
1% Infection Mortality Rate doesn’t mean that your risk of dying is one percent.
That is the aggregate rate for the whole population. Evidence indicates that the burden of C-19 falls unevenly on different age cohorts.
If you are under 45, the mortality rate is about 0.1%, or 1 in a 1,000. Which explains the “half-truth” WH estimate, Covid-19 is “only” as deadly as the flu, IF YOU ARE UNDER 45. Although even that statement is misleading. The overall Infection Mortality Rate for Influenza is about 1 per 1000 but, 90% of the deaths from flu are people over 65. The actual risk of mortality from a normal flu, for someone under 45, is about 1 per 10,000. The fact that C-19 is “only as deadly as the flu” at 0.1% for the under 45 age cohort, makes it 10X more deadly than a “normal flu” for them. COVID-19 IS NOT THE FLU.
If you are 45–65, the rate is about 2%, or 1 in 50.
If you are 65 and over, the rate is about 4%, or 1 in 25. Seventy percent of all US deaths have been from this age cohort, which makes up only 16% of the population. This is reflected in what has been observed in nursing homes and senior communities. Seven people over 65 are dying for each person under 45 who dies.
As you can see, a 1% Infection Mortality Rate over the total population doesn’t mean that your personal risk is only 1%. Your age is a huge influence on your risk, as is your overall health, gender (men die twice as often than women), race (minorities in the US are at greater risk), and income level (poor people are dying more often than middle class and wealthy people).
70/30, the ratio of Male vs Female mortality in all age groups.
Those at the greatest risk are men over 65. Men die twice as much as women from Covid-19 (In the public data set, the number of men who died from COVID-19 is 2.4 times that of women (70.3 vs. 29.7%, P = 0.016). While men and women have the same prevalence, men with COVID-19 are more at risk for worse outcomes and death, independent of age. There are already fewer men than women in the over 65 age cohort. Covid-19 has the potential to kill about 1 out of every 16 men (about 6.5%) over the age of 65 in the next 18–36 months.
The Covid-19 Penumbra
Estimates indicate there are going to be roughly 8% of the population who have long lasting health issues because of being infected with Covid-19. As I stated, multiple studies have shown that about 1 in 5 cases (20%) are severe enough to cause the infected to seek medical treatment. Out of that group, studies from China and Europe are indicating that roughly 40%, of the seriously infected will suffer persistent to permanent damage because of their C-19 infection. About 8% of the population, or 80 per 1,000 people. This is the Covid-19 Penumbra of people who will survive their infection but have scarred lungs, damaged kidneys, neurological damage, vascular, or heart damage.
This percentage seems to be consistent across all age groups. While far fewer of the under 45 population will die from C-19, far more of them (in total numbers) will suffer life altering damage from C-19 infections. The “worst case” is that about 18 million people could be left scarred or damaged from their C-19 infection with lifelong health problems. Like the healthy 22 year old whose lungs were destroyed by C-19 in a matter of days (A critically ill COVID-19 patient just got a double lung transplant):
This section of a lung from the young woman who received a double lung transplant shows damage and scarring beyond recovery. A healthy lung looks like a sponge, with lots of air pockets. Remember, this does not count as a C-19 death. This young woman counts as a “recovery”, although her life will never be the same again.
Millions of people in their 20’s, 30’s, and 40’s are going to get Covid-19 and get seriously ill. About 1 in 5, of them in fact. Of those people, about half, are going to have some degree of long term or permanent damage from that illness. It may not be as bad as the young woman mentioned above but damage is damage.
Even though Covid-19 may only kill 1 in a 1,000 of those under 45, it could cause long term or permanent damage to as much as 8% of their age cohort.
How Long is this Going to Go On?
129,000 is the total number of dead in the US, as of today.
Using an Infection Mortality Rate of 1% and working backwards, this indicates that about 13 million people have had a C-19 in the US. This is just under 4% of the population. The CDC is using a 0.5% Infection Mortality Rate and from that, is estimating 20 million people have had a C-19 infection, about 6% of the population. Either way, there are over 200 million more people in the US who could still be infected with C-19. Current estimates are that without intervention, C-19 would take 18–36 months to spread and infect these people.
Unless you live in one of the most impacted urban areas, like NY, or have a relative in a nursing home, you probably don’t know anyone who has actually had Covid-19. The spread of a disease is a chaotic process with a high degree of randomness, that unfolds over a vast area where conditions change over time. Our efforts to control and suppress the virus will both slow it down and add another level of randomness to its spread. A “real world” virus is not a computer virus it takes a lot of time to infect people and travel. We are just at the start of C-19 spreading through the US population. Without a “miracle breakthrough” on the vaccine, C-19 is going to be with us fir 18–36 months.
We need to stop thinking about getting back to what the world was in February, and start thinking about how we can adapt to get through the next 18–36 months.
Are 2.25 million deaths, 18 million “life altering” infections, and 45 million serious illnesses in the US “inevitable”? Can we prevent this outcome?
Yes, by taking basic public health measures at the individual and governmental levels we can smother C-19 and cause this pandemic to “burn out” before it infects every possible victim. Studies now indicate that simply getting everyone to wear a mask in public and, closure of all indoor businesses where masking is not possible, would reduce the number of total infected by 85%. Instead of 2.25 million dying only about 340K would die, 2.7 million would have “life altering” infections, and 6.8 million would have serious illnesses. This would be a vastly preferable outcome to letting the virus spread unchecked.
Combinations of public health measures, lock-downs, and quarantines that will be used to fight C-19 and make it a certainty that the “worst case” scenario is a low probability event. Far fewer than 2 million people will die of C-19 in the US, the question is, “how many do we save?” We now know the basic parameters for the virus and what the worst-case scenario looks like. What’s difficult to forecast are the social and political measures that will be taken to combat it.
My personal modeling and “gut feeling” is that there will be a huge spike in deaths in August tapering off slowly through September and October with about 300K dead by Election Day. Another, smaller spike will happen when winter arrives, and people have to spend more time indoors in closer quarters, leaving another 100K dead by Inaugural Day. The death rate will slowly taper off through the winter and spring and by June of 2021 I forecast about 500K dead in the US from C-19.
By then there might be a vaccine, we might have enough testing to do instant testing on demand, we might have set up the infrastructure to aggressively quarantine the infected, all sorts of measures should be in place to combat and control the virus so that we can smother it out of the population.
Ultimately I think that about 600K will die in the US as a result of C-19, about 4 million will have suffered “life altering” damage from C-19 infection, and about 14 million will have had serious illness from C-19 infection.