- Written by Michael Z Williamson
From George Avery, PhD. MPA
Dr. Avery has a PhD in Health Services Research from the University of Minnesota School of Public Health, and has conducted significant research in the area of public health emergency preparedness, including five journal articles and two book chapters on the topic. He has served on several CDC advisory boards, including a panel on preparedness and emergency response centers, and consulted for the Defense Department on Medical Civic Action program doctrine. He has edited a special issue of the research journal Bioterrorism and Biodefense and served as a reviewer for the Journal of Homeland Security and Emergency Management as well as Disaster Medicine and Public Health. He is a health services researcher with a medical analytics firm in the Midwest, and has formerly been a professor with the public health program at Purdue and worked from 1990-2000 with the Arkansas Department of HealthΓÇÖs Division of Public Health Laboratories.
We are seeing a panic reaction towards the newly emerged SARS-COVID-2 [Wuhan] epidemic, marked by panic buying of items including the much-joked about toilet paper, drastic action by political figures that often impinges on basic civil rights, and potentially devastating lasting economic impact. Much of this has been fueled by na├»ve and sensationalist reporting of fatality rates, such as a March 10, 2020 report by the Bloomberg news service that implies that 3.4-3.5% of infected individuals die (https://www.bloomberg.com/news/articles/2020-03-09/travel-companies-pull-forecasts-italy-extends-ban-virus-update ).┬á This has caused comparisons to the 1919 Influenza A:H1N1 pandemic and its 2.5% case fatality rate, which would qualify as a level 5 event on the CDCΓÇÖs Pandemic Severity Index (PSI) and has led to a panicked overreaction worldwide. This case fatality rate, however, to a trained epidemiologist is obviously a significant overestimation of the actual fatality rate from the disease.
Ascertainment bias is a systematic error in statistical estimation of a population parameter resulting from errors in measurement - usually, in undermeasurement of a parameter. In this case, we are underestimating the actual number of cases in the population, which is the denominator in the calculation of the estimated case fatality rate. We are accurately estimating deaths, but to get the case fatality rate, we divide deaths by our estimate of the number of cases. Because that it too low due to measurement error, the estimate of the case fatality rate is too high.
For example, for a hypothetical disease if we have three deaths and observed ten cases, then the case fatality rate is 30% (3/10=0.3 or 30%). If, however, there were actually 300 cases, and only 10 were observed and reported, ascertainment bias has led us to underestimate the cases and overestimate the case fatality rate, which is actually 1% (3/300=0.01 or 1%).
In this case, in the absence of population-based screening to more actually estimate the total number of cases, we are only counting cases who are sick enough to seek health care -- almost all disease reports are made by healthcare professionals. We are missing people who have no more than a cold or who are infected but show no symptoms, individuals who almost certainly make up the overwhelming majority of actual cases. Thus, as in my hypothetical example, we are overestimating the case fatality rate for the disease.
There is, however, data available on SARS-COVID-2 [Wuhan] that allows us to get a better grasp on the actual case fatality rates for the virus.
One case is that of the cruise ship Diamond Princess, which achieved some notoriety from the well-publicized outbreak among its 3711 passengers and crew in January and February of 2006. Held aboard in constricted quarters, the population was subject to 3068 polymerase chain reaction (pcr) tests, which identified 634 individuals (17%) as infected, with over half of these infections (328 ) producing no symptoms. Seven infected passengers died, all of them over the age of 70. Adjusting the data for age, researchers at the London Institute of Tropical Medicine have estimated a fatality rate per infection (IFR) for the epidemic in China of 0.5% (95% CI: 0.2-1.2%) during the same period. This is far below the earlier estimates of 3.4% or greater that were promoting panic over the epidemic.┬á See Russell et al, Estimating the infection and case fatality ratio for COVID-19 using age-adjusted data from the outbreak on the Diamond Princess cruise ship, MedRXIV 2020 at https://www.medrxiv.org/content/10.1101/2020.03.05.20031773v2.full.pdf.
South Korea has also implemented far wider population-based screening than the US, expanding their screening past suspected cases to voluntary population screening in geographies frequented by identified cases. As of March 15, as Stanford University economist Richard Epstein has noted, they performed over 235,000 tests and identified 8, 162 infections with 75 deaths (CFR=0.91%). Again, only about 10% of the deaths were in the population under the age of 60. See https://www.hoover.org/research/coronavirus-isnt-pandemic . While their population screening efforts were far better than that of the United States, this was still not a broad-based screening effort (such as was used on the Diamond Princess), being biased because while it looked at a broader population, it still was enriched with cases by looking only at a segment of the population with a higher risk.┬á Still, the case fatality rate is significantly below the 3.4% rate that caused the public panic.
What we are likely seeing, in my estimation, is an epidemic with a real case fatality rate between 0.2 and 0.5%, which is similar to the 1957 Asian Influenza A:H2N2 or 1968 Hong Kong Influenza A:H3N2 pandemics, which were also essentially virgin field respiratory epidemics. These pandemics rate, not as PSI5 events, but as PSI2 events on the CDC scale. They are certainly atypical and more severe than a PSI1 event (such as a routine seasonal flu epidemic), but not a shattering event like the 1919 influenza A:H1N1 pandemic. These earlier pandemics essentially tripled the number of deaths due to influenza experienced annually, and were posed little long-term economic or other damage to the population despite being handled without the extreme measures that are currently being adopted or proposed by political figures. Like those pandemic events, SARS-COVID-2 [Wuhan] has its most significant impact on elderly or otherwise compromised individuals, with few fatalities observed in the population under the age of 60. From what we have observed, half of those infected show no symptoms, 40% show mild symptoms such as a cold, and only about 2% advance to serious or critical illness. What is needed now is for politicians and the population to pause, take a deep breath, and address the epidemic with rational measures, such as social distancing of the older population, ring screening around identified cases, quarantine of identified infected individuals, and adequate hospital triage systems to protect other patients and health care staff rom infection in order to preserve our ability to treat the most severe cases. This is a strategy identified by myself and colleagues at Purdue in 2007 to ensure adequate capacity to deal with another true influenza pandemic, and it applies to this one as well.
- Written by Michael Z Williamson
Greetings, fellow citizens.
You may have noticed most of the country losing their collective minds. Relax.┬á I'm here to put things right.
WHAT YOU NEED TO KNOW: Coronavirus is contagious, but presents with no symptoms in the majority of those infected. ┬áOf those presenting, most only experience a cold. At the extreme end, it can cause pneumonia and death.┬á Complicating factors are: Age, heart conditions, breathing issues (COPD, Asthma), immunocompromise, diabetes. ┬áBasically, if you're old and/or frail, this crap can kill you.
Got that? Good. So, if you are one of those, you should try to sequester yourself as much as possible. Get friends or family to drop off supplies for you. Minimize contact with other people.
WHAT THE STATE IS DOING FOR YOU: For the duration, your employer will not be able to fire you for quarantining yourself. We are encouraging them to pay you if they can afford it, and reducing their tax burden by the amount of your compensation.┬á If they can't, our agencies stand ready with help for utilities, food, etc. I have appointed a special task force, and if you have no local friends or family, the National Guard will drop off food and supplies to you.
IF YOU ARE NOT AT SIGNIFICANT RISK: Wash your damned hands. Don't shake hands. Don't breathe or sneeze on people. Seriously, didn't you learn all this in kindergarten?┬á Try to keep some distance.
DON'T PANIC:┬á If you see a bunch of people having fun at a park, relax.┬á There is no way you can get infected at a distance based on their cheerfulness. Just avoid them and you'll be fine.
EVENTS: We will do our damndest not to cancel any public events, because the hospitality industry runs on narrow margins and employs a lot of people. We'll use a lot of bleach and scrubbing between events, with extras borrowed, if necessary, from the National Guard.┬á It may surprise you, but military people are really freaking good at detail oriented cleaning. It's almost as if they get specific training in it.┬á
IF CLOSURES BECOMES NECESSARY, WE WILL STAGE ACCORDINGLY: Three weeks ahead, events will be advised of potential shutdowns so they can either cancel preparations by choice, or tell their attendees to stand by.┬á Two weeks ahead, the event will be cancelled so travel, transport, and other preparations are not wasted. We're not shutting down months of events based on a vague, undefined threat.
SOME OTHER STATES ARE COMPLETELY FLIPPING THEIR LIDS and trying to end civilization with complete lockdowns. This isn't 1346 and this isn't the Black Plague.┬á Take a deep breath and wash your hands again.
SUPPLIES:┬á You do not need 50 extra rolls of bogwipe, nor a pallet of water--the water from your faucet is perfectly safe, can be settled or boiled, and plenty of filters exist.┬á You don't need 400 lbs of meat, either.┬á God gave you a brain. Use it. Make a list of consumables, try to get two weeks' worth (Why didn't you already?) and stand by. This will all be over soon.
VIRUSES ARE NOT TO BE TAKEN LIGHTLY, but we experience literally thousands of them in our lifetimes. Be cautious, be careful, and remain calm.
Signed: The gov
- Written by Michael Z Williamson
What about a top-rated expert in allergy and asthma?
What about my doctor, Dr Garrick Hubbard, who has brought my lung function back to almost 100% of what it was before I deployed, and reduced my acquired environmental allergies by about 90%?
Sounds like he's pretty knowledgeable about these things, right?
So today, when Jess and I went for our recurring treatment, rather than a waiting area for people who are absolutely "At risk," we went straight into a treatment room and waited there for the standard 30 minutes after our shots.
And then we left through the lobby and doors as we always do.
Non-treatment patients (those just being tested) waited in the waiting area, the way they normally do.
No freakouts, no shutdowns, no "only one person can enter at a time" like some alleged doctors are doing. No "rescheduling" of immunizations at pediatricians.┬á Just a slight bit more social distancing, for ACTUAL AT RISK PATIENTS.
Be like Dr Hubbard.
- Written by Michael Z Williamson
A paraphrase of Pournelle's Iron Law of Bureaucracy is that bureaucrats will ALWAYS go to far.
We started with "two weeks of restricted events." Tough, but bearable, and a good idea. I supported this. ┬áIt was a personal bite to me on my part time gig--a show was shut down literally as I arrived to load in. Okay.┬á Let's do this.┬á Then a bigger one had to postpone because they're 1 day into the existing timeframe, no exceptions, no "let's see if that's enough by next week."
Then the states got into a "We're more quarantine than you!" war.
Blah, blah, the CDC.┬á Per them, no woman of child bearing years should EVER even look at a bottle of liquor, no two people should ever kiss without a doctor's exam first, and we should all live in plastic bubbles.┬á There's hypothetical perfection, and then there's reality, which has kids playing in mud and licking slides others have slid down.
Instead, we have schools closed, possibly for the year.┬á Gyms closed. All public events shut down. No, wait, maybe no more than TEN people at a time is better.┬á No sports.┬á No spring break. No parks!
So what are all these out of school kids supposed to do?┬á Who stays home to watch them if (we're lucky, most aren't) people can't work from home?
Now the goddamned pediatricians are saying well, we can't give your kids their immunizations because of disease. We'll have to "Reschedule."┬á Are you TRYING to give the anti-vaxxtards ammo?┬á Because THIS is how you give the anti-vaxxtards ammo.
The OB-GYN said they can only see single patients without their infants along, figure it out somehow.
Um...why are senior citizens going to pediatricians and OB-GYNs? If they're not, then why not advise the elderly that you're going to be out in public, so Grandma shouldn't visit this month. If you live in an area where it's been an issue.
"This bug kills old people!" Yes, and others at risk. Like me. Who should stay home.
"But people will die!"┬á Jesus, that sounds like Liz "Psychogawea" Warren.
This is literally creating the End of Western Civilization As We Know It over a fucking bug.
"But people will die!"
Then they fucking die.┬á There's a cost benefit analysis here.┬á After enough lost revenue, wages, activities, people stop giving a shit.┬á If they die, they die. Most of them are urbanites anyway, smug in their myth of "efficiency."┬á They can fucking die efficiently, and be efficiently processed into dump trucks.┬á You may have heard this motto if you hang around rural folk for a bit:┬á Five million fewer urbanites is five million fewer urbanites.
And again, those of us who are susceptible should be minimizing contact anyway.┬á You cannot develop herd immunity for the rest by not having herds. We'll come back to that.
Some shithead on Medium (so called because it is neither rare nor well done) lamented we may "never" beat...an upper respiratory infection.┬á Like the 10 million strains of URIs we already have, many of which are... (CUE DRAMATIC MUSIC!)--coronavirii, of different strains. This one is already mutating into subcultures.┬á Which still have more "culture" than your typical city.
And guess what?
Everyone is going to the fucking store. In herds.
BTW, around here, the pussification of yuppies meant they'd cleared out the lowfat and no fat and soy "milk," but left the real whole milk. Please don't tell them that diluting it 50% with water will create their preferred tasteless, nutritionless white drink.
Then, restaurants are still doing delivery...which means the same Uber driver stop at 5 restaurants and 5 houses 3 times a night, along with 12 other Uber drivers, and a hundred random pickups.┬á This is like avoiding VD by skipping the fetish club and only going to singles bars. It's a fuck-all security theater move.┬á We call this "Wetting your pants in a dark suit."┬á It gives you a warm feeling, but nobody notices, and then you realize you're the one suffering.
It is time to mobilize to beat this.┬á Call your mayor, call your governor, call your president, tell them to stop being a huge pussy, to go fuck themselves, and then get on with the real world.
Oh, and Trump? Yeah, if you could stop being a massive faggot, that would be just great.┬á Tell the CDC to STFU, Americans have a world to run.
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