Regulatory Open Forum

Thinking in terms of "the" anything seems to be missing the point.  There is no "the," there is only what happens when many factors collide.  The virus itself is just one factor.  Age is another.

Italy has the oldest population in Europe, with about 23% of residents 65 or older. The median age in the country is 47.3, compared with 38.3 in the United States, and 40 in the UK. Many of Italy's deaths have been among people in their 80s, and 90s.  I'm from Florida, the state with the largest percentage of its population over age 65 (19%), so I appreciate these statistics.  I think a lot of Americans would find "older than Florida" to be a bit of a staggering concept, one that would put Italy's hospitalization and mortality rates in a somewhat different perspective.

From an interview with Aubree Gordon, an associate professor of epidemiology at the University of Michigan:
The overall mortality rate is always going to depend on the demographics of a population.  The reported mortality rates have not been adjusted for the underlying demographics of a population. Given Italy's demographics, you would expect their mortality rate to be higher on average, all else being held equal, compared with a country with a younger population.

Key here is "all else being held equal."  Young populations are often found among developing countries, where a lack of infrastructure, including medical resources, would be likely to offset the "advantage" of a younger population.

Culture also plays a role.  It's my impression that multiple generations mingle much more in Italy than in the US.  If my impression is correct, that unfortunately could mean greater exposure of the elderly to a virus circulating in the population.

I'm not sure what you mean when you say that the ICU wards being overwhelmed does not look like "the" flu.  Influenza is the reason the US stockpiles ventilators, because it has the potential to overwhelm ICU wards too.  What a novel influenza virus might look like in any given population is as unknown as it is with a novel coronavirus.

The story of the Spanish flu, the first epidemic involving the H1N1 virus is a fascinating case study of the many different factors that can drive, effect, and interact with a virus, including a world war.  Because of this epidemic, for many decades H1N1 was considered to be an especially deadly virus. Then, in 2007, an analysis of the available data concluded that most of the victims probably died of a bacterial infection, rather than H1N1.  And that the "Spanish" flu epidemic probably originated at Ft. Riley, Kansas.

Speaking of ventilators, another statistic (if correct, sigh) of interest is that Italy seems to have about 1 ventilator for every 5,000 people, where the US seems to have 1 for every 3,500.

The government is looking for businesses who can support in the supply of ventilators and ventilator components across the UK as part of our response to COVID-19.

As well as manufacturers, we are looking for businesses with the following skills:

• design/specification
• rapid prototyping
• contract/product assembly
• certification/regulation/testing
• logistics
• medical training

https://www.gov.uk/government/news/production-and-supply-of-ventilators-and-ventilator-components

Wow. It is so distressing to read these cavalier posts about the disease, its ability to spread exponentially, and its rate of killing patients at more than 20 times the flu.

It is also distressing that my post to obey the recommendations was reported to RAPS as inappropriate. Posts that are suggesting that we decide for ourselves whether to dismiss or even disobey the WHO, state, and CDC recommendations remain.

People of every age are dying, not just the elderly. Hospitals in the US, especially rural hospitals already on the verge of bankruptcy for serving uninsured people without reimbursement from the ACA (as they had been reimbursed better 4 years ago), are already choosing who gets a ventilator and who dies. Because of limited testing availability in the US, we have no idea about the extent of the infection.

"This week, it's going to get bad" says the US Surgeon General.

Please respect the "herd" and obey all the requirements and recommendations. We might not reduce the exposure, but we can "flatten the curve" so that many don't need extensive health care at once.

https://www.msn.com/en-us/news/world/italy-pandemics-new-epicenter-has-lessons-for-the-world/ar-BB11vMrO?li=BBnb7Kz

Wow. It is so distressing to read these cavalier posts about the disease, its ability to spread exponentially, and its rate of killing patients at more than 20 times the flu.

It is also distressing that my post to obey the recommendations was reported to RAPS as inappropriate. Posts that are suggesting that we decide for ourselves whether to dismiss or even disobey the WHO, state, and CDC recommendations remain.

People of every age are dying, not just the elderly. Hospitals in the US, especially rural hospitals already on the verge of bankruptcy for serving uninsured people without reimbursement from the ACA (as they had been reimbursed better 4 years ago), are already choosing who gets a ventilator and who dies. Because of limited testing availability in the US, we have no idea about the extent of the infection.

"This week, it's going to get bad" says the US Surgeon General.

Please respect the "herd" and obey all the requirements and recommendations. We might not reduce the exposure, but we can "flatten the curve" so that many don't need extensive health care at once.

https://www.msn.com/en-us/news/world/italy-pandemics-new-epicenter-has-lessons-for-the-world/ar-BB11vMrO?li=BBnb7Kz

Wow. It is so distressing to read these cavalier posts about the disease, its ability to spread exponentially, and its rate of killing patients at more than 20 times the flu.

It is also distressing that my post to obey the recommendations was reported to RAPS as inappropriate. Posts that are suggesting that we decide for ourselves whether to dismiss or even disobey the WHO, state, and CDC recommendations remain.

People of every age are dying, not just the elderly. Hospitals in the US, especially rural hospitals already on the verge of bankruptcy for serving uninsured people without reimbursement from the ACA (as they had been reimbursed better 4 years ago), are already choosing who gets a ventilator and who dies. Because of limited testing availability in the US, we have no idea about the extent of the infection.

"This week, it's going to get bad" says the US Surgeon General.

Please respect the "herd" and obey all the requirements and recommendations. We might not reduce the exposure, but we can "flatten the curve" so that many don't need extensive health care at once.

https://www.msn.com/en-us/news/world/italy-pandemics-new-epicenter-has-lessons-for-the-world/ar-BB11vMrO?li=BBnb7Kz

Wow. It is so distressing to read these cavalier posts about the disease, its ability to spread exponentially, and its rate of killing patients at more than 20 times the flu.

It is also distressing that my post to obey the recommendations was reported to RAPS as inappropriate. Posts that are suggesting that we decide for ourselves whether to dismiss or even disobey the WHO, state, and CDC recommendations remain.

People of every age are dying, not just the elderly. Hospitals in the US, especially rural hospitals already on the verge of bankruptcy for serving uninsured people without reimbursement from the ACA (as they had been reimbursed better 4 years ago), are already choosing who gets a ventilator and who dies. Because of limited testing availability in the US, we have no idea about the extent of the infection.

"This week, it's going to get bad" says the US Surgeon General.

Please respect the "herd" and obey all the requirements and recommendations. We might not reduce the exposure, but we can "flatten the curve" so that many don't need extensive health care at once.

https://www.msn.com/en-us/news/world/italy-pandemics-new-epicenter-has-lessons-for-the-world/ar-BB11vMrO?li=BBnb7Kz

Wow. It is so distressing to read these cavalier posts about the disease, its ability to spread exponentially, and its rate of killing patients at more than 20 times the flu.

It is also distressing that my post to obey the recommendations was reported to RAPS as inappropriate. Posts that are suggesting that we decide for ourselves whether to dismiss or even disobey the WHO, state, and CDC recommendations remain.

People of every age are dying, not just the elderly. Hospitals in the US, especially rural hospitals already on the verge of bankruptcy for serving uninsured people without reimbursement from the ACA (as they had been reimbursed better 4 years ago), are already choosing who gets a ventilator and who dies. Because of limited testing availability in the US, we have no idea about the extent of the infection.

"This week, it's going to get bad" says the US Surgeon General.

Please respect the "herd" and obey all the requirements and recommendations. We might not reduce the exposure, but we can "flatten the curve" so that many don't need extensive health care at once.

https://www.msn.com/en-us/news/world/italy-pandemics-new-epicenter-has-lessons-for-the-world/ar-BB11vMrO?li=BBnb7Kz

The media is always unreliable is exactly what Putin and other dictators wants Americans to think.

NYTimes  The Atlantic

Please be careful out there.

The media is always unreliable is exactly what Putin and other dictators wants Americans to think.

NYTimes  The Atlantic

Please be careful out there.

The media is always unreliable is exactly what Putin and other dictators wants Americans to think.

NYTimes  The Atlantic

Please be careful out there.

The media is always unreliable is exactly what Putin and other dictators wants Americans to think.

NYTimes  The Atlantic

Please be careful out there.

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

Hi Julie, I always appreciate your insight.

Let's look at this with a risk management perspective; probability, severity, and mitigations.

Probability would be range depending on how the population is divided. Very low would be those with healthy immune systems and limited social interactions; while those with compromised immune systems and more socially connected would be a relatively higher, not high, probability. Both probabilities are increasing at this time, however we also know the number of cases is underreported because people who are asymptomatic or have mild symptoms aren't necessarily going to be tested.

Severity would also be range to account for the different symptoms, including asymptomatic, mild, and severe, including death. Severity and probability are distinct parts of the puzzle.

Mitigations would be tiered and clocked in, as necessary. Ideally, you want to implement the most effective mitigations, but they are often costly and may not be warranted (locking down countries, shutting down businesses/large gatherings/schools) - this is third tier. First tier would encourage people to be vigilant in their normal behavior - wash hands, stay home when sick, be mindful of vulnerable population and alter behavior around them, limit travel to riskier areas, vaccination, don't be stupid. This may be enough, i.e. manageable. Second tier would be implemented when first tier is not effective by itself and targets optional gathering of people such as conferences, games, asking employers to make arrangements for remote work or schools make arrangement for online classroom, where feasible. We should still be in 1st tier, but some places (Illinois, Ohio, Kentucky, Italy, California) and businesses (Disney, many malls, airlines) are in 3rd tier. Schools and churches are generally in 2nd tier. People behaving like zombie apocalypse is inevitable and stocking up on toilet paper and bottled water are behaving like 3rd tier. BTW, Ventilators are a mitigation for high severity, very low probability cases and should be available throughout tiers.

The tricky part about risk management is avoiding placing too much emphasis on the worst case scenario. For CVirus, the worst severity is death and there is a non-zero probability it could occur, but that is not the case across the entire population, indeed it is remote, at best. It may feel like it is more prevalent because we are hammered by CVirus bad news constantly, but what news reports or social media shares should not drive probability or severity.

We did not give tier 1 mitigations enough time to work (part of the reason was people did not take it seriously. Getting the word out so people get it is part of tier 1), now we are generally at tier 2 and moving slowly to tier 3. While China is manipulating the numbers and is not an example to follow, South Korea took a more rational approach (combo of tier 1 and tier 2) and is dealing effectively with CVirus. Why we chose to do differently is what I don't understand.

THIS. IS. INSANE.

Thoughts?

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

I like the risk management approach, but I don't think available data (such as it is...or is not, sigh) support your assumption that death is a remote probability or that cases needing ventilators are very low probability.  At least, not if you are defining probabilities the way I've usually seen them defined when risks associated with a medical device are assessed.  The head of our state health department reports 29 coronavirus patients are currently hospitalized in NC.

This CDC report summarizes cases February 12 through March 16, with a focus on severe outcomes.  If I'm reading the data correctly, hospitalization was required in roughly 20-30% of cases, ICU in 5-10%, and death rates were 2-3%.  My understanding is that, if a coronavirus patient needs to be admitted to the ICU, there is a high probability that they will need a ventilator.  So without ventilators, it seems that death rates and ICU rates will start to converge.

Hi Julie, I always appreciate your insight.

Let's look at this with a risk management perspective; probability, severity, and mitigations.

Probability would be range depending on how the population is divided. Very low would be those with healthy immune systems and limited social interactions; while those with compromised immune systems and more socially connected would be a relatively higher, not high, probability. Both probabilities are increasing at this time, however we also know the number of cases is underreported because people who are asymptomatic or have mild symptoms aren't necessarily going to be tested.

Severity would also be range to account for the different symptoms, including asymptomatic, mild, and severe, including death. Severity and probability are distinct parts of the puzzle.

Mitigations would be tiered and clocked in, as necessary. Ideally, you want to implement the most effective mitigations, but they are often costly and may not be warranted (locking down countries, shutting down businesses/large gatherings/schools) - this is third tier. First tier would encourage people to be vigilant in their normal behavior - wash hands, stay home when sick, be mindful of vulnerable population and alter behavior around them, limit travel to riskier areas, vaccination, don't be stupid. This may be enough, i.e. manageable. Second tier would be implemented when first tier is not effective by itself and targets optional gathering of people such as conferences, games, asking employers to make arrangements for remote work or schools make arrangement for online classroom, where feasible. We should still be in 1st tier, but some places (Illinois, Ohio, Kentucky, Italy, California) and businesses (Disney, many malls, airlines) are in 3rd tier. Schools and churches are generally in 2nd tier. People behaving like zombie apocalypse is inevitable and stocking up on toilet paper and bottled water are behaving like 3rd tier. BTW, Ventilators are a mitigation for high severity, very low probability cases and should be available throughout tiers.

The tricky part about risk management is avoiding placing too much emphasis on the worst case scenario. For CVirus, the worst severity is death and there is a non-zero probability it could occur, but that is not the case across the entire population, indeed it is remote, at best. It may feel like it is more prevalent because we are hammered by CVirus bad news constantly, but what news reports or social media shares should not drive probability or severity.

We did not give tier 1 mitigations enough time to work (part of the reason was people did not take it seriously. Getting the word out so people get it is part of tier 1), now we are generally at tier 2 and moving slowly to tier 3. While China is manipulating the numbers and is not an example to follow, South Korea took a more rational approach (combo of tier 1 and tier 2) and is dealing effectively with CVirus. Why we chose to do differently is what I don't understand.

THIS. IS. INSANE.

Thoughts?

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

Hi Julie,

Interesting report. Thank you for sharing.

The data in the report comes from cases reported to CDC by states and jurisdictions as of 16 Mar. 

* 12% of cases required hospitalization (508/4226). Half were 65yo or older.
* 2.9% of cases were in ICU (121/4226). Half were 65yo or older.
* 1% resulted in death (44/4226). Half were 65yo or older.

In general, severity of CV symptoms increases with age.

As far as risk management mindset, it looks like some clarification is needed. As you know, when it comes to probabilities it is all about the denominator. If looking at CV cases from a general population perspective, the probability of dying from CV is remote. Ventilators will be needed in these extreme cases. CV is serious, but its prevalence is nothing like the flu or the cold. Be safe.

I like the risk management approach, but I don't think available data (such as it is...or is not, sigh) support your assumption that death is a remote probability or that cases needing ventilators are very low probability.  At least, not if you are defining probabilities the way I've usually seen them defined when risks associated with a medical device are assessed.  The head of our state health department reports 29 coronavirus patients are currently hospitalized in NC.

This CDC report summarizes cases February 12 through March 16, with a focus on severe outcomes.  If I'm reading the data correctly, hospitalization was required in roughly 20-30% of cases, ICU in 5-10%, and death rates were 2-3%.  My understanding is that, if a coronavirus patient needs to be admitted to the ICU, there is a high probability that they will need a ventilator.  So without ventilators, it seems that death rates and ICU rates will start to converge.

Hi Julie, I always appreciate your insight.

Let's look at this with a risk management perspective; probability, severity, and mitigations.

Probability would be range depending on how the population is divided. Very low would be those with healthy immune systems and limited social interactions; while those with compromised immune systems and more socially connected would be a relatively higher, not high, probability. Both probabilities are increasing at this time, however we also know the number of cases is underreported because people who are asymptomatic or have mild symptoms aren't necessarily going to be tested.

Severity would also be range to account for the different symptoms, including asymptomatic, mild, and severe, including death. Severity and probability are distinct parts of the puzzle.

Mitigations would be tiered and clocked in, as necessary. Ideally, you want to implement the most effective mitigations, but they are often costly and may not be warranted (locking down countries, shutting down businesses/large gatherings/schools) - this is third tier. First tier would encourage people to be vigilant in their normal behavior - wash hands, stay home when sick, be mindful of vulnerable population and alter behavior around them, limit travel to riskier areas, vaccination, don't be stupid. This may be enough, i.e. manageable. Second tier would be implemented when first tier is not effective by itself and targets optional gathering of people such as conferences, games, asking employers to make arrangements for remote work or schools make arrangement for online classroom, where feasible. We should still be in 1st tier, but some places (Illinois, Ohio, Kentucky, Italy, California) and businesses (Disney, many malls, airlines) are in 3rd tier. Schools and churches are generally in 2nd tier. People behaving like zombie apocalypse is inevitable and stocking up on toilet paper and bottled water are behaving like 3rd tier. BTW, Ventilators are a mitigation for high severity, very low probability cases and should be available throughout tiers.

The tricky part about risk management is avoiding placing too much emphasis on the worst case scenario. For CVirus, the worst severity is death and there is a non-zero probability it could occur, but that is not the case across the entire population, indeed it is remote, at best. It may feel like it is more prevalent because we are hammered by CVirus bad news constantly, but what news reports or social media shares should not drive probability or severity.

We did not give tier 1 mitigations enough time to work (part of the reason was people did not take it seriously. Getting the word out so people get it is part of tier 1), now we are generally at tier 2 and moving slowly to tier 3. While China is manipulating the numbers and is not an example to follow, South Korea took a more rational approach (combo of tier 1 and tier 2) and is dealing effectively with CVirus. Why we chose to do differently is what I don't understand.

THIS. IS. INSANE.

Thoughts?

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

Hi Julie,

Interesting report. Thank you for sharing.

The data in the report comes from cases reported to CDC by states and jurisdictions as of 16 Mar. 

* 12% of cases required hospitalization (508/4226). Half were 65yo or older.
* 2.9% of cases were in ICU (121/4226). Half were 65yo or older.
* 1% resulted in death (44/4226). Half were 65yo or older.

In general, severity of CV symptoms increases with age.

As far as risk management mindset, it looks like some clarification is needed. As you know, when it comes to probabilities it is all about the denominator. If looking at CV cases from a general population perspective, the probability of dying from CV is remote. Ventilators will be needed in these extreme cases. CV is serious, but its prevalence is nothing like the flu or the cold. Be safe.

I like the risk management approach, but I don't think available data (such as it is...or is not, sigh) support your assumption that death is a remote probability or that cases needing ventilators are very low probability.  At least, not if you are defining probabilities the way I've usually seen them defined when risks associated with a medical device are assessed.  The head of our state health department reports 29 coronavirus patients are currently hospitalized in NC.

This CDC report summarizes cases February 12 through March 16, with a focus on severe outcomes.  If I'm reading the data correctly, hospitalization was required in roughly 20-30% of cases, ICU in 5-10%, and death rates were 2-3%.  My understanding is that, if a coronavirus patient needs to be admitted to the ICU, there is a high probability that they will need a ventilator.  So without ventilators, it seems that death rates and ICU rates will start to converge.

Hi Julie, I always appreciate your insight.

Let's look at this with a risk management perspective; probability, severity, and mitigations.

Probability would be range depending on how the population is divided. Very low would be those with healthy immune systems and limited social interactions; while those with compromised immune systems and more socially connected would be a relatively higher, not high, probability. Both probabilities are increasing at this time, however we also know the number of cases is underreported because people who are asymptomatic or have mild symptoms aren't necessarily going to be tested.

Severity would also be range to account for the different symptoms, including asymptomatic, mild, and severe, including death. Severity and probability are distinct parts of the puzzle.

Mitigations would be tiered and clocked in, as necessary. Ideally, you want to implement the most effective mitigations, but they are often costly and may not be warranted (locking down countries, shutting down businesses/large gatherings/schools) - this is third tier. First tier would encourage people to be vigilant in their normal behavior - wash hands, stay home when sick, be mindful of vulnerable population and alter behavior around them, limit travel to riskier areas, vaccination, don't be stupid. This may be enough, i.e. manageable. Second tier would be implemented when first tier is not effective by itself and targets optional gathering of people such as conferences, games, asking employers to make arrangements for remote work or schools make arrangement for online classroom, where feasible. We should still be in 1st tier, but some places (Illinois, Ohio, Kentucky, Italy, California) and businesses (Disney, many malls, airlines) are in 3rd tier. Schools and churches are generally in 2nd tier. People behaving like zombie apocalypse is inevitable and stocking up on toilet paper and bottled water are behaving like 3rd tier. BTW, Ventilators are a mitigation for high severity, very low probability cases and should be available throughout tiers.

The tricky part about risk management is avoiding placing too much emphasis on the worst case scenario. For CVirus, the worst severity is death and there is a non-zero probability it could occur, but that is not the case across the entire population, indeed it is remote, at best. It may feel like it is more prevalent because we are hammered by CVirus bad news constantly, but what news reports or social media shares should not drive probability or severity.

We did not give tier 1 mitigations enough time to work (part of the reason was people did not take it seriously. Getting the word out so people get it is part of tier 1), now we are generally at tier 2 and moving slowly to tier 3. While China is manipulating the numbers and is not an example to follow, South Korea took a more rational approach (combo of tier 1 and tier 2) and is dealing effectively with CVirus. Why we chose to do differently is what I don't understand.

THIS. IS. INSANE.

Thoughts?

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

Hi Julie,

Interesting report. Thank you for sharing.

The data in the report comes from cases reported to CDC by states and jurisdictions as of 16 Mar. 

* 12% of cases required hospitalization (508/4226). Half were 65yo or older.
* 2.9% of cases were in ICU (121/4226). Half were 65yo or older.
* 1% resulted in death (44/4226). Half were 65yo or older.

In general, severity of CV symptoms increases with age.

As far as risk management mindset, it looks like some clarification is needed. As you know, when it comes to probabilities it is all about the denominator. If looking at CV cases from a general population perspective, the probability of dying from CV is remote. Ventilators will be needed in these extreme cases. CV is serious, but its prevalence is nothing like the flu or the cold. Be safe.

I like the risk management approach, but I don't think available data (such as it is...or is not, sigh) support your assumption that death is a remote probability or that cases needing ventilators are very low probability.  At least, not if you are defining probabilities the way I've usually seen them defined when risks associated with a medical device are assessed.  The head of our state health department reports 29 coronavirus patients are currently hospitalized in NC.

This CDC report summarizes cases February 12 through March 16, with a focus on severe outcomes.  If I'm reading the data correctly, hospitalization was required in roughly 20-30% of cases, ICU in 5-10%, and death rates were 2-3%.  My understanding is that, if a coronavirus patient needs to be admitted to the ICU, there is a high probability that they will need a ventilator.  So without ventilators, it seems that death rates and ICU rates will start to converge.

Hi Julie, I always appreciate your insight.

Let's look at this with a risk management perspective; probability, severity, and mitigations.

Probability would be range depending on how the population is divided. Very low would be those with healthy immune systems and limited social interactions; while those with compromised immune systems and more socially connected would be a relatively higher, not high, probability. Both probabilities are increasing at this time, however we also know the number of cases is underreported because people who are asymptomatic or have mild symptoms aren't necessarily going to be tested.

Severity would also be range to account for the different symptoms, including asymptomatic, mild, and severe, including death. Severity and probability are distinct parts of the puzzle.

Mitigations would be tiered and clocked in, as necessary. Ideally, you want to implement the most effective mitigations, but they are often costly and may not be warranted (locking down countries, shutting down businesses/large gatherings/schools) - this is third tier. First tier would encourage people to be vigilant in their normal behavior - wash hands, stay home when sick, be mindful of vulnerable population and alter behavior around them, limit travel to riskier areas, vaccination, don't be stupid. This may be enough, i.e. manageable. Second tier would be implemented when first tier is not effective by itself and targets optional gathering of people such as conferences, games, asking employers to make arrangements for remote work or schools make arrangement for online classroom, where feasible. We should still be in 1st tier, but some places (Illinois, Ohio, Kentucky, Italy, California) and businesses (Disney, many malls, airlines) are in 3rd tier. Schools and churches are generally in 2nd tier. People behaving like zombie apocalypse is inevitable and stocking up on toilet paper and bottled water are behaving like 3rd tier. BTW, Ventilators are a mitigation for high severity, very low probability cases and should be available throughout tiers.

The tricky part about risk management is avoiding placing too much emphasis on the worst case scenario. For CVirus, the worst severity is death and there is a non-zero probability it could occur, but that is not the case across the entire population, indeed it is remote, at best. It may feel like it is more prevalent because we are hammered by CVirus bad news constantly, but what news reports or social media shares should not drive probability or severity.

We did not give tier 1 mitigations enough time to work (part of the reason was people did not take it seriously. Getting the word out so people get it is part of tier 1), now we are generally at tier 2 and moving slowly to tier 3. While China is manipulating the numbers and is not an example to follow, South Korea took a more rational approach (combo of tier 1 and tier 2) and is dealing effectively with CVirus. Why we chose to do differently is what I don't understand.

THIS. IS. INSANE.

Thoughts?

Great question. I mainly work remote anyways, so no big change there. However, our town, Knoxville, TN, is slowly heading into lockdown. Non-essential biz were notified just today. 

I think the govt and media reaction has been extreme and unwarranted. People's reaction has been mixed with some behaving like zombie apocalypse is imminent and others twerking in Florida for Spring Break, but many others have adjusted their habits. I and my family are only going out when it is essential and adding some hygienic measures. My biggest concern is how does gov't and biz get back to operational state. Since it isn't clear, I assume gov't (gov't bodies, schools, DMV, Building & Safety, etc) will stay shut much longer than necessary and people will start showing their disagreement by opening up their biz and trying to recover their lifestyle long before gov't gives a green light.

It is really stunning that this happened given the relatively small number of high severity cases in the US.  Outside of Washington, California, and New York, there have been approximately 202 deaths as of tonight (Johns Hopkins CV site) due to coronavirus. By comparison, 90 people die in car accidents per day in US (we still drive our cars confidently), 18,000 people will die from the flu in the US this year (nobody wants to get the flu, but does anyone think the end of the world is near when flu season starts?),  3,000 will die from foodborne disease in US this year (Has anyone integrated food inspection steps into their daily habits), 647,000 Americans will die from heart disease this year (Americans are overweight and it is getting worse). 

Why such a strong reaction to Cvirus? I don't know. It is surreal.

• Shopping for basics
• One form of exercise a day
• Medical need
• Travelling too and from work that is "Absolutely Necessary", healthcare workers etc.

The first day is always going to be a mixture as people adjust, collect things from work but I fully expect people to take notice of the restriction.

The government has also advised that around 1.5 million people are labelled as 'Vulnerable' and most at risk from having complications from the Coronavirus. These people are being told to self isolate for 3 months. Personally, I fear that I will be sent a letter which will make things even more scary and real!

Stay safe everyone. 

If you take the ex-China numbers (which were available in the earlier sitrpeps) you can plot them out logarithmically. This gives a global (Ex China doubling rate of around every 5 days and a ten fold growth every 2 weeks or so.   Implications are that if unchecked this has a potential to infect a sizeable chunk of global population by mid May.  So the social distancing efforts really matter.  Let's sincerely hope it is brought under control or at least slowed well before then.  Stay home folks!

Back to more regulatory angle.  Great to see FDA and MHRA being flexible on emergency manufacture of ventilators.

Arthur 

• Shopping for basics
• One form of exercise a day
• Medical need
• Travelling too and from work that is "Absolutely Necessary", healthcare workers etc.

The first day is always going to be a mixture as people adjust, collect things from work but I fully expect people to take notice of the restriction.

The government has also advised that around 1.5 million people are labelled as 'Vulnerable' and most at risk from having complications from the Coronavirus. These people are being told to self isolate for 3 months. Personally, I fear that I will be sent a letter which will make things even more scary and real!

Stay safe everyone. 

If you take the ex-China numbers (which were available in the earlier sitrpeps) you can plot them out logarithmically. This gives a global (Ex China doubling rate of around every 5 days and a ten fold growth every 2 weeks or so.   Implications are that if unchecked this has a potential to infect a sizeable chunk of global population by mid May.  So the social distancing efforts really matter.  Let's sincerely hope it is brought under control or at least slowed well before then.  Stay home folks!

Back to more regulatory angle.  Great to see FDA and MHRA being flexible on emergency manufacture of ventilators.

Arthur 

• Shopping for basics
• One form of exercise a day
• Medical need
• Travelling too and from work that is "Absolutely Necessary", healthcare workers etc.

The first day is always going to be a mixture as people adjust, collect things from work but I fully expect people to take notice of the restriction.

The government has also advised that around 1.5 million people are labelled as 'Vulnerable' and most at risk from having complications from the Coronavirus. These people are being told to self isolate for 3 months. Personally, I fear that I will be sent a letter which will make things even more scary and real!

Stay safe everyone. 

If you take the ex-China numbers (which were available in the earlier sitrpeps) you can plot them out logarithmically. This gives a global (Ex China doubling rate of around every 5 days and a ten fold growth every 2 weeks or so.   Implications are that if unchecked this has a potential to infect a sizeable chunk of global population by mid May.  So the social distancing efforts really matter.  Let's sincerely hope it is brought under control or at least slowed well before then.  Stay home folks!

Back to more regulatory angle.  Great to see FDA and MHRA being flexible on emergency manufacture of ventilators.

Arthur