Epidemiologists as the new gurus: what about the excess death rate?

The New Neo Posted on by

Epidemiologists deal with dry facts and figures, but the subject matter of those facts and figures can be very dramatic: illness and death, and how best to go about minimizing the former and delaying the latter. Usually we don’t pay all that much attention to them unless we have a particular interest in the subject.

But now epidemiologists are constantly in the news, and anyone with an “epidemiologist” before or after his or her name is now the new authority. We hang on their every word as though our lives depended on it. Governments set policy based on their recommendations and those policies are having extreme effects on our lives.

It is definitely true that epidemiologists have expertise in this arena that most of us lack, and that we can learn things from them. But they disagree with each other in their prognostications. They are good at describing something ex post facto, often with estimates derived from statistics that are far from exact. It often takes years to understand what has happened in an epidemic or pandemic. And that’s understandable.

But their forecasts? They disagree with each other. Well, someone’s correct, but who? The worst doomsayer? The sanguine optimist? The in-betweens?

And I have a question for them all. I know we are missing some important numbers for COVID-19 that can’t be ascertained just yet. For example, to know the all-important case fatality rate of this disease, we have to know the numbers of people infected. As we test more and more of the population we learn more about that, but not even remotely as much as we need to know. And unless we test the entire population, including those with no symptoms, and do it at intervals, we can’t know in real time or perhaps ever.

But we do know another important number: how many people have died so far of COVID-19. Or do we? Is everyone who dies of any respiratory disease being tested for the presence of the virus? And if they are all being tested, do we know that those with a positive COVID-19 test actually died from the virus and not from some other condition they might have? That sort of thing has been described as taking place in Italy, for example:

…Prof Ricciardi added that Italy’s death rate may also appear high because of how doctors record fatalities.

“The way in which we code deaths in our country is very generous in the sense that all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus.

“On re-evaluation by the National Institute of Health, only 12 per cent of death certificates have shown a direct causality from coronavirus, while 88 per cent of patients who have died have at least one pre-morbidity – many had two or three,” he says.

This does not mean that Covid-19 did not contribute to a patient’s death, rather it demonstrates that Italy’s fatality toll has surged as a large proportion of patients have underlying health conditions.

To understand the meaning of all the deaths in Italy, it would be extraordinarily helpful to know one figure that I’ve never seen discussed: the number of excess deaths; that is, the number over and above what is usual this time of year in Italy.

I have no doubt the number is higher than usual and that there are excess deaths, particularly in certain regions of the north where the virus has been concentrated. But how much higher? Italy ordinarily has a particularly high rate of death from the flu, which makes the “excess death” figure especially important to know. Are significant numbers of the deaths we’re seeing in Italy deaths that would be taking place anyway from the flu or other illnesses we’re accustomed to? And if so, how many?

One of the huge problems with COVID-19 is that so far it seems to cause localized outbreaks that burden a health system and in particular hospital ICU sections. That in turn results in some people dying who might otherwise be saved but for the sudden influx. That is particularly frightening, and many of the strategies being brought to bear in the US are a result of trying to prevent such a calamity. But in order to know how much we need to do and what we can expect in the worst-case scenario, wouldn’t figures for excess deaths in Italy be especially helpful?

When estimates are made for pandemic death rates (that is, deaths per million in the population, or deaths expressed as a percentage of the population, as opposed to case fatality rates that are deaths among those diagnosed), the “excess deaths” figures are commonly used to arrive at those figures. I would think that epidemiologists would be well aware of the importance of knowing what the excess deaths have been so far.

So why haven’t I yet found anything that discusses it? I realize that, since the disease only began a few months ago, we don’t have figures for total excess deaths. But shouldn’t we have some preliminary figures to compare to average figures per day or per week or per month during a bad flu season and during a good flu season? Aren’t epidemiologists interested in doing this? And why aren’t more people curious about it?

Democrats fiddle while economy burns

The New Neo Posted on by

I wonder who they think this stalling will please:

On the Senate floor shortly after noon on Monday, Majority Leader Mitch McConnell lit into Democrats, specifically alleging they were trying to extract concessions from airlines over their “carbon footprint,” with the economy hanging in the balance.

“They ought to be embarrassed,” he said. “This is no time for this nonsense.”

…

Democrats overnight blocked the massive economic rescue package, teeing up new negotiations Monday morning. But issues having nothing to do with coronavirus have become impediments to the relief package, according to a senior Republican aide.

“As Leader Schumer continues to hold up the desperately-needed relief package, the last-minute list of demands from Pelosi’s and Schumer’s ideological wish list are coming into focus,” the aide said

Oh, I suppose the Democrats’ diehard supporters will back them in this. But won’t most people see the delay as playing nasty partisan politics in a time of crisis?

The Democrats really only seem to see two options right now for themselves. The first is to block improvement and make the crisis worse rather than allow Trump to have any victories. The second is to blame Republicans and try to make it appear as though only the Democrats’ actions somehow led to any improvement that may occur. But if Democrats’ politics-playing is too transparently obvious, the people ought to notice.

I’ve given up on trying to say whether enough people will notice, though. All I can say is that the Democrats’ behavior right now is not only despicable and disgusting, it is in my opinion also obvious and off putting, even to some people who ordinarily would be predisposed to be kind to them.

I think this is the sort of thing that makes people’s blood boil.

Globalization is the first casualty

The New Neo Posted on by

Well, maybe not the first casualty. But the entire concept of globalization is taking a big hit. And rightly so:

The question about assigning agency and blame is pretty straightforward to answer: The communist Chinese state, which for more than three decades has been draining capital and knowledge from the West, benefiting from our greed and myopia, has just let loose a virus that in the coming months is about to effectively paralyze Europe and the United States and bring severe pain, both human and economic on the world. The “eruption at a wet market” explanation for the virus has to be questioned until we know the full story, if for no other reason than the fact that Beijing suppressed data for two months when the coronavirus first appeared, and even to this day refuses to come clean as to exactly what happened. Indeed, the Chinese Communist Party (CCP) is now spinning propaganda stories that both seek to somehow pin the blame on the United States, and that try to frame their bungling, denial-ridden, heavy-handed reaction as some kind of model for the world.

As a result of all this, the West is now shutting down, at least for a while. The ultimate cost to the world, in terms of new government debt, failed businesses, and human lives and suffering, is difficult to quantify at this point. But there are indications that the fallout from the Wuhan Virus could be transformative.

I’ve said many times that one of my weakest knowledge areas is economics. However, even as a liberal Democrat of the olden variety, I always thought globalization was a bad idea. But I figured that since so many people who knew so much more than I did about economics thought it was the bee’s knees and the cat’s meow, then I must be wrong.

But over the years, and by the time I had my political change experience, I stopped trusting their opinion. And recent movements in the US, Britain, and so many other countries in the world seemed to reflect what I was thinking: how could it be a benefit to country A to become so tremendously dependent on Country B, especially if B is not an ally? Isn’t it good to be somewhat self-sufficient and/or to have the power to become very self-sufficient fairly quickly if events called for it?

But I also understood that companies wanted to make things cheaply and be able to sell them cheaply in the US, and that quickened the pace of globalization. Trump finally fought against it, and the globalists of the world howled in response because the stupid populist people (is that redundant?) didn’t know what they were doing.

The COVID-19 crisis may have ended that many-decades-long globalization trend, which will have been proven to be a hollow idol liable to blow down in the first strong wind. Who is going to outsource the bulk of an entire vital industry (drugs) to China after this? My answer would be: no one.

The suddenness with which this has happened is also stunning. The globalists who excoriated Trump as a racist xenophobe might have to face the fact that events have been proving him right: we do need to make America great again. It’s not academic, it’s not just a campaign slogan. It’s a reality staring us in the face.

Trump vs. Biden: A crisis is an opportunity to be presidential

The New Neo Posted on by

When people are stressed and worried by world and/or national crises, most of them naturally look to leaders to help: to communicate with them, to reassure them, and to do something. This is true not only of the relationship between citizens and government, but in most human relations. And if a person is perceived as being helpful in a time of stress, people will generally bond to that person more closely.

If the helper is a president dealing with a crisis – FDR, Lincoln, even George Bush in the first weeks after 9/11 – people tend to cut him some slack if he’s perceived as strong and working on their behalf. It’s even better if what he does is effective.

The MSM and the Democrats seem not to have been cognizant of this at first. They concentrated on almost nonstop criticism of Trump’s dealings with the COVID crisis. If he did something, what he did was wrong. If he didn’t do something, what he didn’t do would have been the best course of action. This is nothing new for them, but in a crisis most people don’t like it, especially if much of the criticism doesn’t seem valid or well-meaning.

Thus it was a bit of a surprise when the Democratic governors of California and New York praised Trump’s help for their states and his general demeanor during their interactions with him around this. But then it occurred to me that not only were they truly grateful for the help their states were receiving from Trump – and perhaps even a bit startled that it came at all – but perhaps they also had seen polls that indicated the public was rallying behind the president. The governors might have concluded that they might alienate a lot of people if they kept up the nonstop criticism, not to mention seeming ungrateful for the help offered.

And sure enough, we have this:

An ABC News/Ipsos poll released Friday reports that 55 percent of respondents approve of Trump’s management of the public health crisis, while 43 percent disapprove. The latest figures represent a boost in the president’s rating from the previous iteration of the survey, published one week ago, which showed only 43 percent approval for Trump and 54 percent disapproval.

Another factor is that, with all the closings of businesses and the constant televised appearances and press conferences by Trump, most Americans are probably watching him perform unfiltered. Those who usually just get a few sound bites from a Trump-hating MSM may be surprised at what they see: a guy who seems rather reasonable and knowledgeable and to be doing pretty well in times of great difficulty, beleagured by a carping press focusing on gotcha minutiae.

Among other things, the MSM doesn’t like the way Trump expresses himself. But so far, the American people seem to be liking what he’s doing. In his previous career, Trump has been good at organizing complex projects of a very different sort, although this is far more complex than anything he’s ever faced.

And then we have Joe Biden, who will almost certainly be Trump’s opponent in November. He’s been a petty and unimpressive man his entire life, and not altogether bright, an opinion I had even back when I was a Democrat. That now, in his twilight years, he finds himself within reach of a long-sought goal that had previously eluded him when he was in better shape is one of those ironies of history. Right now he should either get out of the way or be supportive, and wait. But instead he is constantly carping about Trump in the manner of a very annoying back-seat driver.

And he’s incompetent even at that. “I would have done this and I would have done that” – and then he goes on to list the things Trump has already done, or sometimes lies about them. He manages to look like a petty complainer, a braggart, and cognitively challenged all at the same time. It’s quite a feat. Has this man no advisors?

Developing a serological test; and contact tracing

The New Neo Posted on by

Developing a serological test for COVID-19 is important for many reasons. One is that we can identify people who had the virus and don’t even know it, and are now immune and run no risk and can go back out into the world.

Another is that at least some of these people might be used as blood donors to boost the immunity or aid the recovery of others, as sometimes happened with ebola.

Such a test is being developed:

Serological assays are of critical importance to determine seroprevalence in a given population, define previous exposure and identify highly reactive human donors for the generation of convalescent serum as therapeutic. Sensitive and specific identification of coronavirus SARS-Cov-2 antibody titers will also support screening of health care workers to identify those who are already immune and can be deployed to care for infected patients minimizing the risk of viral spread to colleagues and other patients.

And this is unrelated, but it’s one of the ways South Korea got a handle on its COVID-19: tracing possible contacts through cell phone data. Israel is doing it:

In a statement posted to Facebook, prime minister Benjamin Netanyahu wrote: “We will dramatically increase the ability to locate and quarantine those who have been infected. Today, we started using digital technology to locate people who have been in contact with those stricken by the Corona. We will inform these people that they must go into quarantine for 14 days. These are expected to be large – even very large – numbers and we will announce this in the coming days. Going into quarantine will not be a recommendation but a requirement and we will enforce it without compromise. This is a critical step in slowing the spread of the epidemic.”

There are glaringly obvious privacy and liberty concerns and dangers, and they are very very serious. But if the alternative we seem to be heading towards at warp speed is to effectively put everyone in quarantine (lockdown) and severely undermine the economy, cell phone tracing may actually involve less of a violation of liberty. The people who have been diagnosed are not identified by name, but the people who have been in contact with them are located and quarantined, probably at home.

The US is supposedly considering something like this. One other problem:

That will mean citizens’ smartphones being not just a tool of mass surveillance but also a conduit for targeted containment — raising questions about the impact such intrusive measures might have on people’s willingness to carry mobile devices everywhere they go, even during a pandemic.

I’m not sure this depends on willingness to carry phones outside, though. Is it geographic location that’s involved, or whether a person talks or texts another person who ended up infected?

The number of news stories is overwhelming

The New Neo Posted on by

Not only is the situation overwhelming – health, economics, politics – but the number of breaking stories is overwhelming. Since this is a one-person-blog, I can’t cover even all the most interesting ones unless I were to work round the clock. I’ve been immersing myself in this, but there’s a limit.

And so here’s an open thread to discuss stories such as these:

(1) Senators selling stock after briefings on coronavirus. I have no trouble believing politicians are corrupt. But if it’s true (and it may indeed be) that, as these senators have alleged, they’re not even involved in each of their stock decisions because their portfolio buy-sell decisions are managed by others without their input, it may be an invalid accusation. Oh, and most news stories highlight the Republicans, and only mention Feinstein the Democrat as an afterthought, although her stock trade was enormous.

(2) Want some humor? Turn to Ammo Grrrll. Sample:

I ventured into my local Bashas grocery store which resembled either Venezuela or a 7-11 Store in Florida when a hurricane is already at Cat 5. The shoppers looked like they were on a festive field trip from an insane asylum – many wearing colorful long-sleeved rubber gloves, dousing themselves in sanitizer after putting each item in their baskets.

(3) Needed; a reopening plan. You said it. Cost-benefit analyses are definitely needed as well. I’m planning (not today though, folks) a discussion of that, perhaps a multi-parter.

Or – just talk about anything you want.

That was then: reactions to Trump’s January 31 travel restrictions

The New Neo Posted on by

I remember it well. When Trump restricted travel from China way back on January 31, he was called a xenophobe and a racist, and the restriction completely unwarranted.

Now, of course, experts such as Dr. Fauci have made it clear that they believe those restrictions were prescient and delayed the spread of COVID-19 here, buying us time.

But this is what the pundits and even many health authorities were saying back then. I wonder whether any of those people are now saying “I was wrong.”

Checking to see would take more time that I want to devote to it right now. My guess is probably none or few. I’d love to be proven wrong, though.

[NOTE: Much more here.]

[ADDENUM: Italy didn’t want to be xenophobic, and it has suffered.]

COVID-19: known unknowns and unknown unknowns

The New Neo Posted on by

There are a great many highly important facts about COVID-19 that are unknown. Many of us know they are unknown, but many people think they are known. An obvious one is the case fatality rate from the disease. It only can be calculated properly if you know the denominator: how many people contract the disease. The numerator is somewhat easier to determine: how many people who contract it die of the disease.

Both require testing. Is is likely that, although some deaths from the disease have been missed or misattributed (false negatives or positives), the majority of people who become critically ill and die of COVID-19 have at some point have been diagnosed. That’s the numerator.

The denominator is a whole other story. In no country has testing been anywhere near universal, even for symptomatic individuals – especially if their symptoms are mild, which is common. Asymptomatic individuals are generally not tested, and yet we know from the Diamond Princess data that, at least in that situation, half the infected people had no symptoms at all.

So we have almost no idea what the denominator should be. We can assume it’s not smaller than the number of confirmed cases, but we also can assume it is magnitudes bigger.

Until we know those things we cannot say what the case fatality rate is, or the death rate in the general population. And yet planning – and calm vs. panic – depends on knowing these and other facts such as ease of contagion. Contagiousness (not just a theoretical RO, but how it actually works in real life conditions as any pandemic runs its course) tells us what percentage of the population will get it. The case fatality rate tells us what percentage of those people who have the illness will die. And another good statistic to know for the sake of planning is what percentage of people will become ill enough to need major medical intervention in order to survive.

Those are the known unknowns. But if you read articles and comments around the internet or in the news, you’ll probably notice a great many people spouting facts and figures about them as though they mean something they don’t mean. For those people, they are unknown unknowns,things they think they know the correct answer to and yet are not even aware they don’t actually know it.

The death rate and/or case fatality rate from COVID-19 are often quoted, for example. Or there’s tremendous alarm about the number of confirmed cases going up without a simultaneous report on how much testing has gone up in the same area, and how many of the diagnosed cases are mild and how many serious. Huge decisions are being made on the basis of today’s numbers and the public really doesn’t know if they are valid.

Here’s a good discussion of the dilemma (hat tip: commenter “physicsguy”):

This evidence fiasco creates tremendous uncertainty about the risk of dying from Covid-19. Reported case fatality rates, like the official 3.4% rate from the World Health Organization, cause horror — and are meaningless. Patients who have been tested for SARS-CoV-2 are disproportionately those with severe symptoms and bad outcomes. As most health systems have limited testing capacity, selection bias may even worsen in the near future…

Projecting the Diamond Princess mortality rate onto the age structure of the U.S. population, the death rate among people infected with Covid-19 would be 0.125%. But since this estimate is based on extremely thin data — there were just seven deaths among the 700 infected passengers and crew — the real death rate could stretch from five times lower (0.025%) to five times higher (0.625%). It is also possible that some of the passengers who were infected might die later, and that tourists may have different frequencies of chronic diseases — a risk factor for worse outcomes with SARS-CoV-2 infection — than the general population. Adding these extra sources of uncertainty, reasonable estimates for the case fatality ratio in the general U.S. population vary from 0.05% to 1%…

That huge range markedly affects how severe the pandemic is and what should be done. A population-wide case fatality rate of 0.05% is lower than seasonal influenza. If that is the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.

Could the Covid-19 case fatality rate be that low? No, some say, pointing to the high rate in elderly people. However, even some so-called mild or common-cold-type coronaviruses that have been known for decades can have case fatality rates as high as 8% when they infect elderly people in nursing homes.

There’s much more at the link that’s well worth reading. But I want to highlight these two thoughts which parallel ideas I’ve had for quite some time [emphasis mine]:

In an autopsy series that tested for respiratory viruses in specimens from 57 elderly persons who died during the 2016 to 2017 influenza season, influenza viruses were detected in 18% of the specimens, while any kind of respiratory virus was found in 47%. In some people who die from viral respiratory pathogens, more than one virus is found upon autopsy and bacteria are often superimposed. A positive test for coronavirus does not mean necessarily that this virus is always primarily responsible for a patient’s demise.…

If we assume that case fatality rate among individuals infected by SARS-CoV-2 is 0.3% in the general population — a mid-range guess from my Diamond Princess analysis — and that 1% of the U.S. population gets infected (about 3.3 million people), this would translate to about 10,000 deaths. This sounds like a huge number, but it is buried within the noise of the estimate of deaths from “influenza-like illness.” If we had not known about a new virus out there, and had not checked individuals with PCR tests, the number of total deaths due to “influenza-like illness” would not seem unusual this year.

Our attention was drawn to COVID-19 right at the outset by the bad situation in Wuhan, which was dramatic and well-covered by the media. And now Italy. But what this means for us, and what it means worldwide is still unclear. Is the worst-case scenario correct, is the best-case scenario correct, or is it something in-between? Our lives – and not just our actual lives, but our economic, social, political, and psychological well-being – may depend on knowing the answer.

FDA to push ahead with malaria drug for COVID-19

The New Neo Posted on by

The malaria drug chloroquine “soon will be made available to the public as part of the government’s response to the unfolding COVID-19 pandemic.”

My impression is that it is already possible to use it under a “compassionate care” policy, and that they’re going to speed up testing and also production. It shouldn’t be that hard, since the drug is an old one and its side effects are already known.

I’m really hoping this turns out to be a very effective treatment, even a game-changer.