UPDATED: New England Journal of Medicine: Where We Are, What To Expect

The venerable New England Journal of Medicine (NEJM) published an editorial today that was authored by Anthony S. Fauci, M.D., H. Clifford Lane, M.D., and Robert R. Redfield, M.D.: Covid-19 — Navigating the Uncharted. The authors of the editorial discuss an article, also appearing in the NEJM, by a team of Chinese doctors: Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. While Fauci and his co-authors don't explicitly say so, it seems clear from what they do say that they believe the COVID19 pandemic will play out in the US in a very similar way to what is described by the Chinese doctors.

Before providing what I view as the highlights of the editorial, I want to point out that the editorial confirms the basic features of SARS-CoV-2 that we've been discussing for the past month. Compared to SARS-Classic--the 2003 version--COVID19 or SARS2 is 1) considerably less deadly than SARS-Classic but deadlier than seasonal flu, while 2) possessing a high "efficiency of transmission." Those combined factors make SARS2 a very worrisome disease. Its ease of transmission allows it to spread rapidly and that fact has already allowed it to kill far more people than the deadlier SARS-Classic.

Of particular note, Dr. Fauci states that SARS2 in the US "may ultimately be more akin to those of a severe seasonal influenza ... or a pandemic influenza". That mirrors what President Trump has said. Before anyone starts high fiving, however, realize that a severe seasonal influenza in the US kills around 60K people. Since we don't take the kind of measures against seasonal flu that are being taken against SARS2--to limit the spread of the disease--we can assume that Fauci believes that without the measures that are being taken the death toll might be considerably higher.

So, the highlights--beginning with references to the conclusions presented by the Chinese doctors in their article:

On the basis of a case definition requiring a diagnosis of pneumonia, the currently reported case fatality rate is approximately 2%. In another article in the Journal, Guan et al. report mortality of 1.4% among 1099 patients with laboratory-confirmed Covid-19; these patients had a wide spectrum of disease severity. If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively. 

The efficiency of transmission for any respiratory virus has important implications for containment and mitigation strategies. The current study indicates an estimated basic reproduction number (R0) of 2.2, which means that, on average, each infected person spreads the infection to an additional two persons. As the authors note, until this number falls below 1.0, it is likely that the outbreak will continue to spread. Recent reports of high titers of virus in the oropharynx early in the course of disease arouse concern about increased infectivity during the period of minimal symptoms. 

China, the United States, and several other countries have instituted temporary restrictions on travel with an eye toward slowing the spread of this new disease within China and throughout the rest of the world. The United States has seen a dramatic reduction in the number of travelers from China, especially from Hubei province. At least on a temporary basis, such restrictions may have helped slow the spread of the virus: whereas 78,191 laboratory-confirmed cases had been identified in China as of February 26, 2020, a total of 2918 cases had been confirmed in 37 other countries or territories. As of February 26, 2020, there had been 14 cases detected in the United States involving travel to China or close contacts with travelers, 3 cases among U.S. citizens repatriated from China, and 42 cases among U.S. passengers repatriated from a cruise ship where the infection had spread. However, given the efficiency of transmission as indicated in the current report, we should be prepared for Covid-19 to gain a foothold throughout the world, including in the United States. Community spread in the United States could require a shift from containment to mitigation strategies such as social distancing in order to reduce transmission.

The speculation I've read, presumably on the basis of informed opinions, is that the pandemic may--due to our preventive measures--peak in the US in about the second week of April. Below is a self explanatory video of Dr. Deborah Birx, pleading for just a bit of responsibility from the MSM:

There are ICU beds in NY
There are 2k unused ventilators
No data shows 60% of Americans will be infected in next 12 weeks

"Please for the reassurance of people around the world...there is no situation in U.S. right now that warrants" DNR talk

Be vigilant, without hysteria pic.twitter.com/W25elUBPwP

— Elizabeth Harrington (@LizRNC) March 26, 2020

And here's Sen. Tom Cotton:

Here is a conservative breaking the Trumpist=End Lockdown matrix: https://t.co/IA4FCExmh7

— Mickey Kaus (@kausmickey) March 27, 2020

UPDATE 1: Pandemonium In The Pacific: US Carrier Diverts To Guam As COVID-19 Cases Spike Among Crew.

Who wants to be the one to fly out there and tell them that they'll soon have developed 'herd immunity,' so just suck it up?

UPDATE 2: To be clear, I'm not saying Fauci's projections are correct. We'll find that out probably within 2-3 weeks. But this is the type of thinking that's behind government policy making, that's being given to Trump.