Thursday, March 26, 2020

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:

And here's Sen. Tom Cotton:

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.


  1. I kind of like Cotton, humorless droid that he is. I read his book. It's a fine book. He went to war, so he has courage. He went to Iraq, and then Afghanistan. And to this day, he still doesn't understand a thing about that part of the world. I take anything he says about anything with a grain of salt.

    1. I agree with you about Cotton. I included him because he makes the case against the 'simple solution' well.

    2. Well, regarding Iraq and Afghanistan ...

      Let's just in both cases, stated reasoning was replaced with mission creep brought on by politics.

    3. Most of the US Elite is clueless about that part of the world. The idea of a low trust, tribal society, just does not Grok with the culture.

      Using the Walter Russel Mead framework of Hamiltonians, Jeffersonians, Wilsonians, and Jacksonians. Wilsonians seem to infest State, and have had a huge impact on Foreign Policy, until Trump that is a combination Jacksonian and Hamiltonian.

    4. Trump is talking about listing areas, I believe by counties, showing number of cases. The challenge is State Governors are the ones doing this stay at home, and in some areas it does not make sense. But, they are doing it for entire states. My guess is the governors doing this, are surrounded by white collar workers, that can work from home. So they don't see the economic impact on people that need to go into an office to work.

      With testing finally getting up to speed, and other treatments, there may be alternatives to the stay at home orders.

      The economic impact is huge. Cheesecake factory just said they can't make their rent payments. Lots of residential tenants have the same issues.

      I wish enough masks were available so people could start wearing them, this would drop the spread a lot. I think this is possible, but it does not seem to be a solution that is being focused on in the US.

      In CA, I am hearing 3 months for stay at home. This would wipe out a LOT of businesses.

    5. They have the info and we need to use to the extent possible.

  2. The Teddy Roosevelt is disturbing on many levels.

    A test on a cruise ship indicated the CoronaVirus could stay alive on surfaces for 17 days.

    And details not in the article is the location:

    Where did was patient zero?

    More information - Excellent Blog on Navy Challenges:

    Looks like it was picked up in Vietnam...

  3. This could explain the panic among many government officials:

    Basically somebody set up a website with bad models, that are easy to print out and share, worse case.

    And the people behind it seem to be a bit politically biased. A hypothesis, is some people believe having crises will enable them to get their wishlist (Pelosi..) done. Seems crazy to me. I am noticing a lot of non mainstream sites are getting banned from twitter (treehouse is the latest victim), and of course zerohedge. And I keep on getting the message that on some platforms, we need to follow WHO's guidelines on CoronaVirus. NextDoor was the one I saw this on today. Facebook and Google are also doing censoring based on that. Instagram too I heard.

  4. This may be off to the side some, but has anyone given thought to how the Deep State has benefited from the virus, the response to it, the bailout?

    1. It's a great question, but it's hard to find any info at all. Early on I saw that Trump's new acting DNI Grenell has been quietly removing people. OTOH, Pompeo, in the midst of this crisis, is pushing to start a huge new war. Can we fire that guy yesterday?

    2. Somewhat ironic ...

      Before the Chinese King-flu ...

      "Trump is a fascist dictator!"

      During the Chinese Kung-flu ...

      "Trump refuses to be a fascist dictator and now we all die!"

      (Note, my auto correct supplied Kung-flu when I misspelled it)

    3. "my auto correct supplied Kung-flu when I misspelled it"

      Ha! Very cool!

      Cuomo sounds unbalanced and somewhat hysterical. Biden sounds demented. Pelosi wants to throw our money to illegals. What are they thinking about?

  5. "What are they thinking about?"
    How about, launching a PsyOp, to sabotage the economy, to cost DJT the election?
    Or, to gin up the crumbling of modern industrial society, which they blame for Global Warming, and which (they charge) inflicts such misery on other species, that the human race arguably deserves extinction?
    (See Clemson prof. Todd May, at , on
    "Would Human Extinction Be a Tragedy?")

    1. One thing's for sure--they hate normal people.

    2. When the NYT publishes such a diatribe, I lean toward suspecting that it's a Trial Balloon.

    3. Did you read his Wiki page? Nothing on it will surprise you.

    4. Both political parties take advantage of situations.

      Problem is, the current crop of Dems have no idea how to hide it.

      The day after W announced he worked with Dems to make Medicare Part D law with Ted Kennedy, Ted verbally shoved a knife in W's back.

      Pelosi and company have not a clue to even do that kind of underhanded despicable behavior, they do it out in the open.

      Pssst. ... I hate the GOP because it took a NY Democrat to remind them of their platform.

  6. Meanwhile, a GOPer is pulling a page from Ted Cruz and stopping whatever progress that can he had at the moment.

  7. The elitists want to take away guns, electricity, gasoline etc., for the common man, but they want to keep it for themselves. "Let them eat cake."