I don't see in that link where it shows the CFR in the U.S. changing at all, let alone dramatically.

Here's a paper from 2013 that surveyed CFR reports for H1N1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809029/ After a long discussion about the varying definitions of the numerator and denominator, they had this to say:

> Given that estimates of the infection fatality risk are unlikely to be available early enough for decision-making in a pandemic, a more feasible solution may be to measure the case fatality risk among symptomatic cases. ... Such estimates based on symptomatic cases may provide timely but imprecise estimates of seriousness for risk assessment.

CFR is not population mortality, and is usually not even infection fatality rate--but, confusingly, sometimes is as there's no official definition. After COVID-19 passes I suspect and hope that the medical community will tighten down definitions. CFR should be restricted to symptomatic cases approximating the type of severity that consumes non-negligible medical resources. Early on in an outbreak it's the only possible practical definition for tactical management of medical resources. An ER doctor couldn't care less how many infected people are convalescing at home. IFR (infection fatality rate) should be explicitly broken out. It's an important numbers to have, but often impossible to pin down until late in the game, sometimes only after the epidemic has passed. And IFR is most useful combined with r0, which has it's own definitional problems--do you care about hypothetical r0, r0 with social distancing, etc. Population mortality rate is even more difficult pin down.

I'm not a doctor, but I feel like "CFR" is one of those terms which was never meant to be consumed by the public. Early on it was probably taken for granted by the medical and scientific community to be a "case" as understood by doctors, who would typically only diagnose a specific illness when a patient presented with moderate or severe symptoms that required intervention. But as the medical and scientific community grew more diverse (and lab tests grew increasingly cheaper) the implied assumptions behind "case" became less and less valid, and they completely fall away in public discourse. These types of definitional problems are familiar to those of us in the tech sphere.

That report was from summer 2009, so it was written during the outbreak. Note the early CFR from WHO was 0.4% for the US and over 1% for Mexico.

Later in the year it was found to be <0.03%.

http://news.bbc.co.uk/2/hi/health/8406723.stm

AFAICT, that 0.03% is for the U.K, not the U.S. And it doesn't say what the definition of CFR was. I've read a significant number of papers (primary materials) about SARS, MERS, H1N1, and influenza over the past few weeks. IME, CFR is usually defined as diagnosed or symptomatic cases as the denominator (which, as I've said, was until recently effectively equivalent), especially mid pandemic. But it's not always so defined. One notable exception that adds to the confusion is seasonal influenza, where U.S. annual fatality rates are calculated using post hoc modeling.

Even if we pin down CFR to be # deaths / # confirmed symptomatic, there's obviously still going to be some variability, possibly significant--quality of medical interventions, age distribution, etc. But trying to shoehorn IFR and other definitions into that number would compound such problems many fold.

Knowing the actual CFR allows us to set the right policy. The seasonal flu has a range of 0.10 and 0.015% CFR. At what point do we shut down society? 0.4% 0.6%?

And I know this will get me down=voted, but what if COVID-19 is everywhere already and it turns out the CFR to be close, or even lower than influenza?

The WHO predicted that 150 million people would be killed by avian flu

https://www.google.com/amp/s/amp.theguardian.com/world/2005/...

Using the same logic that had lead to the severe predictions for cv19.

For swine flu they promoted and stood by a CFR of 60%. Again turned out to be nonsense; nonsense known at the time to others

https://jech.bmj.com/content/62/6/555.abstract

When it comes to these estimates, the WHO seem to be really bad at their job.

But the reality now is that no matter what the estimated CFR is, Covid-19 guarantees that without containment there will be significantly more people in need of hospital care than there will be beds and support staff. And that will affect the final mortality rate, and push it higher than a normal flu season.

> and push it higher than a normal flu season.

last major flu season in Italy killed 24k people. We didn't immolate the global economy as a result

At this rate in Italy alone it will kill more than 100k people. And the rate is increasing.

It won't

The rate is decreasing, not increasing

Note enough data to say that, the past 3 days were all twice as high as the 3 days before that, and those days looked like it was decreasing.

How would you accurately attribute that to the risk of the disease being overestimated, rather than the measures taken being effective?

Because it's becoming obvious the disease is vastly more widespread and far further ahead than the official numbers based on death rate/testing data show.

Death is usually around 20 days after first symptoms

Why didn’t the hospital system collapse because of the flu?

Based on the CDC's numbers for the US[1], less than 2% of seasonal flu cases require hospitalization at all. This disease is at about 20% (based on detected infections). Even if 75% of infections are really undetected and asymptomatic, we're still looking at about 3 times the number of hospitalizations as seasonal flu.

[1] https://www.cdc.gov/flu/about/burden/preliminary-in-season-e...

This doesn't make sense.

The flu figures are statistically derived. The cv2 figure is derived from literally actual test cases only, which represent a tiny tiny tiny subset.

They cannot surely be compared, unless I'm missing something

Because the health care system is built with those estimates in mind.

It's the same with electricity infrastructure on climatologically hot days. The infrastructure is only built to handle a certain normal peak load. COVID-19 like a heat wave, is abnormal.

It is because of the consequences of covid-19 on the lungs of some people, which needs intensive care and specialized equipment to cure them, that is rare (ventilators etc.).

People forget that ventilator means not only the machine itself, but you also need couple of doctors - anesthesiologist in the least and nurses that have to keep watch. Person on the ventilator needs to be partly paralyzed to not interfere with the machine. I do not know how many staff on average is needed per patient but it is a significant number.

Also the length of time that people stay on it, with covid-19 it seems to be 2-3 week so bed and staff turnover is slow, which meant you need many more people that are available.

ICU "bed" is a virtual term, it not only means the physical availability of ventilator, but also staff.

Just a nitpick but a regular ventilator doctor that isn’t necessarily qualified to administer anesthesia is a Pulmonary specialist. They are generally the doctors prescribing the ventilation therapy. Below them are Respiratory Therapists who have a core of general knowledge and training for ventilation therapy. The RT is the person who administers the therapy and manages the equipment in the day to day. You don’t need to have run anesthesia ventilators to run regular ventilators. Anesthesia delivery is generally considered a different animal.

People are conditioned by experience to not present to hospital with mild respiratory symptoms. As they get older it gets more common and you still apply the same rules. Often too late by then to do anything other than ventilate.

And COVID-19 is on track to kill way more than that in less time. So what's your point?

If we wait for new pandemics to kill more people than the flu to take them seriously, then it's too late to act.

Overestimates of the severity of the threat have much less harmful consequences than underestimates. For a start, actual casualty statistics are not independent from mitigation actions taken.

Don't underestimate the number of people whose lives will ultimately be shortened by the economic harm being done in panic over the virus.

Definitely agree, but at a certain point, WHO is going to be seen as crying wolf. They've already taken a large credibility hit in this crisis. They can't afford to ignore their perception in the age of populism and social media.

> Overestimates of the severity of the threat have much less harmful consequences than underestimates.

We didn't take the estimates for SARS and h1n1 as "seriously" as now, and they are just as if not worse than this.And look what happened.

I think Asian countries took the estimates pretty seriously. I think both would have been worse if they didn't, especially SARS.

SARS was more lethal and more infectious than COVID-19. It was however easier to contain because there wasn't much asymptomatic transmission, and the incubation period was short. Those two things are what makes COVID-19 more dangerous in practice.

The thing is, there's what happens if you don't contain something and what happens when you do.

Humans are a monoculture across the planet at this point. In many ways it's surprising that there aren't more pandemics.

The estimates in that first article seem oddly cavalier:

> “Around 40 million people died in 1918 Spanish flu outbreak," said Prof [of mathematical biology at ICL] Ferguson. "There are six times more people on the planet now so you could scale it up to around 200 million people probably."

As of 2014 the number of deaths is <500, although the Wikipedia article [1] is written as if bird flu is something that may yet turn much worse.

[1] https://en.m.wikipedia.org/wiki/Influenza_A_virus_subtype_H5...

Both links are for H5N1 avian flu

You're comparing a virus that early on was reported as 3-4% to one that early on was reported as 0.4%.

The cruise ship and South Korea are probably closest to the true death rate of this virus. CFR in South Korea is currently around 0.8%. A common "educated guess" I see from people that work on this is its probably around 0.5%-1% assuming you can get the care needed for it.

This reflects the opinions shared by Michael Osterholm, Amesh Adalja, and Nicholas Christakis: a final case mortality of ~0.7%. But just to highlight the point, that's on a strong assumption that critical cases receive proper medical attention. I don't think that's a safe assumption for the outbreak in the United States.

Now it's really not the time to speculate with numbers that could downplay the risks. We'll see in a few years. 0.\d+% could be someone we love. Keep safe. Prevent if you can.

I'm just quoting experts. But I agree with your point. Only one of them stated that figure with "confidence", but he also was clearly motivated to downplay the risk because he was worried about panic. My intuition is that a final case mortality < 1.5% would be towards a "best case" outcome; and we should expect worse.

Currently, we have 7 total reported deaths from the cruise ship and 696 confirmed cases. Seeing that it's been a long while since the outbreak, let's assume all current cases will survive; this puts us to 1% CFR. But note that Cruise Ship had a higher average age than public, so assuming you'll receive all the medical care you need, ~1% CFR seems to be a good approximate upper-bound estimate.

The majority of people on the cruise ship were older and it's not at all representative of the real population.

That's why I said an "upper-bound" approximation. As in, CFR for general population is likely below 1%.

IIRC all or almost all of those 7 were over 80.

I heard "all over 80" on HN and reddit multiple times as well, but could not confirm. Regardless, Italy's official average age of death is 81, so it wouldn't be surprising.

6 in the 70-79 bracket and one in 80-89, but 70-79 was also the biggest group. https://cmmid.github.io/topics/covid19/severity/diamond_crui...

CFR, whatever it is, isn’t the most significant detail. What is “terrifying” is its high contagiousness combined with its high hospitalisation and ICU rates.

Yeah,and the high hospitalization and ICU rates become high case fatality rates once medical infrastructure is saturated, as well as increasing the case fatality rate for every other condition that creates a critical need for inpatient care.

That's where Italy definitely is, and where it seems Iran is evn moreso (though they are less public about it.)

What no one is talking about is how much social distancing/isolation is needed to avoid hospital saturation.

I ran the numbers for Canada, and it looks like we'd need isolation measures for 2+ years.

I don't see how that's a feasible solution long-term.

The numbers I ran for the UK put it at 12 years:

No. People in UK: ~66,000,000

Est. proportion of people who will get sick: 80%

Est. proportion of sick people who require intensive care: 5% (in Italy it's 10%)

So that's 60,000,0000.80.05 = 2,640,000

Number of ICU beds in the UK: ~4100 (90% occupied, but let's ignore that for now)

Length of time ICU required: at least 1 week (probably longer, but let's ignore that too)

So that's 2,640,000 / 4100 = 644 weeks or 12 years that we would need to spread the cases over in order to have enough capacity.

I did a similar calculation but came back more optimistically (although still on scale of a year to two).

You only need count over 18s as very few cases in this group. It is believed by the UK experts to have a lower fatality rate of 1% and likely lower admission rate due to asymptomatic infections (estimates at 16-75%). Ventilator capacity can increase with stopping surgery and CPAP/other measures can be used in some cases. Treatments developed later should improve efficiency of treatment. Extra ventilators should be manufactured and help ease burden. I think 80% is too high, likely more 60% given an R0 of 2-3. Finally, the chronically unwel elderly are unlikely to benefit from ITU care significantly and would never qualify. With these exceptions it gets down to 1-2 years depending on assumptions.

Around 18 months (until sufficient quantities of vaccine) is this group of experts’ estimate

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

Around 18 months (until sufficient quantities of vaccine) is this group of experts’ estimate

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

It's likely that we'll have a vaccine or at least some kind of treatment by the end of the year, so this should improve the prospects quite a bit.

So, wild speculation aside, what numbers did you use to base your model on, and what is your qualification to do anything like that?

I'd like to see more discussion around this point. I don't care where you got the numbers from. It's been clear from a glance that 3 weeks of cancelled school isn't going to do anything. So now we're looking at 8 weeks. Umm.... According to what? Which is more likely, 8 weeks or 2 years? I don't know, but I'm guessing 8 weeks isn't nearly long enough.

Around 18 months (until sufficient quantities of vaccine) is this group of experts’ estimate

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

> What no one is talking about is how much social distancing/isolation is needed to avoid hospital saturation.

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

People are talking about it, that talk is driving policy, and the answer is “with some local adjustments possible based on caseload, until there is an effective vaccine developed and deployed, which will probably be 18+ months”, and the alternative is a truly catastrophic number of fatalities.

Did you factor in an asymptomatic rate?

Around 18 months (until sufficient quantities of vaccine) is this group of experts’ estimate

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

But, like CFR, we don’t know how high the rates are if we have no idea how many people have or had it.

Here’s a few first hand accounts of what the illness was like. These folks aren’t even that young and they describe it as being quite mild:

https://www.nbcnews.com/video/coronavirus-patient-from-diamo...

https://www.adn.com/opinions/national-opinions/2020/03/01/i-...

https://www.msn.com/en-us/news/us/don-t-panic-says-us-woman-...

"But, like CFR, we don’t know how high the rates are if we have no idea how many people have or had it."

While it's true that the hospitalization / ICU / mortality rates may be lower because we don't know the full number of cases, it still seems to be an immediate and acute problem.

Regardless of the rates, the absolute number of people being hospitalized in Italy was enough over overrun their healthcare system. The same situation looks to be on track in many European countries (Spain, France, UK).

So, the worst-case scenario may be less bad than predicted (let's certainly hope this is the case!), the number of case's we're identifying and having to deal with is still dangerously high.

> These folks aren’t even that young and they describe it as being quite mild...

Take that with a grain of salt. The people for whom it's not mild aren't going to be giving interviews.

It’s literally survivorship bias.

Whatever they are, they’re high enough to be causing major problems for hospital systems in places like Italy. They seem high enough that many countries desperately need to slow the spread of the virus or they will face dire consequences.

Anecdotes are not sufficient data

They are when there's little quantitative data to work with.

A lot of people's biggest questions are what the hell "COVID-19 symptoms" and apparently it means just about anything.

I'm suspicious of the 2 week long illness my family has just gotten over. Hit each of us differently. Predominantly nasal mucus, but the kids had some chest congestion, wife had a fever, and I had what felt like a sinus infection and a bit of a dry cough.

None of it particularly severe. Likely not COVID-19, but given the scattershot presentation of the disease in non-critical cases, I'm not ruling it out.

No, the symptoms are pretty clear:

Fever, dry cough, fatigue, sputum production, shortness of breath (dyspnoe), muscle/joint pain.

https://ourworldindata.org/coronavirus#the-symptoms-of-covid...

We don’t have sufficient data because we are, in our infinite wisdom, not testing every person with a pulse. Or at least testing from as random of a population subset as we can manage. At least in the US. Other countries mileage may vary.

But even then it is my understanding that there currently is no way to test if you already had it.

Technically, the hospitalization rates and ICU rates would also be greatly overestimated due to the number of unidentified asymptomatic cases.

But from a perspective of absolute numbers of patients hospitalized and admitted to ICU, your point stands.

Those high rates are also dependant upon the fraction of cases detected.

We are currently seeing about a 9% hospitalization rate based on detected cases.

If we are really missing 75% of cases, then true hospitalization is only about 2.3%

I really, really hope so.

My hope is it is way more widespread than we think, and while that means it's going to be near impossible to contain, the denominator is so large that the CFR ends up being much lower than expected.

If Covid-19 does end up being a dud, then we are in real trouble if/when an actual pandemic arrives -- because by then everyone will say the CDC is Crying Wolf.

It’s already proven not to be a dud — healthcare systems stretched to beyond 200% capacity is solid evidence of something no one has seen in recent memory. When youngish healthcare workers are dying, something is going on.

Not necessarily. If it's already in a sizable portion of the population but mostly undetected, it will kill some seemingly healthy young people.

They may have some unknown underlying condition, may have the genetics to trigger a lung destroying cytokinin storm, or may just have gotten unlucky.

Here's some more information about cytokine storm syndrome treatment in COVID-19 patients.

https://www.uab.edu/news/research/item/11176-covid-19-do-not...

Where did you get that number from?

A report from Lombardy yesterday says so far everyone with any reasonable chance of recovery has been treated:

https://www.reuters.com/article/us-health-coronavirus-italy-...

As far as I can tell so far, no hospital systems have collapsed due to this, even in the most extreme hot zones. The fear is that they will, and that sounds totally reasonable. But we also are basing that fear on data that's not robust. So we don't really know yet what will happen.

This has been so widely reported, not sure where to start. Operating rooms at many Italian hospitals have been closed and turned into ICUs to handle the demand, which means that surgeries in many places are no longer possible.

You can read about this in any of hundreds of media outlets. Here's one:

https://www.dailymail.co.uk/news/article-8095835/Overwhelmed...

You don't seem to be contradicting me. I'm not saying everything is normal or other operations weren't cancelled. I'm saying that at this time, Italy is saying they have not run out of capacity to treat CV patients. And they definitely aren't 200% over capacity (for CV) as claimed.

You seem to be living in a different factual world than the rest of us, where ICU cases are in hallways and surgical suites is not "over capacity", and leaving people to die of suffocation without standard lifesaving treatment is not unusual.

I'm going to be giving up on this thread in a moment because people aren't even reading what I'm reading and definitely aren't answering in good faith.

The original claim was that people over the age of 80 aren't being treated because they don't have the capacity for it. I queried if they were sure about that, because the Italian government was saying that's not true. An Italian has now replied to that same post also stating it's not true and the international media has exaggerated a comment by a single doctor.

That's the factual world.

In another thread a guy claimed the Italian system was "at over 200% capacity". This turned out to be an exaggeration of another claim by a single doctor, not a real statistic.

I've been querying these sorts of claims by directly citing detailed testimony from the guy who literally runs all of ICU in Lombardy, the worst struck place in the whole world. He is saying, as clear as can be, he doesn't believe people with a chance of recovery have been turned away due to lack of beds. This doesn't mean they haven't increased beds via drastic measures or taken other actions to increase capacity. It means that as of the time that report was made, he didn't believe they'd run out of at-present capacity and had to turn people away at the hospital entrance.

Maybe he's wrong and not living in the same factual world as the rest of us. I don't know. But I'd hope he understands the state of his own hospitals given his job.

Lombardy is not the worst hit place so far. Wuhan is.

Sorry, I meant "at the moment". Wuhan is apparently now in the tail end (if you believe the PRC). But I didn't say that. Precise communication is hard!

They have not enough ICU beds.

That is pretty much the definition of running out of capacity.

OK, so I read the Daily Mail article. I think there are a couple of things going on here.

Firstly, hellofunk made a claim of "health care systems stretched to beyond 200% capacity". I asked where that number came from because it contradicted what I'd read. S/he's provided a source, which is this quote from the DM:

Another medic in northern Italy told a friend in the UK that hospitals were running at '200 per cent capacity' with operating theatres hurriedly converted into intensive care units.

So this is a snippet from a private conversation with a friend repeated on Twitter, and it grew in the telling ("at 200%" became "at over 200%"): it's not a formal claim by someone with all the data. It's a claim that's painting a picture of what it looks like inside a hospital where one person works.

Secondly the report I cited has this:

"Over three weeks, 1,135 people have needed intensive care in Lombardy, but the region has only 800 intensive care beds, according to Giacomo Grasselli ... Grasselli coordinates all the state-run intensive care units across Lombardy."

When I read this the first time I thought, OK, so then they've surely run out of beds and are turning away people they could save. Confusion followed when I read this:

Lombardy intensive care coordinator Grasselli said he believed that, so far, all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated. But he added that this approach is under strain. “Previously, for some people we would have said, ‘let’s give them a chance for a few days.’ Now we have to be more stringent.”

The first quote doesn't actually say they've run out of beds. That would be true if everyone needed to stay 3 weeks. If the average recovery time is 14.7 days then 1135 people could be treated with 800 ICU beds without anyone being turned away, whilst being at full capacity.

In the DM article the anonymous doctor claims Lombardy's healthcare system is one of the best in the world (sometimes this is phrased as most efficient, which isn't quite the same thing: you'd expect a highly efficient healthcare system to run out of capacity earlier than a less efficient one, I suppose). The Reuters article says:

Intubating can be taxing on the body, especially for older patients, says Grasselli ... adding that he would never intubate his 84-year old father. Before the coronavirus broke, “we more often had the luxury to try to intubate patients who were at the limit,” said Mario Riccio, head of anaesthesiology at the Oglio Po hospital near Cremona. Now that’s changed.

So some of this notion of rationing of healthcare is that before, Lombardy could afford to try extreme and risky measures to extend every life even in cases where the likely outcome was severe damage to the body from the procedure. Now they can't afford to take such measures anymore.

Medical systems don't have a hard notion of capacity. Total capacity is flexible: when under stress doctors are forced to triage more aggressively and drop the most extreme treatments. It may not make sense to talk about running out of capacity in a world where medical systems can keep otherwise terminal patients alive indefinitely; there is always triage even in quiet times. I'm not sure how best to measure it but it may be unduly alarming to say Lombardy has run out of beds.

> The first quote doesn't actually say they've run out of beds.

It does. It literally says people without much chances to live had not been treated.

If you had 25% chance of living, and are told you will be dead anyway, I am sure you would understand the quote perfectly at that moment.

And you are not even taking into account the amount of psychological stress to health professionals (and the families of victims) that have to tell people that or, worse, that they will disconnect someone even if it still had chances to live. There are nurses breaking down, and I expect a wave of PTSD cases in health professionals when this is over.

> reasonable chance of recovery has been treated

This is the caveat of what you said. The West, and especially Americans, doesn't take kindly to the realities of triaging. See the arguments on "death panels" regarding the Affordable Care Act.

Hospitals in Italy are over capacity. People are prioritized based on chance of survival. Anyone unlucky is left to die because there is not enough equipment.

Yesterday the news was that anybody over 80 is not treated. They simply don't have the capacity for it, and survival chances are better for people under 80.

It's not a rule i've read on any Italian report. There was a doctor in Bergamo who said that they might have to do that in an interview and it was misreported in the international media. (I'm Italian living abroad) the Italian healthcare system is regularly listed in the top 10 in the world and Lombardy is usually number 1 in Italy. They are building a massive facility in one of the exhibition centers in Milan, it's tough but they're doing amazing work, from what I read and what I hear from people. I am much more worried for my friends in the USA..

Then i probably read the misreported quote. I'm Danish, and despite having lived in northern italy for a few years, i sadly don't speak/read italian :)

As Italy is "3 weeks" ahead of us, news from there is being monitored closely as it could signal what might happen here.

Are you sure?

https://www.reuters.com/article/us-health-coronavirus-italy-...

Lombardy intensive care coordinator Grasselli said he believed that, so far, all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated.

I wonder if we're getting mixed messages here; that is, it's inevitable doctors give up on some cases and unplug them from the ICU but that is always a risk in ICU for any reason to be there.

Doctors "Give Up" on people all the time. If you have advanced pancreatic cancer, are 85 and a heavy smoker, most doctors are going to suggest you go home and spend your last few days with loved ones.

Yeah, that's what I'm getting at.

What I see at the moment on HN and elsewhere is a lot of people who seem to believe that in Italy the hospitals are already overrun and people are being turned away in large numbers because all the beds are gone already days ago.

But this doesn't match what is actually happening there, according to the Italian government. What they're saying is so far they've had to turn away noone; that everyone who needs treatment is getting it.

I think this mismatch is coming from a couple of places. One is mis-interpreting doctors switching off life support for patients who can theoretically be kept alive using e.g. ECMO but for whom their lungs are destroyed and they wouldn't really have a life afterwards. That's terribly sad but isn't the same thing as patients who are in the middle of making a full recovery being switched off, or people who could be saved being denied beds because there just aren't enough. Another is a confusion between "we're about to run out of beds" and "we think we're about to run out of beds".

I'm not trying to downplay the seriousness of the situation here, but we have also have to keep our heads and double check things being claimed about that seriousness, as it's always tempting in times of crisis to lose our heads and go full sandwich-board. Maybe by tomorrow Italy will actually be there, but as of yesterday at least, it seems they aren't.

> What they're saying is so far they've had to turn away noone; that everyone who needs treatment is getting it.

> all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated.

These two quotes from you are mutually contradictory.

They're not quotes from me. I'm directly citing the head of ICU for all of Lombardy.

I think reading the Reuters article I'm citing in full is the best way to understand what's going on. I've also tried to summarise it here:

https://news.ycombinator.com/item?id=22607485

The confusion probably comes from the definition of treatment. It's possible for simultaneously nobody to be turned away due to lack of a bed, whilst terminal cases they know they can't save are now being turned off quicker i.e. less aggressive intervention than before. That's what Grasselli is saying:

Lombardy intensive care coordinator Grasselli said he believed that, so far, all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated. But he added that this approach is under strain. “Previously, for some people we would have said, ‘let’s give them a chance for a few days.’ Now we have to be more stringent.”

So if you have a terminal cancer and get coronavirus that means you don't get a ventilator. That's the nice part.

The next part is "living an acceptable" quality of life. This probably means anyone not brain damaged and anyone they think won't require oxygen later. Might mean people not currently on oxygen when they get covid-19.

And despite all of that he says that this system is under strain.

Read between the lines.

> What they're saying is so far they've had to turn away noone; that everyone who needs treatment is getting it.

You wrote yourself a quote in another comment where it is claimed that has happened. I am confused...

I don't understand what you don't understand. That quote is literally saying they are over capacity.

What are the results of the "over capacity"? Are hundreds of people who could have recovered from the virus dead today because they didn't have access to oxygen, or ICUs?

Yes, that is exactly what it means.

And what the reuters article is saying is that that's not the case at all. So, by your definition, it's not actually over capacity.

How does that quote contradict the parent? If you were a doctor, and you wanted to communicate the concept of triage without baldly stating that people are being left to die, how would you phrase it?

Not sure how, but definitely wouldn't lie about it. Plenty of 80 year-olds would have a chance of making it, so they wouldn't be turned away according to that declaration.

You state this as fact. However there are also plenty of other sources of facts that counter yours. Who is right? Who the hell knows.

We now live in an age where you can dig up facts to confirm whatever you want to confirm. Information overload is a real thing.

This is not a dud, and it will prime whole generations in different countries to have respect for new diseases. If the United States just delays a little longer in its response, it will also be on the list of those countries. Don't know if one should count that as a success or not.

>If the United States just delays a little longer in its response

You'd think following the trend of Italy was scary enough.

https://www.vox.com/policy-and-politics/2020/3/13/21178289/c...

This is my biggest concern. I don’t even think this is “the big one”

Oh, it's absolutely not "the big one", which is why I'm so frustrated at all of the panic buying. It was pretty clear early on that this isn't that deadly and that the main issue with it is filling up hospitals. We later learned that the whole process from infection to recovery (well, enough to be released from a hospital) is about 2 weeks, maybe less.

This isn't some society-collapsing event, but it does require containment so our medical infrastructure doesn't get overwhelmed. If you get it, you'll most likely live, even without medical attention.

That being said, we do need to treat it seriously. It isn't just a dress rehearsal for something worse, but it is telling in how people react. I'm worried about what will happen if something worse comes along.

What I have learned, however, is that my general strategy is always keeping 1-2 months of basic essentials on hand is a good idea, and that I need to be more vigilant about it because people overreact.

I lived in the Tampa Bay area for 7 years. Twice a year (despite the fact that TB has been very much sparred from impact) hurricane panic ramps up and the region is CLEARED out of wood, petro, water, and canned goods. Hurricane Irma results in a complete wipeout of supplies 2 weeks before landfall. The initial landfall target was Miami and all hell broke loose anyway.

So when you get 1-2 months of essentials just in case, it’s a good idea, but when other people do it, it’s panic buying and overreaction?

The trick is to already have 1-2 months of essentials before hand. The issue is when everyone tries to get 1-2 months of essentials all at the same time.

Obviously, but that doesn’t make it an overreaction for people who waited until now to buy what they need.

I dont think thats true. Unfortunatelly I dont see mortality rates like in Seattle reported in other retirement facilities.

Maybe in the end the CFR will be the same as the regular flu.

It has already proven to be far worse than the flu in its strain on healthcare systems.

Isn't that largely due to a lack of immunity? Too many people getting it at once in clusters?

If this becomes a cyclical thing, I'm sure we'll have vaccines for it like we do the flu, at which point it'll just be annoying like the flu is.

The only thing that matters in the end is total population mortality rate.

That is a bad metric. The death rate could be really bad yet the overall death rate would still not change very much.

If I am the only person on the planet with a 100% deadly disease why should I force everyone else to suffer because of me?

The fear and suffering alone is enough to have a negative effect on people, so it matters.

So is shutting down the entire worlds economy. That has massive, very real impacts well beyond just money.

Ya, but the anxiety of thinking you might sick and die also has negative impacts beyond just money.

But the enormous strain in the healthcare system is very unlike H1N1, so it’s probably not too far from the estimates. To see what’s happening in Italy, this is obviously much worse and unprecedented.

"Tangent: I wonder if it’s partly the changing media landscape from 2009 to 2020."

You think that the reaction of health agencies worldwide was the result of a "changing media landscape"? This takes quite an extraordinary perspective to serious posit.

And just to be clear, there was a huge reaction to SARS (a sibling to this virus) six years before H1N1. A massive, coordinated worldwide effort, quarantines, and whole-cities going quiet.

How do you blame the media for that, or was it a "changing media landscape" between 2003 and 2009? SARS thankfully was contained through heroic efforts so it never yielded the catastrophe we have now.

Regardless, they're very different viruses. Even if we pretend that the world "barely noticed" H1N1 (hint: It saw a huge response), health agencies and their experts have rang the warning bell about this virus because of the way it accelerates and presents in an area. They aren't jerking about CFR (which is a post-facto statistic), they're noticing that it hits an area and as it spreads the need for massive intervention explodes. That is why Wuhan got so much attention early on, and why cities are taking extraordinary, historic actions.

Rather than repeat myself - https://news.ycombinator.com/item?id=22607318

Trying to casually blame the media is not useful.

In Italy more than 300 people die every day, the overall mortality rate is between 3% and 8% this is 10 times more than 0.4%. Even if 50%-75% are asymptomatic, there is still large percentage of critical cases that need ICU treatment and currently we are not prepared for it.

For me the title should be 25% of cases require treatment in hospital and we are not able to put 25% of population into hospitals, so, very likely 3%-8% will have to die (3% - WHO estimate, 8% - real numbers we have for now).

That's assuming that all reported cases make up all ACTUAL cases. This is likely completely wrong. What if a much much larger chunk of Italy is already infected and simply not showing symptoms? You would never get permission for a test.

Estimates, I found them on Germany's top Robert Koch Institute website [1], suggest that Wuhan underreported cases by a factor between 4.5x and 11.1x (3 separate studies with different factors).

[1] https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus...

I don't think anyone knowledgeable is assuming reported cases make up all or even a significant proportion of infected cases (I myself am in recovery from moderate lung inflammation which is probably COVID-19, but even with very-obviously-not-regular-flu symptoms don't figure in my country's stats because tests are reserved for those requiring hospitalisation)

Even if it was actually the case that nearly everyone in Italy had it in which case the casualty rates would be much lower than current estimates, the proportion of cases needing ventilators is sufficiently high to overload Italy's healthcare system (so the risk is similar, we're just looking at different risk factors i.e. the disease being less deadly but much more efficient at spreading than current estimates). Knowing that would make it easier to shift from containment to building more ventilators as a strategy, I guess

> I don't think anyone knowledgeable is assuming reported cases make up all or even a significant proportion of infected cases

The WHO explicitly and repeatedly asserted exactly that.

Surely the amount of symptomatic but untested people in Italy is high. If you're sick but readily able to manage the symptoms, and you're already under lockdown because the health system is overloaded, you're not going to bother going in to get tested - you're going to let the doctors work on the people who need it.

> For me the title should be 25% of cases require treatment in hospital

The opposite of "completely asymptomatic" is not requires hospital.

Or it could be like the 1918 Spanish flu - a bad first wave that was most dangerous to the elderly, and a second wave that mutated and killed mostly young adults.

I don't know why there would be any reason to believe that would be the case. Generally viruses become less deadly over time, not more. The Spanish flu was an outlier.

Viruses generally become milder because of selective pressure to do so. If it kills the host, it doesn't get to spread as much.

Plus, of you get slightly sick, you probably continue your life and infect others. If you get horridly sick, you stay in bed and encounter no one.

WWI made the Spanish Flu have it's second wave. Mildly I'll soldiers stayed where they were. Really sick ones were sent in overcrowded trains far from the front lines back to overflowing hospitals with inadequate sanitation.

These lockdowns we are doing are encouraging a deadly second wave.

I'm pretty sure the Spanish flu did become less deadly over time. I'm sure the virus didn't go away after the second wave, however humanity started developing an immunity to it.

No, from what I’ve read the second wave was the deadliest by far. The first wave being mild. There is anecdotal evidence that sick soldiers spread a virus that became stronger with soldier to soldier spread and then infected more venerable people when returning home. How this would extrapolate to the current outcome I’m not sure.

SARS (including this new Coronavirus) does not mutate as fast as the flu, so it's even less likely to become more deadly than the common flu.

> But SARS has a molecular proofreading system that reduces its mutation rate, and the new coronavirus’s similarity to SARS at the genomic level suggests it does, too. “That makes the mutation rate much, much lower than for flu or HIV,” Farzan said. That lowers the chance that the virus will evolve in some catastrophic way to, say, become significantly more lethal.

https://www.statnews.com/2020/02/04/two-scenarios-if-new-cor...

Right, the swine flu pandemic of 2009 was basically a descendant of Spanish Flu. It continues to circulate, particularly in the last couple years - a majority of flu cases this last couple months have been the H1N1 strain that descends from Spanish Flu. We don't hear about it because newer and more deadly pathogens like COVID-19 have cropped up since.

I think most people in this thread are talking about 1918-1919, though, since that time period's a little more relevant for predicting what COVID-19 will do.

If only optimism could kill viruses.

Humans are wired for doomsday scenarios. Our brains love to imagine the worst case scenarios.... probably how we survived as a species for so long.

Our brains have not evolved to deal with 24/7 media coupled with social media, HN, Reddit, YouTube and every other information source feeding us a nonstop stream of raw unfiltered data.

Dunno where I’m going with this but our brains latch onto stuff like this and run wild. Multiply by billions of brains doing the same thing and there is a massive social and political pressure to “do something”.

Who the fuck knows what is really happening. We have plenty of “facts” and “information” floating around but no way to make any sense of it. All we can do is imagine the worst and replay “prepare for the worst, hope for the best” or “better safe than sorry”. Except unchecked that attitude can make things worse.

And, in short, that is why I’m not in the office today and pretending to work at home just like everybody else here.

Perhaps this is a side effect of subscribing to unhealthy number of true crime podcasts and listening to police radio.

The people in the saturated hospitals know what's going on. HN or Reddit had nothing to do with that.

> saturated hospitals

citation needed.

PS: you should easily be able to cite that statement in favor or in disfavor of your statement. Both citations will be equally valid and invalid.

> An anesthesiologist at a hospital in Bergamo, one of the cities with the most cases of Covid-19, the illness caused by the new coronavirus, told the paper that the intensive care unit was already at capacity, and doctors were being forced to start making difficult triage decisions, admitting people who desperately need mechanical ventilation based on age, life expectancy, and other factors. Just like in wartime.

> The hospital in Bergamo was not the only hospital in the area dealing with a lack of capacity and rationing of care. The same day, I heard from a manager in the Lombardy health care system, among the most advanced and well-funded in Europe, that he saw anesthesiologists weeping in the hospital hallways because of the choices they are going to have to make.

https://www.bostonglobe.com/2020/03/13/opinion/coronavirus-c...

That article is five days old. Find something from today suggesting the same. And make it relevant to the entire world. Italy is not a model for how this is going down in other countries. Every region is different (and more important has different data collection methods, making it hard to compare two areas)

Again, nobody knows what the fuck is going on. Chill out, stop spreading panic and think critically about things. It’s okay to question stuff.

I am sad to say, official sources say that the Bergamo hospital ran out of intensive care units yesterday.

This is one of the articles in Italian, there are plenty if you look for the last 24h news.

https://it.notizie.yahoo.com/coronavirus-bergamo-terapia-int...

You are right that every country and region is different, but collection methods have nothing to do with the hospitals being flooded with sick people, that would be true if there were 1 or 1 million tests being administered.

> citation needed

It would be ridiculous to copy here the URL of all newspapers and TV channels in Europe. You can also easily find doctors and other personal in hospitals saying they are over capacity. You can also see how in China they had to build new hospitals.

If you need me to give you a citation to understand that this is a huge shitstorm for our health systems you are just stupid.

Not to mention if pessimism could kill viruses!

I don’t know any reason that wouldn’t be the case, and many/most experts are already predicting a second wave - we don’t know the reasons that the 1918 pandemic mutated to become more lethal, so I don’t know how someone can say that it won’t happen again. Good planning would dictate that we not write off worst case scenarios without reason.

I have heard that the reason 1918 was so bad was because, among all the soldiers in the trenches, it could be virulent and still be able to spread effectively, so it had no selection pressure to not be virulent. (If an illness is too virulent, it usually dies out before it spreads too far.)

Covid is a bit different, because it has a longer incubation time, and therefore has more time to spread before the spreader knows not to infect others, but that wasn't the issue with the 1918 influenza outbreak.

(Note well: I am not an epidemiologist.)

I’ve heard that as well and certainly hope that’s the case. But I’d think it’d be irresponsible for planners to just assume that’s what would happen, and not ask themselves what happens if the pandemic becomes worse.

As I understand it (please correct me someone if I'm wrong), this was a freak mutation. Not to suggest it couldn't happen again. And we 100% should be prepared. But the concept of a virus leaving, mutating to be more deadly, and coming back, isn't on the 'expected' path.

And when people talking about leaving, they mean that the mass transmission stops and it continues to transmit, and mutate, among some small subset population (e.g. remote island, etc). Eventually it recurs in the main population, whether hitting people who never got it, or because it has mutated enough that prior protections don't defend against it.

Which is exactly what happens with the flu and the cold. Lots of viruses, constantly mutating. So much so that when the next season comes around it's like an entirely new virus to your body.

AFAIK, the case fatality rate is always higher than the actual mortality rate, but before reliable antibody tests are available and used on large random samples of the population speculating about it is not helpful.

This is wishful thinking, and it doesn’t take much examination of the medical literature to realize this fact.

Edit: it's super fucking irresponsible to say "this is going to be like H1N1" when there is no reputable medical literature that supports that position

> it's super [] irresponsible to say "this is going to be like H1N1"

Good thing the person you responded to never said that.

that is pretty much the hypothesis in their post

I wouldn't be surprised if it's similar. Many countries, even ones in Europe with high infection rates, still don't test people if they don't show severe symptoms because they don't have the capacity to do it on a large scale.

>Then on the cruise ship full of people over 60 it’s 0.7%. If there are lots of mild or asymptomatic cases it will likely be much lower.

Here is a comedy show lambasting Donald Trump for saying he had a hunch this was the case:

https://www.youtube.com/watch?v=yNfmTMdoao0

Donald Trump's gut probably saved thousands of Americans through closing the borders early (this is a talking point he repeats again and again and I haven't seen anyone argue with this - so I accept that if any other President had been in office that President wouldn't have closed the borders from highly hit areas so early - an unprecedented action - and hundreds, or thousands of Americans would be dead. Since it is unrefuted I accept Trump's assertion that U.S. has a huge number of tourists and ordinarily would have been harder-hit.)

However: not sure how I feel about being led by a gut rather than experts.

I debated whether to submit this but I will do this to judge for myself HN replies and voting on my comment.

I'll argue with this. He didn't close borders early and he didn't close them well. Here's a general link about it: https://www.factcheck.org/2020/03/the-facts-on-trumps-travel...

Specifically as to the timing of travel restrictions, the U.S. was more or less in line with other countries at the time. A wide swath of countries started banning entry to foreign nationals from China around the end of January, beginning of February. In the U.S. travel was banned to foreign nationals from China on Feb. 2nd, around the middle-low end of the pack (although not by much, just a day or two). This was less restrictive than some other countries (which banned flights altogether), but generally in line with other countries. However, the U.S. has consistently been behind the ball when it comes to quarantining U.S. nationals from China. Long after the official announcement people were getting off the plane and not even being asked let alone compelled to at least self-quarantine in their own homes for days if not the full two weeks.

Testing has been infuriatingly slow to roll out and there has been a noticeable lack of coordination between states and the federal government about how to institute protective measures. The 1.5 million tests promised by Pence has failed to materialize as of yet. The CDC stopped counting case numbers (at least publicly) and now the best available case count is one maintained by a private institution (Johns Hopkins University). More generally, Trump has consistently downplayed the threat of the virus through February in a way that medical experts repeatedly complained was far too incautious for the situation and is now doing an abrupt about-face and claiming that he has never downplayed the risk at all and in fact was more cautious than even experts.

I've actually been really surprised by how well he has handled this so far too. The nation-wide lockdown plus direct cash stimulus are exactly the measures I had hoped to see. Pandemics may be one of the rare situations where having authoritarian leadership can actually benefit the populace. Though I guess we have a while before it plays out completely. I have doubts about whether any non-populist president would have taken these steps any sooner.

> I've actually been really surprised by how well he has handled this so far too

No one who knows how national pandemic response works agrees with you. They know that trying to suppress testing, and criminal lack of executive management of the testing capacity was a known and must-be-fixed quantity 6 weeks ago. They know that hundreds of millions of PPE supplies should have been ordered under federal pandemic authorities 8 weeks ago. They know that emergency powers for production of ventilators should have been invoked 6-8 weeks ago, and still haven't been. It's bungled beyond belief and the only thing that will prevent something near a worst-case run of this pandemic will be some luck.

Thanks for chiming in with those examples. I suppose "well" is much too strong of a word then. I guess I just have very little faith that others would do a decent job either.

Since you seem knowledgeable, I guess my question is: While large scale testing seems a reasonable thing to do on it's face - since we already know this thing spreads like wildfire - isn't the best play to just have everyone self-quarantine regardless of health status? Why spend resources on mass testing and preparing for mass-scale treatment when it seems that a total lock-down could nip the transmission in the bud? If you're a non-severe case they tell you that you're supposed to stay away from people if you test positive. So if you're doing that already - what's the difference? Especially considering the logistics of performing large scale testing to identify non-critical cases could expose the people performing the tests if they mess up on their safety protocols. And then there's the issue of false-positives and false-negatives.

I guess I just don't see the benefit of mass testing everybody when we have the option of just shutting down everything now.

> Why spend resources on mass testing and preparing for mass-scale treatment

This is a good question, I hear it a lot. So here's an inarticulate stab at an answer.

[TLDR: After quarantine the population is still at risk and the virus will start its exponential growth again, just a few weeks down the line]

No matter how effective your mass quarantine may be, we will never "nip transmission in the bud". This thing is endemic and may well be chronic.

The purpose today of mass quarantine is just to slow down the exponential growth of the epidemic. It's only worth doing if you have something to stop the growth from starting again at the end since shutting down the economy isn't sustainable and is enormously damaging even in the short term.

What's that something? Wide-spread, universal testing. Rapid follow-up on positive tests to trace contacts and isolate them. This way you cut down the number of people each person can infect so that the growth rate is less than 1.

You have to keep this regime going until a sufficiently large proportion (in this case, 60%-70%) is immune either because they have recovered from infection or they have been vaccinated.

So, barring getting really lucky with some kind of seasonal disappearance of the virus, we will have to maintain this surveillance-tracing-isolation three legged stool until a vaccine is available.

If we had done this from the beginning we would not now have to be shutting down and destroying the economy to prevent a worst-case disaster, which is estimated that it would peak at about 40,000+ deaths per day in the US, sometime in late May, if left unchecked.

If we had done wide-scale test-trace-isolate from the beginning we could just be going about our business, albiet with this new factor in our lives. Since the criminals bungled, and are still bungling the response, we instead will have many many deaths and serious illnesses w/lifetime consequences and unprecedented economic damage.

The U.S. is not under lockdown. Far from it. Any lockdowns have been entirely done at the state and local level and even those are very spotty and a far cry from the lockdowns in Italy at the moment and in China.

Direct cash stimulus is one thing I'm definitely looking forward to. The other big one is the various cash infusions into key pillars of business (e.g. airlines).

I don't think it's been an abject failure, but I think the U.S. response to the pandemic has been at best middling and full of whiplash in both rhetoric and policy pointing to a reactionary plan rather than any sort of proactive attempt to get out ahead of the curve. We didn't learn a lot of the lessons we could've from South Korea and Singapore (and at the very least why couldn't we have imported their testing).

Meh. An actual leader would clearly articulate what is going on—he hasn’t done that. An actual leader would tell people not to panic—hasn’t done that. An actual leader would take strong, very visible action against people hoarding supplies or worse reselling them for profit—toilet paper memes are funny until you run out.

And quite frankly a real smart leader would have started testing the fuck out every person with a pulse. More understanding of how many people have it is important.

It’s up to the states to manage hoarding and reselling, and they are.

Sure but the president’s job is to tell people to chill the fuck out. So far, he is not.

I'm not really a trump fan - but at the same time, these people have to have time to do the work, they can't spend it all in press conferences.

At a practical level on the hoarding - what can the president do, declare martial law? There aren't enough police/solidiers to enforce it anyway. Far better to get to work on the source of the panic, especially if you believe it can be contained if you prioritize that.

It's clear we're behind on testing - and definitely the FDA is owed some blame. But at the same time, if the tests don't exist in quantity, they don't exist. That takes time - and be all accounts, they seem to be working hard on getting there.

They can make clear, well publicized examples of people hoarding goods for resale. They make well publicized examples of people getting arrested in stores who are loading their carts up with every hand sanitizer bottle on the shelf.

It doesn’t take more than a few very visible examples to clamp down on that kind of behavior.

That absolutely should be happening - but that needs to be done at the state or local level, or in consumer protection agencies. That's not a job for the president at times like this.

> That's not a job for the president at times like this

It is absolutely the job of a president, at least a good one anyway, to ask the populace to chill the fuck out and stop hoarding toilet paper and medial supplies.

This seems like a fairly common view to people who have come late to the topic.

If you have been paying attention for a while, the way the USA has handled this is horrifying.

Compare the outcomes in Italy to those in South Korea to see what good handling of this crisis looks like.

Even though we had the example of Italy weeks ago, we waited and waited and waited until now. Our outcomes will be similar to Italy's in a great deal of the USA.

The worst thing was the terrible, terrible failures in testing. We will never know exactly how many lives could have been saved if we ramped up testing the way South Korea did. We will be able to make some rough guesses after we get the final body count.

Trump also did enormous damage by continuously, repeatedly dismissing the new Coronavirus as no worse than the flu. Foot dragging and denial are natural anyway; having the president constantly dismiss the worst epidemic since 1918 as alarmism from whiners delayed action at the state and local levels, never mind all the action that wasn't being taken at the national level. There are still many people--maybe a majority in my area--who think this is all overblown panicking over nothing.

Here's the best I can say. The travel ban was a good idea and would have saved lives if we had not chosen to throw away the extra lead time it gave us. And most of Europe handled this just as poorly as we did, if that seems justifying to you (it does to some people).

So I guess the South Korean CFR of 0.7%, with by far the best testing, a relatively young population, and no overloading of hospitals, is "way under 1%"? And any suggestion that a higher percentage of people died in other circumstances is just a "false number"?