Coronavirus - Flatten the curve

Is America headed down Italy's path ? Italy healthcare system is crashing !! 

This is an example of what the situation in Italy looks like. 
This is what we can do

Context

I published a post 1 week back(on March 1) claiming that California Coronavirus cases will go from 0->100 in a week(by March 8). I also published another post comparing this Coronavirus situation to a "Black Swan Event". Needless to say that it has happened. I am very sad that some of the predictions came true because this involves some ones wife/husband/son/daughter that fell sick. I am super sad and more worried about the one that did not.

Recap :

1. 100 cases in california - True (currently 105)
2. Clusters of infected areas evolve - True (King County in Seattle, Santa Clara in bay area, NYC are all clusters)
3. Some town in the west coast gets quarantined - False

What is the goal of this post? 

I can make further predictions from hereon

1. Santa Clara county in Bay area alone will have 100 cases by next week given it has 25 now
2. UK will cross 500 cases by next week given it has 200 cases at the time of this writing
3. NYC will have 400 cases by next week
4. Washington will have 500 cases by next week
5. California will have 400 cases by next week

I hope you all understood what exponential growth looks like. 

This post is not about further predictions that went right. It is about the prediction that did not go right - some town in the west coast gets quarantined. Why did I get it wrong and what should be our way at preventing this catastrophe. But before we get there, lets see how this week went and some disclaimers.

What is explicitly not the goal of this post?

The goal is not to create panic. I strongly believe that when it comes to public health, honesty is better than hope. 

Disclaimers

Like I wrote in my last post, these are not my employers views. I am no expert in biology or rather in anything. I think nobody knows what is going on right now. I know a thing or two about startups and have seen some hockey stick curves in the past. That said, there are lot of false news on the internet. Use your judgement. Don't use this post or anything on my blog for any material decision in your life before doing your due diligence. 

How did the week go and what did I learn ? 

On March 1, I claimed in my blog that Coronavirus is growing exponentially with a CFR(Case Fatality of 3.4%)  and I urged people to take this seriously and WFH,not take trains, avoid public gatherings, etc to protect themselves, their families and their community. This blog has been widely shared after that and lot of the readers have taken some of this to heart. I am overwhelmed by your response. This post is for those people. This is for those who fought back when some one said "this is just a flu", "only the old or people with underlying conditions are dying".

Learnings and worries

1. At the time of that writing, I was not completely aware how ill-prepared the CDC was and that they were testing 100 people per day. UWash has come up with new testing kits in the mean time which are testing samples at ~7% on average. But we are still far from full testing capacity across the US. This is the biggest point of concern.  In last 10 days Italy diagnosed 95% of total cases they now report; South Korea 85%. 2 weeks ago, Italy had just 9 cases. 7 weeks ago, China reported 50 cases. The point: once the epidemics are discovered, they’ve been underway. I fear we will find a lot more cases in the US in the coming week, hoping that we raise our game in testing. I just hope that the US learns and can turn this graph around. 
2. Past recessions have looked like Financial Loss -> Job Loss -> Depression -> Health Loss. This time, it may be different. It may look like Health Loss due to coronavirus -> Depression -> Job Loss -> Healthcare loss -> Financial Loss. Basically, things may happen in the reverse order. Given American's have no sick leaves and a lot of them are underinsured or dependent on their job for insurance, they are the most vulnerable. 
3. If you had a hard time understanding what exponential growth looks like from my post, here is a much more explicit breakdown. The calculations may be off by days or weeks, but hope you get the point about why this discussion is so important for public health.
4. India is right in the early phases of the spread and it is home to more than a billion people. I am very worried at this stage about how things will pan out in the next 2 weeks. I hope to be wrong, but if India also reaches 100 cases by next week, things could get really bad. 

Recommendations

1. As you may have heard Italy is about to quarantine 10 million people in Lombardy. At this point our goal should be to reduce the total number of cases at the peak of the epidemic. Besides quarantine, there are several measures : reduce public transport, cancel public events, stop non-essential travel, stop gyms, move schools to online classes being some. Here are the CDC guidelines on preventing community spread. 
2. Our healthcare system is going through a denial of service (DOS) attack. This is what delaying/reducing it may look like from the economist
3. 
4. This is the first epidemic that the world is facing in the time of social media. Some social/medical/mental health implications beyond the disease from Ground Zero in China .

A chart from how the situation in italy looks like

Some other readings 

1. Why soap works well against viruses ?

Hope

1. The fact that some of the companies have declared WFH, lot of the companies have cancelled conferences are a positive step towards reducing that R0 and reducing that spread. We need to aggressively quarantine cities and reduce that R0 and reduce the load on the healthcare system to mitigate the disease. I dont want to introduce complacency in this post, this is as bad as it gets.
2. I hope some of the secondary predictions I make here in the post are actually wrong and the government can mitigate using some of the strategies mentioned here. 

Coronavirus in the bay area

Context : At the time of writing March 1(Sunday) , there were 3 cases in Bay Area and 5-7 in Washington.

Prediction by March 8(next Sunday), we will have

1. 100 cases in california
2. Clusters of infected areas evolve 
3. Some town in the west coast gets quarantined

Outcome(Edited on March 7, Saturday)

This is what we can do to flatten the curve

Disclaimer : I am no bio expert. These are learnings I accumulated from reading blogs. Please use your own judgement. Not everything you read on the internet is true. I am just posting the summary of my learnings here and some predictions drawn from that. 

Why am I posting this ?

Lots of friends are asking me whether to work from home and whether they should get supplies stocked up or not. I see a bunch of people clueless about the situation and lot of panic. Also people are not sure whether they should use bart/caltrain/public transport. Wanted to share some of the research that I did over the weekend.

Summary of my learnings and some numbers

Disease -> Spread -> Metrics -> Virality -> Infrastructure hotspots

1. Coronavirus may have spread in the seattle area for weeks as gene sequencing results suggest
2. The virus has a 14 day incubation period
3. The test in the hospital takes 2-3 days 
4. This results in a delay in detection of around ~15 days
5. Thus there are way more people around affected than we know
6. Detection of peak will be delayed after the actual peak
7. As we see from italy, the government will have no way other than quarantine a whole city by the time they detect a cluster where the virus is spreading
8. The disease has a CFR(Case Fatality Rate) of ~2.3%, that means that 23 out of 1000 people affected will die
9. The disease has a R0 of ~2.5, that means that 10 affected people will spread it to 25 people. R0 is a measure of how infectious a disease is and is heavily used for planning strategies to mitigate the spread(R0 calculation is an ongoing task here and it lies between 2 and 3.5). This is what makes it an exponential rate of increase
10. A very good read to learn more about R0 and CFR and to put things into perspective, and how different diseases(measles, flu, rabies) compare against each other on these two dimensions
11. Inspite of the low CFR, this disease is a strain on the medical infrastructure due to clustering around particular locations. 
12. California has 1.8 hospital beds per 1000 people
13. As you can see, that given the CFR, if the disease spreads, we will only be able to care for the critically ill patients only. This is also something that has been observed in the past in other countries. Non-critical patients have been asked to stay home
14. Couple of factors that could test USA: lack of paid sick leave and some people not having healthcare. The high population density in the bay area may expedite things too
15. This will effectively create a Denial of Service(DOS) attack on our healthcare system
16. This could very well put the world into a global recession where rate cuts may not really help
17. Summer is still 1 month away. 

What steps can we take as individuals to prevent/protect themselves

1. Please watch the government video : https://www.youtube.com/watch?v=nnz95Ssgt3k

References

1. Cryptic transmission of novel coronavirus revealed by genomic epidemology by Trevor Bedford
2. Why am I concerned about the coronavirus : applying a viral growth data metric to a viral crisis by Ed Baker - ex Uber and ex Facebook.
3. How to decide when to take precautionary action on coronavirus - an analytical model by Adam Gries
4. Coronavirus dashboard
5. Bill Gates blog post on how to respond to coronavirus now and to epidemics in the future
6. The virus is coming - In public health honesty is worth a lot more than hope - The Economist
7. Harvard FAQ

Update 

1. At Mar 2, 2.30pm PST 16 people are affected across the state of california - 6 people die in Washington
2. Mar 2, 5.20pm PST - 100 cases of coronavirus in the US
3. Mar 3, 10.30am PST, 24 people are affected in california
4. Mar 3, 11.45am, Seattle times has taken down their paywall https://www.seattletimes.com/seattle-news/health/coronavirus-kirkland-seattle-updates-tuesday/
5. Mar 3, 11.45 am New cases in washington looks like doubling every 6 days
6. Mar 3, 2.20pm - 45 cases in california
7. 
8. March 4, 11.28am 58 cases in california, 1 person sadly dies
9. 
10. Mar 5, 10.45pm update : Coronavirus - Black Swan of 2020
11. Leaked presentation in hospitals show that they are prepared for millions of hospitalizations
12. 
13. March 7, 3.09pm, 104 cases in California. The predictions came out true. 
14. 
15. If you have read till here, this twitter thread breaks down what exponential growth looks like. 
16. Please stay healthy and stay safe for yourself, your family and your community. 

1. Must watch video from NYC ER doctor - author of superbugs, race to stop an epidemic