Coronavirus (COVID-19): Underappreciated Unknowns & inexplicable failures | A Pragmatist’s Take | Douglas Moran

Public complacency about COVID-19 is being promoted by the authorities' message of "Everything is (currently) under control" where the "currently" comes from the larger context and will not be part of the quote that will appear in the media. These statements diminish the impact of warnings from the epidemiologists, even when given by the same official or in the same press briefing. In my previous blog on coronavirus,(foot#1) I discussed the long-established pattern of officials and high-ranking medical experts believing that the public can't handle the truth. Recognize that the understatement of the danger may come from what the medical experts have told the officials to say or from the officials' own political instincts.

My focus here is to promote a healthy skepticism of what you are being told and to read past the headlines and consider whether the details provided support the claims.
Note: As of Thursday 2/27, California is monitoring 8400 people for COVID-19.(foot#2)

Caution: Much of the information below comes from the media with their sources being press releases and similar official statements. Because the various media outlets add, omit and edit this information, I try to find articles from multiple media sources to filter out misrepresentations of the original material. However, it is not uncommon for errors in one media outlet's article to be replicated in others.

Disclaimer/My background: I was introduced to the problems of responses to epidemics as part of volunteer work on emergency preparedness. Because of my professional background in computer software development, Artificial Intelligence, and computer security, I was drawn to the part of the problem of how under-resourced systems responded to stresses, and how such systems adapted to a poorly understood, evolving threat. I have no medical skills and my knowledge of epidemics centers on the political/management histories.

----Serious failures by the US government----

On Thursday, it was publicly revealed that a whistleblower complaint against the US Department of Health & Human Services (DHHS or HHS) that stated more than a dozen workers had been exposed to people evacuated from China and Japan with a high risk of being infected with COVID-19. They were given no training or protective gear, and allowed to circulate in the general population. Of the evacuees at Travis Air Force Base in the center of ^Solano County^, seven became seriously ill and had to be transferred to hospitals with special quarantine and treatment units. Solano had 5 beds available with the other 2 patients going to Napa.(foot#3)

The day before this failure was revealed, the CDC reported a case of COVID-19 in Solano County, stating that the origin was unknown. Was CDC unaware that DHHS's failure was a likely source? Or was the CDC complicit in trying to keep that information from the public?

The story gets even worse. The patient was seriously ill -- on a ventilator -- upon arrival at UC Davis Medical Center. However, despite the doctors' diagnosis, the request for a COVID-19 test was denied for four days by the CDC "the patient did not fit the existing CDC criteria for COVID-19". The CDC claimed that this delay was not due to a backlog of testing. However, unwarranted denials are a time-honored tactic for preventing the creation of backlogs.(foot#4)
((Update: 2019-03-02: The CDC criteria limited testing to those who had been to a hot spot such as China or who had been in direct contact with a confirmed infected person. Notice the problem: People are known to be "carriers", that is, they can infect others but show no symptoms themselves. People who have infected by a carrier do not qualify for testing, and the CDC fails to detect and respond to developing clusters. In effect, the CDC criteria was to test the high-probably cases while ignoring important cases.
))

Earlier, an infected evacuee from China was erroneously released from quarantine in San Diego. Reportedly, the hospital was using a labeling system different from the CDC and the CDC liaison didn't notice. When that sample arrived at the CDC (in Atlanta), they were put aside. When the hospital called for results, they were told the person had tested negative, rather than being told that there were no test results. These two mistakes in Atlanta were generic procedural mistakes, not some special handling needed for COVID-19. Yes, mistakes are to be expected, but not these types of mistakes. It shakes my belief in the basic competence of the CDC.

Another nasty error occurred during the return of US passengers on the cruise ship Diamond Princess. The Japanese had so badly botched the quarantine that they were facilitating the spread of COVID-19.(foot#5) President Trump had ordered that no infected people were to be returned to the US. The CDC, the State Department, and the (cabinet) Department of Health & Human Services (DHHS or HHS) developed a plan, but at the last moment, State and DHHS decided to include infected passengers, overruling the CDC.(foot#6) I have seen multiple accounts of how this happened, but none identify their sources. One story is that when the bus from the cruise ship arrived at the airplane, it was discovered that there were infected people on board, and that low-level State Department employees decided that it would look bad to turn them away. Another story is that the decision was made at higher levels a little before that. Additionally, reports are that the staff in Japan simply took the passengers' word that they had tested negative, and included one couple that hadn't received their test results. The husband became very sick during the flight, potentially infecting the other passengers on that plane.

Faulty test kits:
The Chinese test kits have an estimated 50% false-negative rate, that is, when testing an infected person, 50% of the time, the test will say he isn't infected. In an experiment on a person known to be infected, only one of the four tests administered return a positive result. You might think that the CDC would take note. Apparently not. The first set of kits distributed to the states and counties had to be recalled because of a manufacturing defect (ineffective chemical reagent). Was this a mistake in testing or QA (quality assurance)? The replacement kit has a lesser defect: The last of the three tests is reportedly beyond the skill set of most to the people intended to administer it. Not a big problem, yet: There is such a limited supply of the kits that few actually have them.

The Chinese finally admitted to themselves that the persistent shortage and unreliability of their test kits called for alternative diagnosis measures. In the reporting of the testing delay of the Solano County case and the CDC's continuing problems with its testing kits, it was reported that the CDC had started developing its own alternative methods. Way to not learn from others' mistakes!

In my previous coronavirus blog, I enumerated similar shortcomings by the CDC to Ebola reaching the US, despite many, many months to prepare.

----Irresponsible personal behavior of those who should know better----

Iran provides an interesting example of the difficulty of predicting how fast a disease will spread. In one video clip, the obviously feverish Deputy Health Minister is standing next to the Spokesman for President Rouhani. In another clip, he is coughing during an interview in a TV studio. He was subsequently confirmed to have COVID-19. Then Rouhani's Spokesman appears to be coughing in another clip, and then absent from a video of a leadership meeting. Then there are clips of the Tehran city council where a District Mayor is seen wearing a mask and in close contact with other council members. He is later diagnosed with COVID-19, and physical meetings of the council are canceled.(foot#7)

These officials were not just spreading COVID-19 to generic others because those contacts themselves were highly networked and would be spreading the virus to their contacts, and so on.

Additionally, contagious people don't just infect their contacts, but leave the virus on doorknobs, railings and many other surfaces. And this wouldn't be just any surfaces, they would include surfaces in high-traffic public buildings.

The Iranian clips are memorable because they are so egregious, but similar situations will happen in many other countries. For example, in President Trump's press conference on Wednesday, he recounted how an acquaintance who knew he was running a fever came up to him and hugged him.

----COVID-19 is very different from Flu (influenza)!----

The flu is being widely used as an analogy for COVID-19, often without the limitations of the analogy being noted. There have been a flurry of articles on social media and traditional media claiming that the flu is more dangerous than COVID-19. I don't know the sources, but it could be statistical malfeasance, trolling, or some agenda. Whatever, this can lead people to make inadequate or wrong preparations.

Airborne: When people with the flu cough, the virus is embedded in a drop of moisture which typically falls to the ground within 6 feet. Consequently, "social distancing" can be very effective in reducing transmission. In contrast, COVID-19 seems able to float much longer distances. In a report from China, the virus spread quickly through a block of buildings and it is suspected air circulation between the buildings was responsible, with the worry that many other groups of buildings utilized similar designs.

How many are infected by a single person? In the US, the estimates I have seen is that one person with the flu will pass the disease on to 2-3 other people. With COVID-19, the data is very bad, but 10 is the number being widely cited, with reports of 20-40. Part of this difference is due to herd immunity: Many of the people that someone with the flu comes in contact with already have some degree of immunity -- either from the annual flu shot or from a similar flu virus in earlier years -- thereby breaking the chains of transmission. Aside: This year's flu shots appear to be only 45% effective because some of the virus variants in circulation were not among those selected for the vaccine, which has a long production lead time.

Who is most in danger? The traditional flu doesn't kill people: What is does is weaken the immune system, thereby leaving an opening for other opportunistic diseases, such as pneumonia. Consequently, those in most danger are those with already weak immune systems, the old, the very young, the sick, -- However, the 1918 (Spanish) Flu was very, very different: I killed mostly healthy adults. Why? Because it caused the immune system to attack the body as if it was an invading disease, and put that immune system into overdrive. Thus having a strong immune system puts one in danger. COVID-19 deaths among healthy adults seem to involve different attacks on the body.

While the warnings from medical organizations for those in most danger from COVID-19 are the same as for traditional flu, word from China has an unusually large number of doctors and nurses dying. Because there is a severe shortage of protective clothing -- which is mostly manufactured in China -- medical personnel becoming infected is not surprising, one would expect them to recognize symptoms early and then to receive good care.

The doctor credited with trying to alert other doctors to this novel coronavirus was one of those who died. The reports are that after being diagnosed, he was doing well for about a week and then the disease turned savage and died about a week later, despite being supported by various medical devices. He was in his early 30s.
To me, this strongly indicates that COVID-19 is dangerous to much more of the population that traditional flu.

What is the death rate? Unknown. Most of the guesstimates fall in the range of 2-4%. However, one compared the number of people diagnosed with COVID-19 who recovered to those who died and got 10%. However, these guesstimates all suffer from serious selection biases and other problems because there isn't good data to work off of. For example, if the 10% rate was derived from patients who were in intensive care, it is
In contrast, the death rate from traditional flu since 1990 has averaged 0.00056% (roughly 1 person out of every 200,000).

Preferred conditions: The flu virus thrives in cooler, drier conditions and is killed by brighter sunlight. Consequently, flu subsides in the summer in the US. COVID-19 is showing up in countries that are warm and humid. Does this mean that COVID-19 is different from the flu in this regard? Unknown: The sample size is so small that these could simply be outliers.

----The data from China is utterly unreliable----

There are numerous reports from China of strong political pressure to underreport cases and deaths. There are also serious technical problems. Kits to test for the virus were very limited, and when alternate diagnostic tests were approved, they too were very limited. People would show up at hospitals to be diagnosed and get turned away because there were no available beds -- or even makeshift beds -- and sitting in a waiting area was likely more dangerous to them and the others there. There is no sense of how many returned home and died.

There are multiple reports coming out of China -- for example through social media (via VPNs?) -- that estimate that the real numbers are 10 times what the government is reporting. An interesting metric is cremations. Chinese custom is to have the funeral before noon, so the crematoriums commonly operate from 6am to noon. In Wuhan (origin of the outbreak), the crematoriums are now operating full time. And 40 mobile incinerators have been sent to Wuhan.(foot#8) The specifications are that each can handle 5 tons per day (200 tons/day total) and that they are intended for medical wastes and carcasses of diseased animals (and ...). In a reporter's discussion with a crematorium operator, the latter complained of a shortage of drivers to pick up bodies, and a need for more vehicles because they have already stripped out the insides of their cars and vans to carry more bodies.(foot#9)

----Disincentives----

I am seeing little discussion about trying to reduce the disincentives for people to isolate themselves and get tested if they have symptoms that could be COVID-19. For example, a Florida man who had returned from China before the checks started was coming down with the flu. However, to make sure it wasn't COVID-19, he went to a local hospital to get tested for the flu since there were no tests available for COVID-19. Understandably, the hospital treated him as potentially infected with COVID-19 until the test results came back. His initial bill was over $3000, with more charges to come.(foot#10) Worry about similar billings may well cause people to decide that they can't afford testing and to hope that it is just the flu.

Alleging concern about "fake news", Google/YouTube and other social media giants are disincentivizing (suppressing?) alternate news media and citizen journalism on this issue. For example, YouTube is disqualifying all videos mentioning coronavirus, COVID-19 ... from receiving ad revenue. Of course, this doesn't apply to big corporate media because we all know that they wouldn't seek to profit by pushing false narratives and exacerbating divisions in our country. And that they would never push out unverified information because it is good click-bait. And ... Yeah, right.

And YouTube and other social media companies are reportedly making it harder for people to find videos, even deleting some. Maybe Google/YouTube, like the CDC, is ignoring the lessons from China -- that this sort of information will find a way to get out to the public. Some YouTubers have resorted to using euphemisms or code-words for banned terms, while others are defiantly accepting being sanctioned.

----Preparing----

The official advice on how to prepare for an epidemic or pandemic tends to be poor, for example, telling you to have games for children to play if schools are closed. Reportedly, some government agencies have recognized this deficiency and have decided to consider who should be assigned the task of overseeing the assembling of better guidance.

I considered adding a few suggestions, but as usual, this is already too long.

----My other blogs on coronavirus (COVID-19)----
"Is Palo Alto prepared for a Coronavirus outbreak?", 2020-01-30.
"Preparing for COVID-19: An epidemic is not a hurricane. Panic buying harmful", 2020-03-03.

----Footnotes----
1. Previous blog on coronavirus:
^Is Palo Alto prepared for a Coronavirus outbreak?^, 2020-01-30.

2. ^8,400 people for coronavirus^ - The Hill, 2020-02-27.
^Governor: Coronavirus changing "by the hour" in California^ - Palo Alto Online, 2020-02-27.

3. Hospitalized patients from Travis:
^Case Of Coronavirus, Possible Second Case Under Quarantine In Napa^ - KPIX, CBS SF Bay Area, 2020-02-18.

4. ^Diagnosis Of Coronavirus Patient In California Was Delayed For Days^ - NPR, 2020-02-27.

5. ^Coronavirus Update: Diamond Princess Passengers Leave Ship As Expert Slams Quarantine^ - Goats and Soda : NPR, 2020-02-19.

6. Departments of State and HHS overrule CDC:
^Trump's fury over Covid-19 patient repatriation may be justified^ -- Quartz, 2020-02-23.
Note: this article needed better proofreading.

7. Irresponsible behavior with Iran's leadership:
^VIDEO - Iran Govt Officials Infected & S Korea Coronavirus Head Leaps Off Bridge^ (14:40) - NeoUnrealist, 2020-02-25.
This YouTuber has been providing good coverage of COVID-19.

8. Mobile incinerators:
^China deploys 40 incinerators to Wuhan amid fears of coronavirus death toll "cover up"^ - Daily Star.

9. Crematorium operator report:
^@14:36^ in ^Coronavirus Outbreak in China 10 Times Bigger Than Reported?^ (40:17), Zooming In with Simone Gao, 2020-02-14.
Warning: This video is age-restricted because it includes segments of people suspected of being infected being dragged away, of bodies (in body-bags) being picked up and transported, and of the detention/isolation facilities.
Note: This YouTube channel has other interesting coverage from China on COVID-19. It is part of ^New Tang Dynasty Television^and has some relationship with ^The Epoch Times^, with both being founded by Falun Gong movement which has been suppressed/persecuted by the Chinese Communist Party.

10. ^Novel coronavirus test for Miami man leads to $3,275 bill^ - Miami Herald.

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An ^abbreviated index by topic and chronologically^ is available.

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