That is the optimistic takeaway.
The pessimistic takeaway is that even the hardest hit areas are nowhere near herd immunity levels and that we are either going to be isolating until a vaccine is created or we can expect to see a lot more death once nonessential people are forced back to work.
It depends on how long the immunity lasts. If it's permanent, this is indeed great. If it lasts only a few months, this 21% won't make any difference for another wave of infections this fall.
It's likely enough, but we don't gain long term immunity to every virus that we successfully clear.
https://en.wikipedia.org/wiki/Memory_T_cell
You are conflating active circulating antibodies with the memory T cells. Which is literally what my entire comment was about.
Not only does evidence seem to point against that, but when you do the math on mortality due to suicide and overdose it’s not clear that containment would even save more lives in the long run.
Here’s how you can tell people’s philosophical positions: if they talk about fear of a “second wave” they are Containers, since that implies the initial “wave” will not infect the majority; ie the virus is successfully contained (EDIT: See https://news.ycombinator.com/item?id=22961927 for the caveat here).
Ironically, leaders like Fauci are verbally saying that containment is not the strategy, yet every word that he says and the IMHE model everyone is relying on are all the result of a Containment ideology.
The alternative is what I would call Pareto mitigation. The vulnerable portion of the population self isolates, while the rest of us are _allowed_ to resume working and living more or less normally (still no large gatherings presumably).
I'd like to take this moment to put out a brief PSA that the serological data coming out, while not 100% reliable, is all telling more or less the same story. Let's look at these IFRs (the second link is CFRs but for Italian healthcare workers who presumably are all getting tested so I'm treating it as a de-facto IFR):
https://old.reddit.com/r/COVID19/comments/g4tqvk/dutch_antib...
https://old.reddit.com/r/COVID19/comments/g6nmtf/update_on_i...
(I'm linking to the reddit comments instead of the actual study because they're really nice tables and the links are still there for anyone who wants to double check)
As others have said, for those around age 45 or less, Covid is equally or less dangerous than Influenza. And particular for those under 30 the flu is an order of magnitude more deadly at least.
In the general population overall, Covid is undeniably more deadly than the flu, but only about 3-5x (and I think 3x personally right now).
Recall that the flu is characterized by deaths in the very young and very old, while being less harmful to those "in between", purportedly due to the "cytokine storm" which is a scorched earth reaction of the immune system. Covid is very different, it is extraordinarily deadly to the very old, extraordinarily non-deadly to the very young, and about the same as the flu to those in between.
A disease with such a "spiky" (highly variable) mortality rate based on your risk factors is precisely the kind of disease that is most effectively treated with risk-informed self quarantine rather than a national lockdown.
Unemployment is correlated with a 2-3x higher chance of suicide, of which perhaps half can be explained away by mental health confounds [1]. There's unique factors in play here - rampant social isolation and widespead fearmongering, propagated even by health experts and "trusted" news sources at times - that lead me to believe that the spike in suicide and overdoses will actually be much higher than predicted by just unemployment alone.
We're currently at 50,000 suicides per year in the US as a base rate, it is not unimaginable that we would see at least 50,000 _extra_ suicide deaths attributable to a mixture of lockdown and the general socioemotional environment.
--
I haven't even gotten to the philosophical battle of "freedom versus security". I am, ideologically, someone who drank the koolaid and really believes in freedom and civil liberties over "security" (which I view as illusory anyway), but _even just viewed through the lens of reducing mortality_, the evidence is stacking up that lockdown is going to do more harm than good.
Is the evidence fully settled? Of course not. But it's shocking to me how many people seem to be operating off of the projected CFR's we had in early February, shouting from the rooftops about "1 in 20" people dying (random recent case in point: https://news.ycombinator.com/reply?id=22952764&goto=threads%...). I don't know whether it's just that a large swath of the population already had clinical anxiety which is further magnified by social isolation and social media and news headlines, or whether something else is at play, but I'm very concerned about the state of discourse in the United States right now, and more broadly, the entire world. In fact, ironically I feel a bit luckier to be in the US than some of these other countries because in the US _every_ issue is partisan, which while entirely irrational means that roughly half the country will be in favor of ending the lockdown at any given time (the position I am advocating for, within reason, insofar as hospitals are not overwhelmed), as opposed to other places where you can get given a $1600 ticket for driving a car by yourself, based off of a superstition that _being outside_ causes Covid as opposed to exposure to infected respiratory droplets...
--
EDIT: Lastly I should mention that in a perfect world we could have voluntary variolation; I would love to be able to expose myself to a controlled dose of SARS-CoV-2 and self isolate for several weeks to ensure that I can never pass on Covid to someone else. Unfortunately that would be very hard to make a reality due to the political environment, even though I am advocating for it to be totally voluntary. I was heartened to see this recent paper toying with a variant of that approach: https://www.medrxiv.org/content/10.1101/2020.04.12.20062687v... (I don't agree with an "Immunity Card" for ideological reasons but I'm glad we have a paper attempting to model it out which does show benefit of voluntary self exposure)
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1732539/pdf/v05...
> Here’s how you can tell people’s philosophical positions: if they talk about fear of a “second wave” they are Containers, since that implies the initial “wave” will not infect the majority; ie the virus is successfully contained.
Here in the SF Bay Area we pretty effectively blunted the first wave with public health controls, which meant health care was not stressed much. Despite the Stanford serosurvey saying that we have 3% with a history of infection, the real number is probably more like 1%. Daily case counts are decreasing, so the initial "wave' did not infect the majority.
It's not enough to decrease Rt noticeably at all. We need to figure out how to loosen up controls in a way that provides economic benefits, keeps a nice constantish burn towards herd immunity, but with enough safety margin to prevent catastrophe that New York got too close to.
Instead, our public health seems to be further tightening instead of experimenting with small measures to relax the controls. There's a loud contingent advocating what would effectively be permanent controls.
But given the way that California aggressively locked down early into this, I agree that we have been sloping down and thus there is guaranteed to be subsequent waves.
Basically, the waves are real but are arbitrary and are caused by our own misguided interventions.
> We need to figure out how to loosen up controls in a way that provides economic benefits, keeps a nice constantish burn towards herd immunity, but with enough safety margin to prevent catastrophe that New York got too close to.
100% agreed. Now the argument I do somewhat agree with is that it's very hard to get that balance right when dealing with exponential transmission. Which is why on balance I'm leaning much more towards "we'll cross that bridge when we get there" (because the alternative is that we have to stay permanently locked down).
Also the portion of the population I am advocating should be allowed to return to work is precisely the portion of the population that produces very low hospitalization rates.
I strongly believe that anyone who has been reading CNN the last few weeks would be _shocked_ to learn that we get 1 hospitalization for every 500 20-29 year olds infected (and again, these numbers are not fully settled but they're at least in the right order of magnitude IMO)
> There's a loud contingent advocating what would effectively be permanent controls.
Yup, this is what has me really scared. The widespread belief being that it is actually plausible to avoid ever getting infected and therefore any infections that follow a softening of lockdown introduce deaths that never would have occurred in the hypothetical alternate universe.
--
So, thanks for raising that point, I fully agree. The TL;DR is that implicit in "we need to watch out for the second wave" is the notion that "we need to fight these waves and halt their spread" which I strongly disagree with.
EDIT: And just to be clear, if we "re-open" we'll still all be wearing masks and keeping arbitrary distance between each other so it's not like we're all running around exchanging bodily fluids willy nilly. But I really do think that the shutdown has been, in some part, effective in curtailing spread, and thus naturally I would expect a higher infection rate following a re-opening.
EDIT 2: Removed the part about the political leanings of those advocating for long-term lockdown because it's going to set off people's defense mechanisms and potentially cause them to draw the wrong impression of what I'm saying
Another data point is the US military. I believe they test much more widely due to their living conditions. So far the cfr is about 0.4%.
We should expect that the proportion of people with Covid should be heavily biased towards the young for that reason, as it is for any disease that does not have a biased transmission.
Most indications I've seen is that the young are not harmed much by covid, but can still get infected just as easily, thus why we see:
"X% of hospitalizations are young people" as opposed to the statement that people actually interpret it as: "X% of young people infected with covid are hospitalized".
Does that make sense?
I don't think anyone enjoys lockdown. At a minimum we need sufficient testing, sufficient ppes, sufficient surge capacity and training for standard supportive care. We are still quite a ways from that. Even if death is unavoidable people deserve to have reasonably good care.
This is broadly in the range implied by a number of measures across the entire population. 20x for randomized population sampling (Iceland), 20-80x from serology studies, etc.
In this analysis, https://www.medrxiv.org/content/10.1101/2020.04.18.20070821v... 35x is actually the exact factor that cases are estimated to be under-reported by in California. :P
> I don't think anyone enjoys lockdown. At a minimum we need sufficient testing, sufficient ppes, sufficient surge capacity and training for standard supportive care.
Here in the SF Bay Area, ICU usage peaked 3 weeks ago, and controls have been tightening. We're well below seasonal norms for ICU usage at this point. Surely the original controls that caused the original trend down in disease would be good enough now, and could even be loosened slightly further to have more parity with other jurisdictions that are successful.
People under 30 are over half the population in San Diego, so you've just said there's 1/10th as many of them in the hospital as we'd expect if the total risk were equal.
The serology data tells us that an even greater portion of cases in the young are missed-- they are probably actually half the number of infections in San Diego, but a much smaller proportion of hospitalized cases.
The current data implies something close to what he said: about a 1 in 500 to 1 in 1000 chance of hospitalization for people under age 35.
The lock down was a choice between what we are going through now and a much worse disaster if the spread continued through a couple more doublings. Of course the extreme stay at home orders should be continued for as short a time as possible, but what we do next also doesn't have to be exactly what we were doing before (and realistically won't be).
My impression at the moment is that containment isn't going to happen, but mostly because people don't want to bother, not because it is the more costly alternative or impractical. Given the lack of appetite to test and isolate, we had better all start doing things like wearing masks.
Note that ~80% of American's favor the stay at home orders right now. It's not a partisan issue, it's an issue where a loud minority is getting some attention from the media.
Can you share the specific numbers you used to reach this conclusions? The reason I ask is because I'm seeing a lot of people in this thread comparing:
1) Overall influenza fatality rates to age stratified Covid fatality rates, and
2) Symptomatic influenza fatality rates to symptomatic + asymptomatic Covid fatality rates.
Both of which are highly flawed comparisons for reasons that should be obvious.
I came across https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-.... It's not clear if it's referring to CFR or IFR but I imagine it must be CFR given how high some of the numbers are (500 deaths per 1000 in some cases).
I agree that finding properly stratified data that is comparing IFR and not just symptomatic CFR is quite tricky.
At a minimum though, if we assume the chart I linked is CFR and compare to the Covid 5-20% CFRs we've seen, we still get that order of magnitude difference for the very, very young. But like I said in my previous comment here, I don't think the statement for all under 30's holds. It'd have to be <18 years old (and to be clear while https://bmcmedicine.biomedcentral.com/track/pdf/10.1186/1741... is helpful, I still haven't proven anything)
I'm waiting for people to do the analysis of mass unemployment from lockdown leading to people losing their healthcare, just in time for the pandemic to widen or return this summer or fall.
You're exactly right to consider all of the externalities of our current approach.
I quit my job Feb 7, before all this unfolded. And COBRA costs me $612.54 per month.
For the same reason I was able to quit my job, I will be totally fine. I have over 5 years of living expenses in liquid assets, so I will be fine.
But for someone who was living paycheck to paycheck and lost their job because it's not the type of job that can work from home, how the hell could they possible afford healthcare?
Along those lines, I do really think that part of the reason so many people don't see the harm in locking down for the next several months is because, like me, they work in the tech industry and really have not been affected by this as far as employment goes.
I generally have to spend more time prefacing the ideas with "I'm not a trump supporter and I think covid is real and I think it's more deadly than the flu and..." than talking about the actual ideas themselves. Especially on Reddit...
I also think that given we know about the level of competence of our government, it will be very difficult for "real" safety nets to be put into place. That's not even getting to the partisan divide inherent to our system.
So in my eyes, we had one big problem, covid, and turned it into two big problems, covid and an economy in ruin. And these two problems affect a greater set of individuals than either one alone. Since a huge number of deaths from Covid are those who weren't working because they're 70+.
Lastly, one of the most "famous" social safety nets in America is social security, which is a farce that is known to redistribute money from the poor to the rich. (It is an eternal frustration of mine that the Left in America is so heavily in favor of social security despite it being flawed from its inception) [1]
[1] See Milton Friedman's excellent take https://www.youtube.com/watch?v=rCdgv7n9xCY
We're currently at 50K deaths in the US, largely in a four week period. I think it's safe to say that the shutdown has cut the death rate in half, if not more. If 100K people die in 4 weeks in the US, the people will shut the economy down whether the government initiates it or not.
Either way we're screwed. And I think your data is far off in terms of IFR and CFR. Imagine the IFR being a magnitude higher for COVID versus influenza. I personally think this is a safe guess based on what we've seen in a wide variety of environments, complicated by different testing methodologies etc etc. So we'll use 1% for the IFR.
Now current thought is the R0 is between 2 and 5. Hopefully closer to 2 since R0 dramatically affects the percentage of infections required to reach herd immunity. But to be simple, we'll assume we need 50% to reach herd immunity. So we'll use 164M as the number of Americans needing to be infected before we can "return to normal."
With 164M cases, and an IFR of 1%, 1.6M Americans will die. An additional 9% will need hospitalization, but survive. That's 14.8M.
Say we're off by a lot and "it's just a flu" with an IFR of 0.1%. You'll have 164K fatalities, and we'll still have the 14.8m hospitalizations. Say the hospitalization rate is off by a magnitude, it's still 1.48M.
There's no way our country can operate "normally" with these types of numbers.
Also if we are going to use government incompetency as an argument here. I would throw it right back at you and say I have little faith in the government implementing a reopening plan that doesn't either kill people or damage the economy long term.
Lastly it is a false dichotomy to present a choice between protecting people from COVID-19 or protecting the economy. If we refuse to do the latter, we are going to ruin the economy anyway. Hundreds of thousands of people dying would certainly put a damper on demand. And while there are certainly people protesting about reopening sooner, I don't think think movie theaters would be selling out if they opened tomorrow.
I don't see how you get close to 3X more deadly than the flu. If 14% of New York state residents have been infected, 20M population, 15000 deaths + another 3000 that are infected now and will die (this disease takes a long time to kill people) you get an IFR of 0.64. If the IFR for flu is 0.05, that makes covid 12X more deadly than the flu.
Lots of people reporting an IFR of 0.5 based on the NY serological data; that is "right censoring" the deaths. It's got to be a bit higher than that. Either way you have covid with 10X the infection fatality rate of the flu. If worst flu years have IFR of 0.1 then covid is still 5X worse than the worse flu seasons. And as contagious as the worst flu seasons too.
So twice as contagious as the flu, 10X deadly. Much more likely to put you in the hospital, and thus overwhelm the hospital system, causing many ancillary deaths. This NYTimes article sums it up: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doc...
At the peak in NY, hospitals stopped seeing heart attacks and strokes, because those people were too afraid to go to the hospital. Many of those people died at home, as supported by the overall death rates in NY.
The narrative put out there by those that look at the recent serology results and say "this proves that this disease was really just a bad flu all along; we can reopen the economy without fear" is just not supported by the data. An IFR of 0.64 and hospitalization rate of double that, like 1.2%, for a disease this contagious, shuts down the economy until we get a vaccine or effective treatment or a Korea-like testing/tracing regime in place.
And one more thing: the Great Depression was great for public health. https://www.pnas.org/content/106/41/17290
Yes suicides go up. But this is more than compensated for by other benefits. Overall, people may well be much healthier in a depressed economy. We will certainly see a decline in car accidents.
The third option is, when you take into account that it's approximately as bad as the flu for folks under 40, we let out the young and keep the older folks and the vulnerable inside. This will boost our progress towards herd immunity without materially increasing the death counts.
The fact is, the number of deaths is too high in NYC to be able to cherry-pick your way to an argument that supports your view. Either R0 is really high, and we need to shutdown to prevent it from infecting the entire population in a very short time span, or the IFR is way higher than the flu and we need to shutdown to prevent it from killing a lot of people.
The only sane way to open things back up at this point is to implement widespread testing and contract tracing.
No. If you miss a constant percentage of cases, you get the same shape of exponential curve.
That is, a virus with an R0 of 2 and 1 case doubling to 2 and 2 cases doubling to 4.... looks the same when you miss 99% of infections and see 1 of 100 infections doubling to 2 of 200 doubling to 4 of 400.
This fallacy has been common in the response to this data, but it makes no sense. Large numbers of missed cases shift the curve forward and backward in time, and don't change the shape of it.
All of the current findings are still consistent with R0 in the range of 2.0 to 2.5.
We are talking about 1 serological study at a single point in time. We have no idea what percentage of cases we were missing before or after that point.
The only way that missing cases affects estimates of R0 from time series is if we're missing a much bigger proportion of cases now than we were in the past. All the evidence I've seen leans the other way-- more testing, better testing, more cases diagnosed by "presumed" criteria.
So, it actually implies the opposite of what you're saying, and argues for lower R0.
Considering we have been under lockdown for over a month (which greatly impacts effective transmission), and considering our estimates of latency hasn't changed dramatically, I think my above assumption is fair.
I don't necessarily believe the Santa Clara County study, but there are plenty of other alternatives, including a pretty likely one: gross undercounting at the start of the epidemic and/or earlier cryptic spread in communities. This is something that SCC public health officials / Dr. Sara Cody has stated in recent days is her belief-- I am not sure I agree.
At this point we're accumulating a lot of evidence IFR is 0.3-0.5%.
Search for "Table 1: Estimated influenza disease burden, by age group — United States, 2018-2019 influenza season"
As I've said elsewhere, Influenza is defined by being deadly to the very young and very old, and so-so to those in the middle. Meaning that healthy young people do regularly die of the flu (it's still rare in absolute numbers, but it happens WAY more than covid).
Unfortunately, and I know people read this stuff and their quack heuristics start firing, the reason people are so afraid about Covid's impact on young people is because the mainstream media has intentionally promulgated a narrative that "young people are at risk too" because they fear that otherwise young people wouldn't submit to glorified house arrest for months straight.
Yes, young people get _infected_ by sars-cov-2, but they do not develop deadly cases of covid in any appreciable numbers. You really should be worrying far more about the flu as it pertains to a college-aged demographic.
EDIT: I do need to find some sources for you though. I saw some NY data broken down by comorbidites but am having trouble finding it.
They've reported that because young people who very likely won't die from COVID-19 (they may still need to be put on oxygen and may have lifelong effects from it, but they likely won't die) can still spread it to those that will. Further, they'll put more strain on the health system, and the ability to care for COVID-19 patients is a big determinant in the fatality rate. Everyone needs to stay practice social distancing and shelter, because everyone can carry and spread.
> Everyone needs to stay practice social distancing and shelter, because everyone can carry and spread.
Sweden has demonstrated at national scale that's not the case. [2,3]
The reality is about 60% of us are going to get it one way or the other, so let's control which 60%, and in what order, and on what timeline before everyone stops listening and just walks out.
[1] https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e3.htm
[2] https://www.bloomberg.com/news/articles/2020-04-19/sweden-sa...
[3] https://theconversation.com/coronavirus-are-we-underestimati...
https://www.washingtonpost.com/opinions/2020/04/09/my-near-d...
Or I don't know, Google ventilator effects. Lung scarring. Young people get this, and it hurts them, maybe forever. It's not common, but it's absolutely not never, and you can still spread the virus if you're asymptomatic. Seems like people should try and avoid getting it!
> Sweden has demonstrated at national scale that's not the case.
Sweden is so unlike the US in so many ways, this is a worthless anecdote. Imagine the differences in demographics, density, culture, literally everything.
> The reality is about 60% of us are going to get it one way or the other, so let's control which 60%, and in what order, and on what timeline before everyone stops listening and just walks out.
It's by no means certain 60% of us will get it. Especially if we do what we should do and build a competent testing and tracing system. The attitude that this is inevitable is lazy and puts thousands of lives in jeopardy.
But you can't let up at any point, because it'll still be endemic and ready to explode up to that herd immunity threshold.
I prefer approaches that get us to that 60% in an orderly fashion-- staying short of healthcare overload, and preventing as much infection in the vulnerable as possible.
Since Feb 1, 204 people from 15-34 have been confirmed to have died from COVID-19 in the US. 162 people from age 15-34 have been confirmed to have died from influenza in the same period.
I don't think you'll find either statistic broken down by comorbidities.
There is data on comorbities with the flu from prior years. This article says half of deaths had no preexisting medical conditions.
https://pediatrics.aappublications.org/content/141/4/e201729...
And the deaths among healthy young people from both kinds of viruses is commonly blamed on the cytokine storm:
Note that a few of the deaths are -both- COVID-19 and influenza.
The statement you differed with is "The third option is, when you take into account that it's approximately as bad as the flu for folks under 40," You're ignoring data in order to make a wishy-washy statement that it must be much worse for people under 40 based on anecdotes you hear.
I don't agree flu infections were higher for those 2 months, either. Distancing has been spectacularly effective against influenza, since it has a lower Rt in the absence of controls. Under 1% of influenza surveillance tests are positive right now, which is a level usually only seen in the middle of summer.
Our best guess for overall infection fatality rate is about 0.3%, double or 3x influenza (because of the very high death rate in the elderly), but COVID-19 deaths overall have been 4x influenza in that time period, indicating that COVID-19 prevalence is higher.
(We do already know it's -way less dangerous- for people under age 18).
I also agree that COVID-19 does appear to be way less dangerous for the under 18 group. However practically none of the under 18 group is able to isolate themselves away from the 18 and over group so there is no real societal benefit to this distinction.
I think we have enough data to exclude more than 2x. The range of potential danger has influenza's risk right in the middle of it.
> I also agree that COVID-19 does appear to be way less dangerous for the under 18 group. However practically none of the under 18 group is able to isolate themselves away from the 18 and over group so there is no real societal benefit to this distinction.
There's a huge societal benefit to this distinction, because if children are at relatively low risk, and also do not seem to be index cases very often for how COVID-19 is spread to households, schools can reopen. This is different from most diseases, where schools are often a key mechanism of disease spread. e.g. see https://www.medrxiv.org/content/10.1101/2020.03.26.20044826v...
Indeed, influenza has been greatly impacted by distancing. The surveillance numbers for influenza are lower than you'll ever see for this time of year.
I can't exclude it's twice as bad as the flu (or half as bad). But even those broadly agree with the poster's statement.
I’m on mobile right now so won’t be able to look up the influenza numbers, but perhaps you could find some quality data on influenza mortality in those without comorbidities?