Coronavirus: 'Baffling' observations from the front line | Hacker News Reader

Coronavirus: 'Baffling' observations from the front line

bbc.co.uk

234 pointssjcsjc165 comments

The pathology of COVID-19 is really interesting. As the article describes, the viral pneumonia is well-described, but there are a lot of knock-on effects from infection of epithelial cells. Namely, virus binding to ACE2 receptors causes oxidative stress which can give rise to disease and cardiovascular events. MedCram did a really great video talking through some papers on this subject. [1]

If you want to learn more, also check out This Week in Virology, a podcast that has been covering COVID-19 in great detail the last few months. It features a panel of virologists and other folks in the scientific field (immunologists, etc) plus a doctor reporting about the situation at a clinical level.

[1]: https://youtu.be/Aj2vB_VITXQ

Oxidative stress, why? I’m really confused at why we don’t think of the mechanics of this disease in terms of the cell and tissue types that express ACE2 receptors. ACE and ACE2 receptors regulate fluid pressure. ACE increases pressure by constricting tissue and ACE2 decreases pressure by dilating tissue.

ACE2 receptors are found in the lungs, blood vessels, heart, kidneys, and gastrointestinal system. This makes sense and matches the pathogenesis of SARS-CoV. SARS-CoV-2 also infects the epithelial cells of the upper respiratory tract, like the cold-like HCoV-NL63.

All the symptoms seem to match the spread of the virus to new tissue types. The timing matches too, with each new tissue type having an independent incubation period. Am I missing something? Children only seem to be susceptible to gastrointestinal infection which looks like Kawasaki’s disease when it spreads to adjoining blood vessels.

Thats a lot of disputin' for not having clicked the attached explanation links.

> MedCram did a really great video

I also recommend the followup videos that continue looking into the theory he discussed in episode 63 (your [1]). In particular, episode 69's discussion[2] of glutathione in existing research related to oxidative stress is very interesting. Comparisons are made to acetaminophen (tylenol) toxicity. A very plausible hypothesis is presented that high dose NAC (N-Acetylcysteine) might be a treatment for (some of) COVID-19's worst effects.

NAC is obviously interesting as an antioxidant, but MedCram found a few papers that suggest it might also be important as a way to break the disulfide bonds cross-lining von Willebrand factor that seems to be causing a strokes and other thrombosis-related problems in the worst COVID-19 patients.

Obviously this is all very speculative an turning these hypothesis into something practically useful will require a lot of work. However, as someone with multiple of the serious risk factors[3] for COVID-19, the last few months has mostly been hoping I can avoid dying from the virus before a vaccine is available. The ACE2/glutathione/NAC hypothesis is the first time 3rd option - an effective treatment - has seemed... plausible.

[2] https://www.youtube.com/watch?v=Dr_6w-WPr0w

[3] diabetes, heart failure and cardiomyopathy from too many years of high-BP and bad sleep apnea (AHI=148)

His videos seem informative but I worry that he has sort of a bias for supplementation and holistic medicine. His videos lately seem to purport that this virus can be handled by mostly OTC supplements.

> that this virus can be handled by mostly OTC supplements

This is simply not true. Most of his recent[1] videos have discussed his hypothesis about how the virus may be causing oxidative stress when it abuses the ACE2 receptor, and how this might explain why some people are asymptomatic and others people need ventilators or die. Most people can handle the dramatic increase in reactive oxides, while those of us with diabetes/etc may have already spent some of the protective capacity and may not the necessary "defense in depth".

This is speculation about the mechanism causing the damage; the closest I've heard in those videos to anything related to how the virus "can be handled" is some high-level speculation that can basically be summarized as "if the problem is oxidative stress, maybe we should investigate trying to mitigate the damage with antioxidants?" That would probably be in addition to existing treatments, not some kind of "holistic medicine" nonsense that thinks you can replace the usual treatments with vitamins.

[1] I'm assuming you're referring to the "Coronavirus Pandemic Update" videos on the channel since the [1] link above (update 63).

These articles can certainly be scary. It might be good to keep the risks in mind too.

“for people 49 and under, the agency [CDC] estimated that 0.05% of symptomatic people will die.”

https://www.cnn.com/2020/05/22/health/cdc-coronavirus-estima...

That would be comforting if the outcomes were limited to 'death' or 'full recovery'!

Do you have a source on the amount of other outcomes for the 0-49 group?

I haven’t come across that data. I’d be curious.

ARDS is limited at this point almost exclusively to those over 75 with critical cases who happen to recover.

source?

I have not seen those numbers but regardless, ARDS is not the only morbidity we need to worry about.

What if, of the 10% of hospitalized cases, half of those patients permanently lose a noticeable portion of their lung function? Not supplemental oxygen dependent but can’t walk as far or exercise the same way they could before. That’s a major life change for a huge number of people, when you extrapolate it out to the entire world.

The threat of minor but permanent disability should not be ignored, especially in those who spent weeks on a vent.

That's what still has me worried about this virus. What percent of people under 49 survive, but don't fully recover?

When this disease started I thought I'd rather just get it and get it over with, but now I'd rather avoid taking a risk I don't have to.

From what I got, lung damage was actually caused by unnecessary ventilators. We now know that the vast majority of people are out of oxygen because of their blood and not lungs.

This is an extremely mild disease, I would assume that in a few months we'll know enough to make it a minor inconvenience for most people (more than it already is, since most people don't even experience symptoms today).

What long-term damage you know of (not saying there isn't, just curious)?

Prolonged ventilation is damaging to the lungs. But ventilation is not given lightly - usually it is for an acute deterioration and is life saving (ie without it, patient would have died in that instance).

Interestingly in COVID it appears that positioning and CPAP/BIPAP can be more effective that venting in edge cases. This is a very new phenomenon in medicine, and we probably over vented in the early course of the pandemic. We were acting in what we knew of other severe respiratory diseases, and the case data from COVID hadn’t had enough time to present best treatment modalities.

However, to suggest that the lungs are not being absolutely ravaged by the virus infecting, replicating and rupturing lung cells is ludicrous

> However, to suggest that the lungs are not being absolutely ravaged by the virus infecting, replicating and rupturing lung cells is ludicrous

I was talking about permanent damage. I actually read my comment again, and that isn't really clear.

Doctors in Italy are saying that ventilators were thought to be useful because people complained that they couldn't breath, but now they're saying that it's not the lungs that aren't working, but it's oxygen that is not carried out in the blood, and that ventilators can actually cause permanent damage in many cases.

I'm not a doctor, so I just base everything on what the (supposed?) experts are saying. As far as I know they might very well say that on TV because there aren't enough ventilators, no idea.

One of the reasons we worked out we could get people through without ventilators was because we ran out of ventilators. And people with COVid are being vented for 2 weeks plus. A normal time (and a time that would minimise Kung damage from a vent) would be several days.

But if someone has saturation’s in the shithouse, they’re going to die. Lack of oxygen (Hypoxia) in the blood is many many fold more common than severe thrombosis or whatever else was suggested; and the answer is right there - if the oxygen isn’t getting to the blood it’s because the lungs are shot. If we have enough gear, we put someone in ECMO to solve the gas exchange problem.

Lung damage severe enough to do this is caused by the effects of the disease, not the ventilator

I see. I guess it was just one theory.

What you're saying makes sense, thanks for explaining.

When did we run out of ventilators?

As far as I know nowhere ever ran out of ventilators, not even in Lombardy. But I sure saw that claim made a lot of times back when people thought that would happen. Spent a lot of time pointing out the authorities were denying it'd happened too. I concluded it's very easy for people to mix up "we think this is about to happen" with "this has happened".

Lombardy was utilising operating theatres and had ICUs and trauma bays full (70-80% is full because you have lost lost of your surge capacity), using the vents in all these areas. There was a shift to NIV because once you have no vents you let people die

80% isn't full. 80% is 80% full and is about normal for an ICU. The whole point of having some headroom is you can lose it without being full!

What % of people are asymptomatic?

The jury is still out AFAIK

Varies, but in well studied outbreaks seems to end up around 5-10% more or less. Early on it seemed like the rate was higher but turns out that was presymptomatic.

Is this for the current coronavirus outbreak or historical? If current, can you share a few links to those. Honest question.

Honestly, just go rummage through the links in r/covid19 on reddit. Skip the comments altogether since the audience there is becoming mostly optimists. Skip r/coronavirus for the opposite reason, all the doomers congregate there. But at least in r/covid19 the moderators are very aggressive in preventing posts that are not some kind of plausible scientific source. It's useful to see the latest studies as they come out, without any editorializing. But you do need to read them critically, since most have not yet been peer reviewed.

You can also learn a lot from the occasional scientific commenters, they are quick to explain why a serosurvey showing 5% prevalence using a test with 98% specificity means the published results aren't worth much.

> for people 49 and under

It’s always easy to downplay the risks if you start excluding the most vulnerable.

vice versa, it is just as easy to exaggerate the risks if you report and extrapolate from the subset of the worst cases,

There is definitely a large number of people who haven't died, but have recovered extremely slowly; a friend of a friend was hospitalised for over 30 days.

I have no idea how well this can be captured by the statistics.

Why do those numbers seem off.

To get those stats you have to include even uneffect children getting it. A disproportionate about of 20 year olds are infected. If you are in you 30s/40s you are still in danger.

In the well tested korean population the fatality rate for 40–49 was 0.2%, 0.16% for 30s https://en.m.wikipedia.org/wiki/COVID-19_pandemic_in_South_K...

The Korean number is the CFR (known deaths divided by known cases). The CDC number is the symptomatic IFR (all deaths divided by all symptomatic infected). These can't be directly compared--Korea has done a good job tracing and testing, but they're not claiming to be catching every case. In the other direction, Korea's number also includes asymptomatic cases while the CDC's doesn't.

Korea's average CFR over all population is ~2x even the high estimates of IFR from serology in high-incidence regions (New York, Lombardy) or universal PCR testing of isolated populations (Diamond Princess). It would make sense that their underascertainment would be yet higher for younger people, if they experience lighter symptoms and are thus less likely to seek medical care.

The entire article talks about plenty of other risks than death. To try to pretend like death is the only risk is frankly stupid and harmful. Getting any of the conditions this article talks about would have life-changing repercussions and lead to a horrible and possibly much shorter life. So if you want to talk about the risks, the talk about the risks. Don't pick one single risk, ignore all the others, and pretend like you're not doing yourself and others a huge disservice. "Risks" is a plural word, after all.

Doctors often want to keep pneumonia patients "dry", that is, somewhat dehydrated. (That's maybe contributing to the kidney failure.) To what extent could this also be resulting in increased clotting?

When we keep patients ‘dry’ in ICU we aim to keep their urine output at a level that indicates safe glomerular filtration rates.

ACE2 is expressed extensively in renal tissue, so the virus is transported there in the blood, infects cells, hijacks the cellular apparatus to replicate, and then explodes to cell to continue its march of death. So I think your speculation is a bit misplaced

Ah, thanks!

As someone who has been treating COVID patients since early April, my working theory has been that many if not most of the secondary disease processes (non-respiratory effects of the virus), and even to some extent the worsening of respiratory function, have been largely driven by micro-thrombotic disease. Delicate capillary beds, like the ones seen in the lungs and kidneys, are highly susceptible to becoming blocked in this sort of setting. When these small vessels get plugged up, end-organ dysfunction necessarily follows. The kidney won't work properly if the blood needing filtration can't reach the nephron (functional unit of the kidney).

I'm in large part guessing here based on clinical observation, but my feeling is that you can extend this logic to other syndromes that accompany COVID-19. For example, we often see worsening liver function in the setting of this illness (albeit delayed by a few days). This could be explained in a number of ways, one of which is by impaired perfusion within capillary beds in the liver. Further, there is a myocarditis-like picture we sometimes see as well that could be explained by direct viral infection or again by impaired perfusion of the cardiac muscle by small vessel clotting.

When the thrombotic disease progresses, you start to see a more macro version: think strokes and pulmonary emboli in patients who are otherwise low risk at baseline. Thus, there's some interpolation going on here.

Hope that makes some sense.

Hey, it's great to see something from a professional !!!

A dear friend is dying of pancreatic cancer. And one of the key reasons that she's still alive was getting thrombosis under control. Initially with IV heparin, and now with Lovenox.

Are those commonly used for COVID patients? Or do they use oral anticoagulants?

I'm sorry to hear about your friend. Unfortunately, cancer is one of the big predisposing factors for thromboembolic disease, so I'm glad to hear that controlling this issue has helped her along.

Based on our institutional protocol, hospitalized COVID-19 patients receive therapeutic dose Lovenox, Eliquis, or IV heparin.[1] Lovenox is the first line treatment, but is contraindicated in patients with, among others things, severely impaired renal function. If these patients are able to tolerate oral medications, they can be given Eliquis. If not, they’re typically put on IV heparin drips (and are subject to the uncomfortable and burdensome blood draws that come with them).

Typically, all of these patients are discharged on two weeks of Eliquis if there are no major contraindications. The thinking is that the risk of damage to the body by microthrombi doesn’t necessarily end just because the patient is stable enough to go home.

Of course, with all of these medications, preventing clotting has to be balanced with preventing bleeding. We’ve had to stay vigilant for things like GI bleeds and hemorrhagic strokes, as these things become more common when everyone in the hospital is being heavily anticoagulated.

[1] Therapeutic dosing in this case is higher than typical prophylactic dosing. In the case of Lovenox, it would be something like 40 mg twice a day for the therapeutic dose versus 40 mg once a day for the prophylactic dose, which is what would be used in non-COVID-19 patients to prevent thromboembolism.

Thank you, very helpful!

It's wild to see how much the thinking has changed on how this disease works.

Naïvely I would think factor v Leiden defect (prone to clotting, DVTs) would be a risk factor, but I understand it's most prevalent in white Europeans and Americans, which is somewhat the opposite of covid's (suspected vitamin D related) bias.

Has anyone seen any studies mention it, or otherwise know that it's a silly suggestion that wouldn't be worth studying?

On second thoughts I think it raises the clotting risk particularly in the event of severe blood loss, so maybe that's it. Covid patients are clotting but for unrelated reasons?

You’re choosing a narrow band of the population. Undoubtedly there are thousands of groups out there who, by way of genotype, phenotype or lifestyle, are at higher risk.

Teasing these all out is going to be the work of the next decade. It’s all in the last paragraph - (to paraphrase) ‘we’re having to learn in months what we’ve had hundreds of years to learn about other diseases’

When I was at Med school I naively thought ‘there will be no new pathophysiology’ - we knew all the continents and had mapped most of the interiors, in varying levels of detail. This is an entirely new continent. (So was vaping associated lung injury actually)

It’s fascinating

It's not that narrow among aforementioned populations though - 15% iirc.

Enough that (again, as a naïve layman) I'd have thought it would be noticed or considered when discussing clotting and DVT/PEs? And enough to have an counteracting impact on the opposite African/Caucasian divide that's actually being seen - not to say that they couldn't coexist, but that if so it'd make the latter even more dramatic.

From UpToDate:

In the general population without a personal history of VTE, a study involving 1690 unrelated individuals from Europe found a prevalence of FVL of approximately 4 percent, and a study involving 356 individuals from Canada found an incidence of approximately 5 percent [47,48]. In a series of 4047 men and women participating in the Physicians' Health Study and the Women's Health Study (both in the United States), the following frequencies for FVL heterozygosity were found [49]:

●Caucasians – 5.3 percent ●Hispanic Americans – 2.2 percent ●Native Americans – 1.2 percent ●African Americans – 1.2 percent ●Asian Americans – 0.45 percent

A higher prevalence of FVL (12 to 14 percent) has been reported in populations in parts of Greece, Sweden, and Lebanon

Compared to a more likely cause for thrombophilia in the patient population, ie inflammatory response, endothelial damage, up regulation of clotting factors; I think focusing on factor V Leiden (and I’m speaking just as a clinician, not as someone who has had to work with covid patients, we’ve had relatively SFA here in Australia thankfully) is a footnote. And any patient who is admitted is going to be on anticoagulants anyway, nullifying most of any procoagulant effect of FVL in hospitalised patients.

It might show up in the data, it might be a footnote, but treatment would be covered under normal VTE prophylaxis (and seems like many protocols are now stepping up fairly significantly the prophylaxis regime)

"This is an entirely new continent. (So was vaping associated lung injury actually)"

I haven't read anything about this yet. Link?

https://en.wikipedia.org/wiki/Vaping-associated_pulmonary_in...

Probably not inherent to vaping, but a nasty additive in some of the fluid.

It was from using vit-e oil as the base liquid, found exclusively in one individuals homemade THC carts (although others are suspected as having the same mistake). The media really dropped the ball on tht one.

You also kind of dropped the ball on providing a source.

Find it yourself, a single Google search will find that he's correct about the vitamin E

A deeper dive will find that it’s not conclusively proven yet, and I can’t find much evidence for the “one guy’s fuckup” assertion.

Anyone know the SNPs for ACE2 expression? Curious which variant I have...

More complex than having "more" or "less" because while the presence of certain SNPs would mean more expression by default, the presence of the virus downregulates them, which means you could tolerate "more" virus.

SNPs: rs4646127, rs1996225, rs2158082, rs4830974.

Source: https://selfdecode.com/blog/article/ACE2-coronavirus-128

When your per-capita covid19 mortality rates are almost 200% of the US and almost 600% of Germany you need all the bafflement your citizens can buy.

Personalized medicine has been a big deal lately, which makes me wonder if perhaps the "weirdness" of COVID-19 is only due to the fact that this disease is being studied at large scale, across the country and the world. It's already known that not everyone reacts to drugs the same way, why would we expect everyone to react to a disease the same way? Western medicine focused on it's successes with a one disease, one drug model, but just like it's obvious one drug doesn't always work for everyone, one disease could affect different people in different ways and could in fact manifest as several different diseases. Possibly if we had studied flu and colds at scale in the population we would have found a wide variety of reactions that would also surprise us.

I also wonder why we seem to never have even tried to cure the flu and colds (there seem to be only a few tiny research groups studying either). We thought mapping the genome was impossible till we tried it. The variety of viruses causing flus and colds caused medicine to make the same claim, impossible to solve because it's so complex, but is it really that complex? We have 100 candidates for a vaccine for what is essentially a cold virus after a few months work. What if we'd started working on colds and flu seriously a few decades ago? Cold and flu cost society tens of billions each year, why have we lived with this disease burden for so long? I'm not an expert but the complexity seems less than that of decoding DNA. Is the fact that colds and flu only kill a few tens of thousands of people a year really a good reason not to eradicate them? The cost/benefit ratio here seems skewed because the benefit seems really high and the cost not so high. For one thing, it could have saved us from this, previous, and future pandemics which have enormous costs.

I do not have answers or facts to offer, but I suspect they are similar in nature to those for the question of “why haven’t we solved security critical bugs? Why haven’t we just heavily invested in software verification? Etc.”

Every anti-opinion in the comments was [flagged]. I guess this is done by algorithms. Only the anti-anti-opinion comments survived.

That above is the main issue with this disease.

No, the situation is that everyone is fed up with contrarians and downvotes them on sight. Cautious well evidenced dissent should still get through.

This might be a rant, but it would be awesome if these new findings lead to laws that required doctors to give accurate cause of death for people that also test positive for COVID.

At least in Italy, doctors were pressured to put "COVID" as cause of death of people that were given 10 days to live because of cancer and other diseases, but also tested positive.

Newspapers went as far as saying that a policeman that was shot by a colleague by accident and had been on a coma for 3 months was the country's youngest COVID victim, because allegedly he tested positive (of course, they failed to mention he had been shot and in a coma, other journalists exposed that lie).

From what I read and understood, since in the US hospitals get reimbursed by number of patients doctors came out saying that they were pressured to put "COVID" as cause of death even without testing, just because it was presumed to be COVID because the symptoms matched.

Unfortunately, politicians want power and businesses want to make money—and other people have their own agenda. This pandemic and been spun out of proportion by people that gain from it, at the expense of workers and most importantly small businesses, and at the advantage of China (and perhaps Amazon)—who are the only ones who are actually making money.

I wish the world was less corrupt—or at least people that are given positions of power in good faith.

Citation for the shot police officer's name?

People seem to have chosen bad faith attack media and elected bad faith leaders. That's why the US, UK, and Brazil are doing particularly badly.

> That's why the US, UK, and Brazil are doing particularly badly.

And Russia.

And Italy, Spain, France, Germany, Sweden, Turkey, Iran, etc etc

Does anyone know of any large country that managed to:

- not lockdown

- keep the disease under control

Japan maybe but it's unclear why at this stage.

One important aspect is that in Japan, there were no huge clusters in old folks homes.

There are many others, but this is one of the most important.

Naively, could a factor be that in Japan wearing masks all the time was already normal practice, long before this pandemic?

No, people did not wear masks "all the time" nor did even "most" people wear masks. Go to any image search. Find images before February. (Search Hardly a mask in sight. They are common enough no one finds them strange but they weren't remotely the norm either.

https://www.google.com/search?q=tokyo+crowded+before:2019-12...

https://www.google.com/search?q=tokyo+station+crowded+before...

By "all the time", I mean take any given adult in Tokyo and there's a good chance they have experience wearing a mask for a couple days every year.

In Japan it's not only the immunocompromised or healthcare workers who have ever donned a mask: it's nearly everybody.

You'd be hard-pressed to ride the metro and not see a handful of mask-wearers on any given Tuesday in recent years.

Whereas in countries like the United States you'd rarely see masks outside of a serious medical setting, and you wouldn't be able to buy masks for a dollar at literally every corner shop within 100 meters of your home.

Yeah, your list kind of lacks nuance. Eg compare

    https://covid.observer/de/#daily

    https://covid.observer/gb/#daily

and

    https://covid.observer/de/#per-capita

    https://covid.observer/gb/#per-capita

The German numbers peaked 2020-04-06, the British numbers have yet to peak. The former are at 0.099 fatal cases per 1000 citizen, the latter at 0.54

Looking at cumulative graphs like that is misleading. It's also impossible to conclude anything about peaking in the UK from the total figures, as the baseline for testing has been changing as the number of tests has increased rapidly in the last few weeks. Fortunately there is one dataset that has remained constant throughout. In the government's daily releases https://www.gov.uk/guidance/coronavirus-covid-19-information... there are "pillar 1" statistics. This number is the hospital admissions that test positive, and it's the only data set that has been gathered in a consistent way throughout. The pillar 1 stats peaked at 5903 new cases on April 5th. Yesterdays pillar 1 new cases were 1277, so the UK cases indeed have peaked and have declined significantly since the peak. They're being a bit stubborn at decreasing below 1000 per day though.

Anders Tegnell, some say the head of Swedish plan against COVID was recently on BBC HARDtalk. You can hear his views on the plan they implemented.

Like the British numbers, the Swedish ones have yet to peak, and they are at 0.4/1000 fatalities (ie four times the German numbers I cited in my sibling comment).

If your primary goal was prevention of loss of life, the Swedish approach doesn't look so hot either.

I am struggling to reconcile "the british numbers have yet to peak" with stories like that:

https://news.sky.com/story/coronavirus-disappearing-so-fast-...

As for deaths, they have peaked in early April in England (see first spreadhseet "COVID 19 total announced deaths"):

https://www.england.nhs.uk/statistics/statistical-work-areas...

I provided links plotting daily numbers for various countries in my other comment. Just compare

    https://covid.observer/gb/#daily
    https://covid.observer/se/#daily

to eg

    https://covid.observer/it/#daily
    https://covid.observer/de/#daily

There's also the possibility that numbers will essentially stabilize, eg

    https://covid.observer/fr/#daily
    https://covid.observer/es/#daily

We don't know yet which way the UK will go, as the number of active cases is still growing.

And it doesn't strike you that zero people recovered in the UK based on your chart...?

It's the Johns Hopkins University CSSE dataset, and recovered cases are indeed not properly tracked for some countries. But you can just look at the crude numbers of confirmed cases and fatalities to see that the situation in Germany and the UK follow different dynamics (cf this plot[1] of the new confirmed cases, though the difference is of course in part due to the testing rates),

However, from looking at the daily fatality rates, you're right that the UK might indeed be already past the peak as well.

[1] https://i.imgur.com/6YJ6op8.png

All you are measuring with your chart is the late ramp up in testing in the UK. Deaths is a much more reliable indicator.

From your spreadsheet:

"This file contains information on the deaths of patients who have died in hospitals in England and have tested positive for Covid-19. All deaths were reported during the period specified below and are recorded against the date of death rather than the day the deaths were announced."

It doesn't include people dying in nursing homes. It doesn't include people dying in care homes. It doesn't include people dying in supported or sheltered accommodation. It doesn't include people dying in prisons. It doesn't include people dying in their own homes.

From research we think care home deaths are a significant fraction of the total (between 30% to 50%), although we need more information.

We stopped transferring people from care homes to hospitals. We put them on palliative pathways instead of transferring them to ICUs.

You can’t know whether the lockdown saved lives until after you see whether countries that locked down have another wave of deaths after reopening.

It’s possible that Britain only delayed deaths by a few months, which is why they currently look better than Sweden.

Why do you think Swedish numbers has yet had to peak? As far as I can tell they peaked in first half of April when the infection peaked in Stockholm and since then it has been bad but stable. We might see a smaller peak now in the end of May when it peaks in Gothenburg.

The primary plan was to keep the load on the health care system within capacity. Preventing loss of life due to insufficient availability of health care. Which according to the models looked like the major contributing factor that could be controlled.

The primary plan was to do the absolute only thing available against the virus: social distance. We have no other way to fight it than to starve it out with 14 day quarantines and other social distancing tactics. No other motive is needed when you’ve only got “one bullet in the chamber” that’s the bullet you’re going to fire.

There's another method: masks. Making them mandatory seems likely to have real, significant effects. It seems almost impossible to make them mandatory in western countries without absolutely massive cause, though.

That’s what I thought too but michael osterholm‘s recent comments led me to believe masks are ineffective.

AFAIK Germany has done much better than the other ones on your list.

> And Italy, Spain, France, Germany, Sweden, Turkey, Iran, etc etc

This assertion grossly misrepresents the facts.

Italy and Spain were one of the first countries after China to be massively affected by covid19.

They endured a fast and entirely unexpected rise in infection rates during a period where WHO was still repeating the Chinese regime's claims that covid19 didn't spread among humans.

Still, once they started to track the disease and register hundreds of of deaths in patients infected with the disease, they acted decisively. Not only regarding quarantine and social distancing but also putting up massive field hospitals like Madrid's IFEMA hospital.

Spain and Italy's government did not overreacted or downplayed the threat. The UK, US, Brazil and Russia's government started by either pretending it did not existed, assumed they could ride the wave while doing nothing at all, or that everything would just kill off a bunch of people and vanish without any need to worry. Arguably, the government of Brazil is still in the denial stage.

That approach to an epidemic is world's apart than the approach taken by either Spain or Italy or France or Portugal or Greece or Germany or any other country in the world whose government decided to act responsibly and looking after their citizens best interests.

>They endured a fast and entirely unexpected rise in infection rates during a period where WHO was still repeating the Chinese regime's claims that covid19 didn't spread among humans.

Do you have any evidence from that? China locked down 11 million people in Wuhan on January 23[0] which was a whole week before the first cases showed up in Italy[1].

[0]: https://www.reuters.com/article/us-china-health-who-idUSKBN1...

[1]: https://www.corriere.it/cronache/20_gennaio_30/coronavirus-i...

There is some current US right-wing propaganda that China was lying to (in some versions, paying off or running) the WHO to intentionally spread the virus. It's effective because most people don't know the difference between "no confirmed spread between humans" (which the WHO said early in the pandemic) and "confirmed no spread between humans" (which they did not, but is what the propaganda claims was said).

1. You yourself are muddling facts, and 2. the left wing seems to parrot it as well.

The fact is, there was some some oddness between china and the WHO, be it influence, manipulated data or just the appearance of such, it is still not ignorant for the layperson to be suspicious. The problem lies where suspicions become vile forum fanfic, and others start taking it seriously.

The answer is not to point at any side, but at ourselves for promoting the division of our humanity.

I agree about Italy, but I don't agree about Spain.

By March 8th 2020 there were 366 deaths in Italy and over 7000 registered infected, according to: https://www.worldometers.info/coronavirus/country/italy/

The same day the Spanish government let hundred of thousands take part in the 8th of March International Women's Day rallies all over Spain: https://www.reuters.com/article/us-womens-day-spain-idUSKBN2...

According to the Reuters article there were already 589 confirmed cases in Spain at that time, 202 of them in Madrid.

Since Spain did not react earlier I don't think it is right to say the following about Spain (not referring to Italy here): "Spain and Italy's government did not overreacted or downplayed the threat".

Spain was following the indications of the OMS at that point. The pandemic was not declared until March 11th, three days after Woman's Day.

By default, anyone can rally in Spain at any point. They don't seek authorization for the government, they have it by default. It can only be revoked and not granted. While there probably was some thought given to preventing the rallies, given what the OMS was saying at the time it looked like an over reaction. It was, of course, an error in hindsight, but I don't think it's indicative of a big failure of leadership.

I'm afraid politics have been a big part of bad decisions. There were enough cues to stop the rally and they still encouraged people to go there.

Not that the other side isn't being as idiotic now, asking for raising the restrictions immediately.

But there's no excuse for March 8th. Different agencies had clearly warned what was happening and were ignored.

Edit: for fargren, what I mean encouraging:

https://www.youtube.com/watch?v=9Juy7YnqCTQ

For extrangers: it's the vice-prime minister saying on tv that all women should go to the rallies because "it's a matter of live or death" to them. Indeed.

There are many facts that have been arising later, like ministry of health forbidding doctors to attend conventions, police acquiring masks massively and several medical agencies and organizations advicing against the rallies.

It was a typical case of management discarding what every technician under them was telling them for politics.

Edit 2: please don't adopt the typical partisan position with "the opposition was also organizing rallies". No they weren't. There was one party that had its national convention around the same days. Still, it isn't comparable. The government had the direct access to the official sources of information and ignored and hid them.

This isn't a right vs. left matter. More to the left is labour minister Ribera and she was correct to inform the public of how lockdown scenarios would affect workplaces. No good deed goes unpunished, everybody attacked her from all sides... until a few days later it became obvious that what she said was unavoidable.

In the right wing, Ayuso was correctly willing to wait a couple of weeks more to open Madrid, when her coalition partner Aguado forced her to ask for immediate unlock. Central government didn't consent, so change of position was useless, but now there's a left for lockdown, right for unlock division, that's it.

I won't go into the masks issue. It's too painful to just recall.

What do you mean by encouraging? I was out of the country at the time so maybe I missed something.

To be clear, I think the 8th was a mistake. But at the same time, the opposition was organizing rallies and those were not stopped either. There were also massive football matches. At the time, I think the government simply underestimated what was going on, in a large part because the OMS guidance wasn't prudent enough. The fact the 8M aligns with the government may have entered into it, but it's not clear given other events that happened around those dates.

> There were enough cues to stop the rally

This is blatantly and shamelessly false. On the day of the rally there were zero reported deaths by covid19 in the entire country, let alone Madrid. By then the total number of confirmed cases in the entire country barely reached 1k.

There isn't a single nation or government in the history of humanity that decided to lock down an entire country just because there was 1k cases of what was described by then as a mere atypical form of viral pneumonia.

On the day of the rally there were zero reported deaths by covid19 in the entire country

But the situation in Italy, our neighbours, was clear enough, no need to be Nostradamus.

There isn't a single nation or government in the history of humanity that decided to lock down an entire country...

You're very good attacking a strawman. Between encouraging massive rallies of hundred of thousands of persons packed in the streets and locking down an entire country, you know, there's a whole lot of intermediate points.

...just because there was 1k cases of what was described by then as a mere atypical form of viral pneumonia.

https://www.marketwatch.com/story/coronavirus-update-107758-...

By March 8th, they had been 3k deaths in Wuhan. It was blatantly obvious by that time that Covid-19 was dangerous, and also that the testing situation was such that no one knew how widespread the virus was. Since the strict Spanish lockdown started just 6 days later, it seems clear that not halting the march was a big mistake, although it seems unclear how many were actually infected there.

The Spanish government did little or nothing before Saturday the 14th of March when the government decided to lock down the country, starting Sunday 15th of March. By that time there were 193 dead and more than 6000 cases in Spain according to: https://www.theguardian.com/world/2020/mar/14/spain-governme...

So even when WHO (OMS) had declared a pandemic March 11th, there were no policies taking effect before March 15th.

Even I, that has never had any interest in epidemic diseases, started to follow the Sitraps from WHO almost daily from February 24th (even mentioned it in a comment on March 2nd, https://news.ycombinator.com/item?id=22464056). Professionals for much longer I assume.

Saying that Spain didn't downplay the threat, as parent 'rumanator' was saying, is therefore not something I can agree with.

> The same day the Spanish government let hundred of thousands take part in the 8th of March International Women's Day rallies all over Spain: https://www.reuters.com/article/us-womens-day-spain-idUSKBN2....

On March 8th Spain barely registered 1k cases, and counted zero deaths due to covid19.

The first confirmed death in Spain due to covid19 was registered on March 9th.

https://en.wikipedia.org/wiki/COVID-19_pandemic_in_Spain

It makes no sense to criticize a democratic government to impose emergency measures a kin of totalitarian and oppressive regimes just because there were barely 1k cases of an atypical pneumonia which even the World Health Organization claimed that wouldn not spread between humans.

Italy had 79 total cases on 22nd Feb, a full month after China confirmed H2H and went into full lockdown. China had 10k+ cases by 31st Jan, confirming the exponential growth of the virus. Countries had ample time to come together and act. They were caught blind because they were actively looking away. Look at the entire South East Asia, Taiwan, South Korea to see what proactive measures look like.

Italy began engaging similar proactive measures on 23 Feb, including lockdowns of towns with confirmed spread. We just don't remember it that way because their proactive measures didn't work.

Large country: Vietnam

- More than 2x population of California

- Next to China geographically

- Zero death from COVID so far [1]

- Has a very active campaign on raising awareness for COVID, including the famous COVID song.

[1] https://news.google.com/covid19/map?mid=%2Fm%2F01crd5

Vietnam has used targeted lockdowns. Overall Vietnams strategy was very aggressive on all fronts.

https://www.snopes.com/news/2020/04/21/vietnam-has-reported-...

Given that almost nobody suggested doing nothing, I imagine that a targetted lockdown is really the opposite of a country-wide lockdown. Without elaboration "lockdown" is usually understood as referring to a country-wide lockdown.

Taiwan.

The country has 23M inhabitants, most of them are clustered in a few densely populated metro areas (Taipei, Kaohsiung, Taichung–Changhua, Taoyuan–Zhongli, Tainan and Hsinchu). Taiwan had many daily flights to/from China, including daily directs from Wuhan (stopped 31 December 2019). Taiwan is one of the world's older countries (median age ~43). Taiwan permitted the docking of the Diamond Princess [2] and allowed passengers to disembark in Keelung (near Taipei), on 31 January, before the ship left for Japan. The ship was subsequently found to have numerous confirmed infections onboard. In reaction, Taiwan's government published the 50 locations where the cruise ship travelers may have visited and asked around 600k citizens who may have been in contact with the tour group to conduct symptom monitoring and self-quarantine if necessary. None were confirmed to have COVID-19 after 14 days had passed. (The only advantage Taiwan had was that facemasks were widely used and even expected on public transport for years.) For all those reasons, Taiwan was at unusually high risk from Covid.

Yet, no lockdown.

No country managed the disease better than Taiwan. We should learn from Taiwan. See [1] for an analysis of Taiwan's response from early March 2020.

It is interesting to reflect upon why most countries ignored Taiwan. The World Health Organization's locking out Taiwan on China's request is probably one reason. Is it the only one?

[1] C. Y. Wang, C. Y. Ng, R. H. Brook, Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. https://pubmed.ncbi.nlm.nih.gov/32125371/

[2] https://en.wikipedia.org/wiki/Diamond_Princess_(ship)

The Taiwanese have been practicing wearing face masks since the early 90's. My first time there in 1991, up to 30% wore face masks when in crowded spaces. My last time in 2018, up to 80% wore face masks when in crowded spaces.

??? Last 3 times I went to Taiwan I didn't see 80% wearing face masks in crowed places. I have pictures from this last December 2019 as well January 2018. Walking around shopping centers, being on the subway, going to night markets, no one is wearing any masks. At least no in Taipei or Dansui

Japan, Sweden, Taiwan.

How did you arrive to this conclusion?

A significant number of ill people is only in Moscow and a couple of other cities, and they are doing good if you compare them to other cities in the world with the same population.

This line of thought sounds exactly how the US got into such bad shape with this virus. "Oh, it's just in the cities" Until it's not.

I haven’t kept in touch recently, but for a long time NY alone was responsible for 50% of the total cases and deaths, presumably overwhelmingly driven by the NYC metro. If you ignore that outlier, is the US in dramatically worse shape than other countries? How bad is the spread in rural America?

Since at least a few weeks ago when it hit meat processing plants in the plains, extremely bad.

I’m from a town that was profiled by CNN and others for having an outbreak in a meat plant. Things seem quite a lot better there than in the larger city where I now live. The impact outside of the meat plant seems minimal. Not sure how it is elsewhere, but my feeling is that the meat packing plant issue overblown.

> The impact outside of the meat plant seems minimal.

COVID-19 has a significant incubation period and a large number of infections are asymptomatic and even with moderate symptoms people often won't qualify for the limited testing being done. The upshot being that unless there is a nexus with another highly-tested subcommunity in the same community, an outbreak that occurs rapidly and is detected in one subcommunity (in which impacts might be visible sooner through testing) that is disproportionately tested will take several weeks before it has significant visible impacts in the broader community. And by the time it does, it will be impossible to contain.

But those broader impacts are pretty much inevitable unless the those exposed to the outbreak were strictly quarantined from the broader community.

Rural communities with minimal testing also tend to lack their own hospital / ICU resources, so outbreaks in those communities also tend to unexpectedly deplete resources in nearby cities. Sometimes these are also counted as deaths in the city rather than the rural area the case originated.

I can appreciate your logic. But think about total number of cases in the US. If you divide that in half (according to your logic) there would still be 800,000 cases in the rest of the U.S. That's still roughly the same amount of cases in the next 3 countries COMBINED.

Now think about the percentage of world population that the U.S. accounts for. Our infection rate is inexcusable. And getting worse.

There is a significant portion of the country that has politicized a viral infection -- and that line of thinking is just making this a worse situation.

> If you divide that in half (according to your logic) there would still be 800,000 cases in the rest of the U.S. That's still roughly the same amount of cases in the next 3 countries COMBINED.

Forgive me if I'm mistaken, but don't you need to adjust for population in order to make a meaningful comparison?

From reports of various people in Russia that had the misfortune to deal with Russian healthcare system.

“Doing good” because doctors aren’t allowed to attribute death to covid is not really “doing good”.

Russia seems to have an odd problem with window safety: https://edition.cnn.com/2020/05/04/europe/russia-medical-wor...

In Putin's Russia, window open you!

Yeah, seems like forming a national (or at least regional) consensus around basic facts like "this is dangerous and so we should really self-enforce some sort of social distancing" seems to be the main discriminating factor.

Who'd have thought that being distracted with pointless discussions about what the weather was and where a shooting did or did not happen could be detrimental to your nation's (mental) health? <shrug>

> People seem to have chosen bad faith attack media and elected bad faith leaders. That's why the US, UK, and Brazil are doing particularly badly.

This is something we tend to assume somewhat intuitively, but I'd love to see some actual research on it.

The relationship between weakened trust in media and a societies pandemic response performance is not a trivial research question.

I wouldn't even necessarily trust the premise that overall trust declined. Could as well be perception or based on publisher selection.

... and that didn't jet include seriously operationalizing or discussing the nebulous "bad faith leaders" term or their relationship to pandemic response performance.

Sure, here it is: https://www.ilrestodelcarlino.it/bologna/cronaca/muore-di-co... (this is the first result on Google, but it was all over the news).

Title of the article: "Muore di Covid a 30 anni: è la vittima più giovane", which translates into "30-year-old dies of Covid, he's the youngest victim yet".

Article starts with: "Dying younger than 30 for Coronavirus: a cruel fate, that of Michele Grauso, 29-year-old financier (he would have turned thirty in August)."

Second paragraph, finally mentions the small detail that he had also been shot in the head and had been in a coma for 2 years: "He was hospitalized in a vegetative state in a private facility here in the city. A coma from which he had never come out since a partner in 2017 shot him in the head by mistake..."

On TV, most news channels didn't even mention the coma. The family actually complained and it came out.

Not sure if news want to be sensationalistic for clicks, or because they directly get paid to keep the level of panic high by whoever makes money from the emergency (which is many, many people in Italy). Probably both.

There is no doubt fear mongering about this topic exists in the media. This shouldn't be surprising. The death coding is surprising, at least to me. This idea of coding deaths in this way is not limited to Italy, but is happening in many countries including the U.S.

Dr. Deborah Brix replied to a reporter asking questions about death coding methods by saying that the U.S. was using liberal methods. In this article Professor Walter Riaccardi (scientific adviser to Italy’s minister of health), complains about such coding methods:

https://www.telegraph.co.uk/global-health/science-and-diseas...

So he'd been alive for two years in a coma? And presumably "stable"? And then contracts coronavirus and dies? It does sound like he'd have still been alive if he'd not contracted the virus.

You're right!

If a lightning hit the hospital and made the power go out and turn his life support off, they would've written he was killed by a lightning.

> This might be a rant, but it would be awesome if these new findings lead to laws that required doctors to give accurate cause of death for people that also test positive for COVID.

In England that law already exists. It's called the Coroners and Justice Act. http://www.legislation.gov.uk/ukpga/2009/25/contents

You want to read about the reforms which arose out of the Shipman and Mid Staffs scandals (the Shipman Inquiry and the Francis Inquiry). You can read about those here: https://www.gov.uk/government/publications/changes-to-the-de...

Yes, in England there is no such thing as dying from old age. But this is still considered an official reason in Italy for example.

There are three level of excess deaths in E+W

Those that are defiantly covid

Those that mention covid on the certificate

Those in excess of level of normal deaths over last 5 years

That puts covid deaths at between 40k and 70k. With an IFR across the country of between 1 and 2% based on the latest antibody tests.

That’s disastrous and we can only hope that either the most vulnerable have been disproportionately exposed or the antibody tests are massively overreading false negatives.

Doesn't the third level also include those who died from the side effects caused by the lockdown?

Yes, hence the large gap in death estimation

Noice.

The Shipman reforms were repealed by the coronavirus laws!

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