The Japan Experience: No mass shutdown. No mass isolation. Fewer cases and fatalities. What can we learn?

The big question that is on everyone’s mind is what is going to happen when America ‘gets back to business’ and people have the freedom to move about as they please.  It may take awhile before we get back to the freedom to work and live like we did just 3 months ago, but I am confident we will get there.  In the mean time, what can expect we in the next few weeks?  Of course, it’s impossible to know for sure, but examining how different states and countries have handled the infection may provide some insight into at least the breadth of things that might occur and provide some concepts we could use.s

I believe that looking at places where there have been less restrictions placed on the people AND where people have been less impacted (number of covid 19 cases and fatalities per million people) show us that we can live with open businesses where Covid 19 is no worse than the seasonal flu.  I believe that Japan provides an example.  I know we can’t mimic Japan in many ways, but there are experiences which we could learn from.  It is a story of how a different approach, mind set and cultural behaviors combine to give a final result.

Relatively little has been said about Covid 19 in Japan with its population of 126.7 million.  Most businesses have remained open, yet the Covid 19 infection and fatality rates are much, much lower than in the US (in the range of seasonal flu).  Some estimates are that less than 20% of Japanese businesses have been closed.

As of March 28, 2020, the Covid 19 stats for Japan vs the US are shown below. It is important to note that the US has done far more testing than Japan, but neither country has done much antibody testing, so the true infection rate is not known for either country.  Nonetheless, the statistics for Japan are very good. Covid 19. How many people are actually infected? Santa Clara County

Population (millions)126.7340
Covid 19 cases136141,031,437
Cvoid 19 deaths38558705

The difference in number of deaths/million people is dramatically lower in Japan than the US.

They used a ‘cluster-based approach’ to manage Covid 19..  The principal of this approach is that infection is spread from certain people being more contagious than others.  This concept was used to explain why many passengers on cruise ships are not infected despite having close contact with infected persons.

These more highly contagious people form clusters of infected people which go on to infect others.  Under this cluster based approach, each cluster of infections is identified and tracked to the original infection source(s) and these highly contagious people (and those they infected) are isolated.  This approach requires rapid targeted testing.  The government has a dedicated  department which does this monitoring.

This cluster-based approach is conditioned on clusters of infection get detected at an early stage.  In February 2020, a cluster based approach was used when an outbreak was identified in Hokkaido, Japan..  The source was located, containment measures employed (like closing all travel on/off the island, specific quarantine)  and the outbreak was rapidly contained.

It is noteworthy that South Korea used their version of the cluster based approach to contain their Covid 19 outbreak where they found 1 woman who infected over 1000 others and 60% of the cases in South Korea could be traced back to two churches.  Again, targeted testing and quick identification of clusters of infections were keys to success. South Korea: Covid 19 Containment vs Privacy

The Japan version of social distancing is called avoiding‘the three C’s’ : Closed spaces with poor ventilation; Crowded places and Close Contact places.  This is somewhat opposite to US instructions where we have been told to socially isolate but have closed parks, playgrounds and beaches.  Most, but not all Japanese elementary and high schools have closed, but the closures are only planned for 2-4 weeks depending on the local government.  It is not clear, school closures have (or will) influenced infections of fatalities given the relative low numbers of both.

There are also cultural practices that helped Japan limit the spread of the virus.  Large numbers of Japanese were already in the habit of wearing masks before Covid 19.  Western behaviors such as shaking hands, hugging, kissing and other forms of physical contact are not part of Japanese social behavior.  It is also interesting to note that on the famously crowded public Japanese transit systems, talking is considered to be poor etiquette so again, transmission methods are greatly reduced when no one is speaking and they are wearing masks.

Another cultural consequence of covid 19 isolation policy is suicide.  In Japan, the suicide rate has always been proportional to the unemployment rate.  Suicide rates have already increased in Japan even though the increased unemployment rate is still low compared to the US.  There is a real fear that Japanese suicide rates will increase dramatically if there is a US type of business shutdown.  Given the small number of Covid 19 deaths in Japan, it remains to be seen if the lives saved by sheltering in place are offset by lives lost due to suicide.

It is true  there has been an increase in the number of cases and deaths the past few days, but the numbers would have increase dramatically to reach the numbers of cases (108/million vs 2116/million) and fatalities in the US.  Due to these increases, this week, Prime Minister Abe declared a ‘state of emergency’ granting local governments power to make their own decisions about restrictions,  but there have been few nationwide mandatory shutdowns and only an appeal to ‘stay home’.  The state of emergency has also been set to be only 2 weeks long.  The Prime Minister’s opponents are calling for a larger shutdown but so far Abe has resisted.  Although the number of cases and deaths are increasing, Japan is still doing very well compared with most other countries it’s size.

Recent days have seen reports that some Japanese hospitals in major cities are running short of personal protective equipment. However, this may be a failure of poor planning and procedures rather than a failure of the cluster based approach.  The early success of the cluster based approach may have lulled the government into complacency and they failed to procure equipment and supplies when they could.  They are now playing ‘catch up’ to get supplies when they could have done so earlier.  Japan has far fewer ICU beds/100,000 people than the US and they are concerned about needing more ICU beds than they have, but they are not at that point yet.  The US has demonstrated that large numbers of hospital beds can be erected in short periods of time should they become needed.

The Japan model is based on geographic and social conditions which could be difficult to apply here.   However, I think there are clear experiences we can benefit from.

My summary is:

  1. You can limit the effect of the virus without mass shutting down businesses and sheltering in place as long as you have the ability to immediately identify outbreaks and identify and isolate the source of the cluster.
  2. Infections can be minimized by avoiding the ‘three c’s’: Closed in Spaces, Crowded Spaces and Close contact with other. Their version of social distancing.
  3. Infections can be minimized by reducing physical social greetings, kissing, hugging and handshakes.
  4. Mass transit can still be used if other behavioral changes are made.
  5. If you feel sick, stay away from others
  6. If you feel sick, do not go to work.

Japan is an example where people can live in an environment where Covid 19 is no worse than the seasonal flu (bad as that is) without a shutdown of the economy and staying indoors.  There’s always a chance of an outbreak in a closely packed country of 127 million people, but they have done well so far. Only time will tell if Japan’s approach was successful, but I am hopeful.

I am encouraging on our scientists and politicians to include the Japan experience in their thought and decision making process as they develop and implement plans to reopen America.


Reopen Businesses – What should the new ‘normal’ be?

Returning to normal…but what’s normal?

As the nation and the world turns toward reopening the world to business, there has been a lot discussion of whether we could ‘return to normal’, but what does that mean exactly and how do we know when get back to normal?  We have lived with numerous causes of death that are higher in number than we are seeing for Covid, yet we did not shut down our country for any of these other causes.  In other words, we accepted as ‘life’ that there are many things cause death but we continue to go through life without stopping.

We should not have to complete end or stop Covid 19 before we ‘return to normal’. ‘Norma’l includes yearly deaths many times that caused by Covid 19.

We get daily briefings and headlines about Covid new cases and new deaths from the US and around the world.  To date (April 27, 2020) there have been 1,004,942 Covid 19 cases and 56,527 deaths.  However, the view of the number of actual cases has drastically changed in the last week.  The availability of antibody tests, which can determine if someone has been infected, has resulted in several reports that the actual number of people that were infected may be somewhere between 16 to 80X higher than this value (up to 21% of the population).  This means the actual number of Covid 19 cases may in the range of 16,000,000 to 80,000,000.  This makes the fatality rate between .34 and .07%.  This is in the range of the seasonal flu. New York: Nearly 3 million infections – not 276,000

The early concern over Covid 19, which caused the nationwide lockdown were basically two concerns. The first was the seemingly high fatality rate which was generally reported to be between 5 and 10% back in March.  The second was the concern that the number of infected patients would overwhelm our health and hospital systems, and whether we could treat everyone who needed help.

As it turns out now, fortunately, neither of those concerns happened.  The fatality rate is most likely be well under 1% and may be in the range of the seasonal flu.  There was not one city, including the hottest spot, New York where there was a shortage of beds, intensive care units or ventilators.

The shelter in place and closing of businesses undoubtedly helped to slow the spread of the virus, but perhaps not as much as we previously thought.  Before antibody testing, we were operating under the fact the 1 million people had been infected.  In a country of 370 million, this would seem to say that the lockdown was very effective.  However, the antibody testing now suggests that the number of people infected may be as much as 80 million!  This means that the lockdown was not nearly effective as we thought.  It also means that the vast majority of those who were infected did not need hospital care and had no or minor symptoms.

As plans are being considered to how reopen America’s business, the question is what state of health are we going to return to or accept?

To try and answer this question, it is useful to examine the top 10 causes of death in the US in 2018.  The CDC reports:

Heart Disease655,381164
Lower Respiratory (COPD)159,48640
Seasonal Flu5912015
Covid 19 4/27/202056,527*15*
  • Covid 19 Numbers still increasing, but rate of increase has slowed

Note that as a society, we did not shut down our businesses or go into lockdown over these numbers.  In particular, it interesting to note that in the 2018 season, flu claimed more lives than Covid 19 has caused to date (although Covid 19 is sure to increase further).  We also did not stop driving cars even though over 100,000 per year die from car accidents.

It would seem reasonable that if Covid 19 statistics could be brought into line with these other causes of death that we would be back to ‘normal’.

A key factor to consider is that Covid was much more fatal to those over 65.  Currently 79% of the Covid 19 deaths were in people over the age of 65.  The 65 and older group represents just 16% of the population.  The data strongly suggests that those over 65 may suffer more fatalities.  The younger you are, the less likely that Covid will be fatal, even if you get infected.

When businesses open up, both businesses and individuals may have different behaviors depending on the age of the people involved.

Although, there has been a long and strong voicing that Covid 19 is not the flu, it acts more and more like a flu the more we study it.  It has been thought that Covid 19 was more contagious than the flu, but the recent finding that the number of infections known may be off by many millions, it is not clear how much more contagious it is.  As I always state, comparing Covid 19 to the flu is NOT downplaying the seriousness of Covid 19 – instead it is a reminder that the seasonal flu has always been deadly (25,000-60000 fatalities a season and up to 60 million infections) and will continue to be so.

I will discuss vaccines in an upcoming blog, but it is critical to note that the data regarding the seasonal flu is WITH an annual vaccine.  There is no current vaccine for Covid 19, so Covid 19 statistics should look much better once a vaccine is found.  However, it is very important to know that the seasonal flu vaccine does NOT always work well.  The effective of the seasonal flu vaccine has varied from 10 to 50% depending on the year.  Hopefully, the Covid 19 vaccine will perform much better.

Covid 19 Tests: What we can and can’t say.

Miami Dade: 165000 cases, not 10,000. More Good News

More good news.  It seems that each day, the results of another study of the actual extent of Covid 19 infection show that the actual number of people infected is much greater than we expected.

As always, this is good news.

Until now, Miami-Dade county in Florida has reported 10,600 cases of Covid 19.  However today, a University of Miami reported on a study designed to determine the actual extent of infection by selecting a wide range of patients with and without symptoms for antibody testing.

They found that 6% of those tested were positive for the antibody.  Assuming that their study group was representative of the Miami Dade county, this would mean that 165,000 were infected with Covid 19 instead of the 10,600 reported.  About 50% of the people tested reported having no symptoms for 14 days before being tested.

This data is consistent with the data reported for Santa Clara (2-5 %) and Los Angeles County (4%) in California and New York (up to 21%) as well as testing in Robbi Italy (10%) and Gangelt Germany (14%).  Although each study tested only a few thousand representative people, in all cases, the number of people tested ranged from 4 to 21% of the population- representing 10 to 80X the number of cases that have been reported.

This means that the ‘curve’ that we have been trying to flatten is NOT representative of the actual number of infections that have occurred.  Taking an average of 5% infection for discussion sake, this would mean that in the US alone, there have been 18,750,00 infections, not 953,851.  This would also make the fatality rate .28%.  If it turns out that 10% of the population was infected, the fatality rate would be .14%.  Recall that New York city reported an infection rate of 21%.

Caveat:  All of these studies represent cross sections of different areas of the US, Italy and Germany.  More data is necessary from many more places with wider demographic of study subjects until the actual infection rate is known.

However, even as we watch the daily count of new cases increase, it is certainly the case that the cases being measured are 10 to 80 times less than the actual number of people being infected.  Again, this is good news.  It means that 50-80% of the people who get infected have no or minor symptoms and that the fatality rate gets closer and closer to the values we associate with seasonal flu.  This is especially good news as the seasonal flu numbers are WITH a flu vaccine.  To date, there is no proven vaccine for Covid 19.  The numbers for Covid 19 can only improve with more antibody testing and the introduction of a vaccine.

This also has implications on reopening businesses as sheltering in place may have been effective, but perhaps not nearly as effective as it was thought to be.

New York: Nearly 3 million infections – not 276,000

New York: Infection rate 10x higher than previously thought.  This is good news.

New York reported their first results in larger scale antibody testing to see how many people may have had actually had a Covid 19 infection.  43% of the tests were conducted in New York City while 32.8% of the test were taken out of the city.  The presence of the antibody means the person had and recovered from Covid 19 infection.  In most cases, the person was unaware they were infected.  This is GOOD NEWS.  It means that most people who get infected have no or minor symptoms and it makes the fataility rate (the % of people who die after getting infected) much, much lower.  See my earlier blog on antibody testing. Covid 19 Tests: What we can and can’t say.

The results reflected large differences between different areas of the state.  The number of people who tested positive for the antibody was:

New York City: 21%

Long Island: 16.7%

Westchester 11.7%

Rest of New York 3.6%

This corresponds to 1.7 million people in New York City and more than 2.6 million statewide who have been infected.  These number are much, much higher than the 275,000 confirmed cases that his reported today.

The tests show that the spread of covid 19 was not very different for different age groups:

  • 45-54 age: 16.7%
  • 65-74 age: 11.9%
  • Over 75 age: 13%
  • Less than 45 ranged from 8 to 15%

It is reminded here that this is percentage in each age group that had the antibody – they are the survivors.  The fatality rate among the groups is very different, with those over 65 accounting for 40% of the deaths.  The fatality rates will be discussed in a future blog.

Black, latino and multiracial New Yorkers had a 22% average positive tests while White accounted for 9.1% of the positive results.  Although it is clear there is a racial component to the infection rate, strict comparison of the numbers should be done carefully, as most of the testing was done New York City which has more minorities.

Importantly, this make the fatality rate around .5%, 10x lower than what was known just a couple of weeks ago.

This does not negate the severe impact the disease has had on the public but it does provide more insight into the disease.

The results here are consistent with other immunity tests reports in Santa Clara County, Los Angeles County, Robbi, Italy and Gangelt Germany and continues to indicate that the fatality rate of Covid 19 is likely to be significantly under 1%. Covid 19. How many people are actually infected? Santa Clara County 

Caveat:  This study and others should be considered preliminary studies.  They clearly show a high number of infections but only in limited locales.  Much more data from more locations and wider demographic inclusion will be necessary before the actual numbers of infections are known.  The results may also vary from country to country or county to county.  However, all indications so far are that the number of infections  determined by antibody testing is far higher than the number of confirmed cases being reported.


Really? Hair Salons, Massage Parlors, Tattoo Parlors, Gyms First?

Unlike my normal posts – this one is mostly my opinions and thoughts on how businesses are reopening in Texas and Georgia.  Texas and Georgia Hair Salons Opening: Would you go?

Overall,  let me say that I am for reopening businesses as soon as it is safe enough to do so and I try to make data driven decisions.   Several states including Georgia and Texas have allowed the reopening of some businesses.  However, the list of businesses seems odd to me.  Why are hair salons, tattoo parlors, bowling alleys, massage parlors and gyms among the first businesses to be allowed to reopen?

It seems peculiar to me that after weeks of hearing we will follow the data, that these businesses are opening with essentially with no specific data and no plan to actually collect the specific data.  I’m for opening business but I prefer it be done in a manner where there are not so many risk factors and so few answers.  For instance, with all the testing that has been done (over 4 million and counting) has any gym or massage parlor ever been a source of an outbreak?  If the answer is no, that would be good to know.  If the answer is yes, then why open them now?

It seems odd to open these businesses for two reasons. First, in three of the businesses, hair salons, massage parlors and tattoos, it seems impossible to maintain 6’ of social distancing while conducting business.  In fact, the customer is likely to spend most of their time within 6’ of business staff.  I can imagine how bowling alleys and gyms may be able to maintain social distances, but both of these businesses involve a lot of touching of surfaces by the clients (bowling balls, bowling shoes, score sheets, weights, pull up bars, bikes, rowing machines etc.)  Each of these surfaces would have to be disinfected after every use – will this be done?  Is it even practical

The second oddity about these businesses is that there are not a lot employees involved.  Texas has 28000 people that work in hair salons and George has less than 10,000.  With respective population of 29 million and 10.6 million, this will help a small fraction of the unemployed, but hardly a significant contribution.  Similarly, there were just over 6900 registered masseuses in Texas and only 2700 in Georgia.

There are around 2500 health clubs in Texas with a membership of over 5.3 million.  However, it is not clear how often these people go.  However, 5 million people is a significant number.  If the early antibody testing holds up under further investigation, somewhere between 4 and 14% of the 5 million people were or are infected with Covid 19…that makes roughly 200,000-700,000 gym members who have had or have Covid 19. Actual Number of Los Angeles Infections: over 400,000

I could not find any statistics about the number of bowling alleys but in my own county of 1 million residents, I believe that there are two bowling alleys.  I know it’s not Texas or Georgia but I find it hard to believe (no criticism intended for people who work in bowling alleys) opening bowling alleys is not going help unemployment numbers much.

Some have called this a social experiment, but it’s not being conducted like an experiment.  In an experiment, you have a question you are trying to answer and you have measurements that you will make to get an answer.  I have not heard of any additional testing or tracking that is going on with these openings and comparisons to the people who use these businesses and those that don’t..

If this was truly and experiment:

Because of the built-in lack of social distancing, workers should be tested for Covid 19 and the antibody before they can start work.  Workers should be continued to be checked every 5 days to make sure they have not picked up the infection.

Customers should also closely be tracked.  Preferably the customers would also be tested for Covid 19 5 days after the appointment (or work out, or tattoo) to see if they have the antibody indicative of infection.  If there is an outbreak somewhere, it would be good to know if there was a hair salon or gym that was the epicenter (like the church in Korea). South Korea: Covid 19 Containment vs Privacy

If after this testing, the Covid 19 does not seem to spreading, then I’ll be ok with it.

I am not OK with opening these businesses that do not put very many people back to work but can increase the exposure to Covid 19 especially if they aren’t going to follow what happens.

It seems there’s a lot of other types of businesses that could be reopened (with guidelines) that would benefit larger number of people as both employees and customers.

The good news is that over 80% of the people who get infected will have no or minor symptoms and the fatality rate is overall getting lower, but at risk groups should remain very vigilant.

I am hopeful that the opening of these businesses will be successful.  However, I wish I had more confidence in that wish.  The results from the first openings will have a large impact on how reopening other businesses will be conducted.



Texas and Georgia Hair Salons Opening: Would you go?

This week, several states like Georgia and Texas are beginning to cautiously allow the opening of selected businesses.  They are doing this in the wake of the Federal Guidelines for reopening their businesses which provides guidelines for reopening but allows local governors to make final specific decisions. I’m going use the opening of Hair Salons as my discussion focus because it is controversial but brings out all the complexities of reopening a business.

In the past month, grocery stores, pharmacies, big box stores and Home Depot have opened without starting any outbreaks – this suggests that other businesses may find ways to reopen and stay safe as well.  It is hopeful that gyms, schools and other places can find ways to open and operate safely.

It should be emphasized that within a state the infection rate of Covid 19 can be very different. This means that you should know the situation around where you live.  Some areas have much higher rate of infection and people should behave accordingly.

Texas.  For instance, in the last 14 days 155 of the 255 counties of Texas have not reported any cases of Covid 19.  Another 19 counties have reported less than 10 new cases of Covid 19.  This is in contrast to the largest county, Harris and Dallas counties which reported 754 and 556 cases respectively in the same time period.  Just 10 counties account for 72% of the Covid 19 cases in Texas.  However, on percentage basis, on average 1.2% of the population of each county has been infected.  Keep in mind that this is a lower percentage that catches the seasonal flu.  Your risk of getting the disease is highly variable in Texas (and everywhere else).

Similarly the 10.6 million people of Georgia live in one of 158 counties.  The top 10 counties account for over 55% of cases.  It is a much different environment in Dekalb County (1600 cases including Atlanta) than in Montgomery County (2 total cases).

The reopening of businesses is not only economically crucial but also crucial to the health of the general population.  Over 50% (some higher) of the people live paycheck to paycheck and lines for food banks are enormously long.  Also, ‘elective’ surgeries and medical treatments have been stopped but the long term health implications of these stoppages are not yet known.  For instance, cancer screening stopped so there are people who may have been able to be diagnosed with cancer and start treatment have been waiting over a month just to get the diagnosis.  People with chronic pain are also not being cared for during this time.  A topic for another blog will be the costs involved.  BEFORE the over 5 trillion dollars recently allocated by congress, the national debt was 18 trillion dollars which translates into an interest payment of approximately $500 Billion each year.  That is $500 billion that could be spent on other things like education, homes, health care etc….the new spending will send our interest payments to over $600 Billion/year – over 10% of the US budget.

On the other hand, no one wants to ‘reignite’ the infection of Covid 19 after working so hard and making so many sacrifices to get the disease under some management so it will be balance to get back to work and stay safe.  I’m sure there will be some good decisions and some bad decisions in the coming weeks. Choices have to made on imperfect and incomplete data and the interpretation of the data we do have can often be interpreted in different ways.

It is important to emphasize that in these states that are beginning to allow businesses to open – it is NOT business as usual.  Social distancing guidelines remain in effect and there are many more procedures that must be followed in order to reopen and stay open.

One of the big controversies is the opening of hair salons.  It seems that this puts two people closer than social distance guidelines.  Is this a good idea?  The first answer is, that we don’t know how this will work – especially if they follow the guidelines.  This may be too much detail, but it illustrates the details that have to be taken for ANY business to reopen.  Here are the Georgia Guidelines for Hair Salons.  Also, consider that everyone should use some common sense along with government guidelines.

If you feel sick – don’t go out. 

If you’ve been in close contact who has been sick, don’t go out. 

If you feel sick – don’t go to work.

If you have been in close contact who has been sick don’t go to work.

Be mindful of exposing others to risk.  Most recent data suggests that 80-90% of infected people have few or no symptoms but can transmit the disease to others.  So even if you are feeling good, be mindful of who you come into contact or close proximity with.

Also, getting testing for Covid 19 just tells you if you have been infected on that day.  If you were recently infected, you may not have had the time for the infection to become detectable.  The test also will not tell you if you get the virus the next day or anytime in the future.  If you feel like you might be sick – stay away from others (test or no test).

Look the hair salon guide over, consider where you live and decide if you would go to hair salon if you were in need of a hair appointment.  I know this is only a small segment of life, but the same decisions will have to be made for every business that opens and every business you frequent.

Salon Guidelines – Georgia

  • Salon/shop employees will be required to wear masks at all times. Salons may want to consider providing masks to clients. Clients should wear face masks to the extent possible while receiving services.
  • Salons/shops should also make use of face shields, gloves, disposable or re-washable capes, smocks, neck strips, etc.
  • These items should be disinfected or disposed of between each client. Employees should should arrive at the salon/shop showered and wearing clean clothing and change clothes before leaving the salon/shop each day.
  • Hand washing with soap and warm water, for a minimum of 20 seconds will be required by employees between every client service.
  • All salons/shops should be thoroughly cleaned and disinfected prior to reopening. Disinfect all surfaces, tools, and linens, even if they were cleaned before the salon/shop was closed.
  • Salons/shops should maintain regular disinfection of all tools, shampoo bowls, pedicure bowls, workstations, treatment rooms, and restrooms.
  • Additionally, salons/shops should remove all unnecessary items (magazines, newspapers, service menus, and any other unnecessary paper products/decor) from reception areas and ensure that these areas and regularly touched surfaces are consistently wiped down, disinfected, and that hand sanitizer is readily available to clients and staff.
  • Avoiding the exchange of cash can help in preventing the spread of the virus, but if this is unavoidable, be sure to wash and sanitize hands well after each transaction.
  • The use of credit/debit transactions is preferred, using touch/swipe/no signature technology.
  • Employees who are sick will be expected to stay home.
  • Salon/shop owners/managers should provide training, educational materials, and reinforcement on proper sanitation, hand washing, cough and sneeze etiquette, use of PPE, and other protective behaviors.
  • Ensure break rooms are thoroughly cleaned and sanitized and not used for congregating by employees.
  • Be flexible with work schedules/salon hours to reduce the number of people (employees and clients) in salons/shops at all times in order to maintain social distancing.


Actual Number of Los Angeles Infections: over 400,000

Los Angeles County is now the second county to show that the number of people actually infected with Covid 19 is much, much higher than previously expected.  This is very good news.  It means that most of the people who were infected with virus had no or mild symptoms.  They only found out they were infected after the antibody test. Covid 19 Tests: What we can and can’t say.

Yesterday, I wrote about a Stanford study of 3300 people of Santa Clara County that found the actual number of people infected with Covid 19 was between 49000 and 81000 people.  This is 50 to 80 times higher than the 1820 of confirmed cases reported.  This was one of the first areas in the US to report antibody testing that can indicate if the person was ever infected by Covid 19 (whether the person knew it or not).  If this trend continues, the fatality rate will much, much lower than expected. Covid 19. How many people are actually infected? Santa Clara County

Today, researchers at USC and the Los Angeles County Department of Health released results from a study of people in Los Angeles County. Their results show that approximately 4.1% (2.8-5.6) of the adult population had the antibody for Covid 19 indicating that they had been infected.  This translates to between 221000 and 442000 have been infected.  Currently, there are 7994 confirmed Covid 19 cases reported for LA County.  This means that the actual number of people who were infected is 28 to 55 times higher than previously known.  This makes the fatality rate between .2 and .3% – much lower than the 3-5% number based on confirmed cases alone.

This is now the 4th report of larger scale antibody testing along with, Santa Clara County, California, Robbi Italy, and Gangelt, Germany.  In every case, the number of people  who were infected was 25-80 times higher than previously thought.  This has several implications.  One is the question of how effective sheltering in place was.  With only 8000 cases confirmed (before this study) it appeared that sheltering in place was very effective in a county with nearly 10 million people in it.  However, if several hundred thousand got infected anyway, the effectiveness of sheltering in place must be examined.  The second possible implication is that Covid 19 is not 10x more deadly than the seasonal flu.

These are only 4 specific areas, but the results are amazingly similar.  This is overall great news.  It means that the vast majority of people who are infected have no or minor symptoms.  It does not take away from the sadness and loss of the thousands of people who died from the virus, but it does place a different perspective on the disease that is very different from just a month ago.

A key unknown is how the presence of antibody corresponds with actual immunity from further infection.  It is not known if someone with the antibody is immune or how long the immunity lasts.

The world wide research is amazing.  However, read carefully as not all studies are rigorously and the limitation of each study are not always publicized.  The Stanford and USC studies just represent the very tip of the research iceberg on antibody testing.

In the meantime, keeping social distancing and washing your hands often remain good practices regardless of what these research studies report.


Covid 19. How many people are actually infected? Santa Clara County

One of the key questions that remains unanswered about Covid 19 is how many people have actually been infected.  To date, most of the people tested have had some kind of symptom.  More recently, there have been more asymptomatic patients tested but the results are still pretty sparse.  The issue is tha fatality rate (the number of people who die if they get infected) will be greatly overestimated if large numbers of patients have no or only mild symptoms.  Some have speculated that at the number of people who are infected and don’t know it are many times higher than the number that have actually tested positive.  It is hoped in the coming weeks, when antibody tests can be given to large populations with and without symptoms, the actual number of infected people will be known.  See yesterdays blog about testing for an over view of antibody testing.    Covid 19 Tests: What we can and can’t say.

In the mean time, Stanford researchers reported doing this type of antibody screening in Santa Clara County.  In this test, the researchers chose 3300 Santa Clara residents that were representative of the residents of Santa Clara County.  At the time of this study, Santa Clara County had the largest number of confirmedcases of any county in Northern California (1,094). The county also had several of the earliest known cases of COVID-19 in the state -including one of the first presumed cases of community-acquired disease -making it an especially appropriate location to test a population-level sample for the presence of active and past infections.  Today (April 20, 2020) there have been 1820 Covid 19 cases reported in Santa Clara County.

They measured both the IgG and IgM antibodies which are indications of recent and earlier infections.  The prevalence (percentage of people who have the disease at the time of the study) was between 2.5 and 4.2%.  The population of Santa Clara County is 1.93 million people, so this would indicate 48250 to 81060 people were actually infected.  As there have been 73 deaths attributed to Covid 19, this new value makes the fatality rate .097 to .10 % – the same as for the seasonal flu.

Of course, it remains to be seen what the data looks like in a bigger area and across the US.  However, it is interesting to note that similar antibody studies in Europe (where asymptomatic people are tested as well) have shown the prevalence of Covid 19 in Robbio, Italy to be 10% and 14% in Gangelt, Italy.  This would suggest that the fatality rates in these area are also in the range of the seasonal flu.

Again, this is NOT downplaying the devastation of Covid 19 – but rather that although Covid 19 appears to be more contagious, the actual fatality rate hopefully, may not be very different from the seasonal flu.  There are currently 41575 deaths due to Covid 19 (18776 (45%) in NY alone).

It is reminded that in 2017 flu season, 44 million people got the flu in the US with 61000 deaths (1.3% fatality) so comparing Covid 19 to the flu does not diminish the terrible losses caused by the disease. 

One of the benefits of increased antibody testing that actual numbers for the disease will become known and it will better inform us on how to make health care decisions.  The good news continues to be that we, as a country, seems to have ‘stabilized’ as hospitilization rates have decreased everywhere.  NY continues to drive our nation wide statistics.  Your local area is likely not to be as bad as NY.  This and other data should guide the reopening of business and life.

You can read theentire Stanford paper at:  https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf


Covid 19 Tests: What we can and can’t say.

I am a data driven person by training, education and personality, but data must be very carefully examined – ‘granularly’ as Dr. Birx would put it.  Simple interpretations of data can provide some very wrong direction.

Much of the discussion around the management of Covid 19 has been around the concept of testing.  However, the details of testing and what you can and can not say about the results of testing are almost never discussed.  As of April 19, the US has conducted 3.7 million tests.  The country with the next most test is Germany with 1.7 million and then Italy with 1.3.

Are there different tests?  Who needs to get tested?  Does everyone need to get tested?  These and other questions will be addressed here.

First, there are 2 general kinds of testing, molecular and serological.

Molecular tests were the first type of Covid 19 test available from the CDC and WHO.  At this time 22 companies have received FDA authorization of distribute these tests and additional 50 companies are preparing their applications for approval.  The Abbott 5 minute test is a molecular tests.

In a molecular test, a non blood sample such as a nasal swap or saliva is collected.  The molecular test detects the presence of genetic material from the virus.  In this test, the genetic material from the swab is copied to make large enough quantities for use and the compare the known genetic sequence of the corona virus.  If you want to impress you friends, this process is called reverse transcription polymerase chain reaction of RT-PCR.  Depending on whose product you use, the time for analysis in the machine is 5 minutes to 48 hours.  Note that often the rate determining step is getting the sample to the lab, often the lab is not the hold up.

What does the molecular test tell you.  A positive test means that is possible that an active Covid 19 infection has occurred.  However, a positive test does NOT rule out bacterial infections of infections by other similar viruses (eg influenza)

A negative samples means that there was no Covid 19 infection found.  However, if you were tested soon after you were infected, they may not be enough virus to be detected.

The guideline is a positive test is indicative of Covid 19, especially if you have a hard time breathing and fever, but there is still a chance that you do NOT have the virus.

If you test negative, you have either been too recently infected for detection or you don’t have the virus.  The only way to be sure is to be tested again in a couple of days (if you are still symptomatic)

Serology Tests

These are the antibody tests everyone is talking about.  The human body is an amazing thing.  When the body detected a new infection, like Covid 19, it sets about making a protein specifically to combat the virus.  This takes awhile but eventually the body develops a protein which will kill or neutralize the virus.  The proteins it makes are termed immunoglobulin (Ig).  The presence of immunoglobulin M (IgM) in the blood indicates a recent infection.  The presence of immunoglobulin G (IgG) indicates that the infection has been around for awhile.  The test used to detect the presence of these proteins is called ELISA (enzyme linked immunological assay).

It typically takes less than 20 minutes to do an ELISA.  However, it can the body several days to make enough IgM to be detectable, so if you get tested too soon after infection you test negative.

If you test positive for IgG, then you probably had the disease and in the best of worlds, you are immune.  However, it is critical know that (at this point) we do not know how long the immunity lasts or even if it’s possible to get reinfected even though you have the antibody. If you test negative, then you probably have not had the virus, but it doesn’t mean you won’t get it tomorrow.

Key points:

Molecular tests are available but will only tell you if you are likely to currently have the disease.  You could get it tomorrow.  This means that there is little reason for asymptomatic people to have the tests.  It only means you are infected the day of the test.

Even if the molecular tests is positive, it is not 100% assured you have covid 19.  There are some number of false positives and the positive result may be from other strains of related flu or bacteria.

The antibody tests must be run several days after you are infected, otherwise it will be negative.  It is not know what level of immunity a positive tests means.

A key specification that is never discussed in the news is the specificigy and sensitivity of each test.  That is each test a different accuracy rate of the number of false positives and false negatives.  The much vaunted Korean test has over a 20% error rate for instance.

Final Points

  1. It is not likely necessary or desirable that everyone get tested. Especially if you are asymptomatic.  Going in to get this test while you are asymptomatic gives little helpful information as far as treatment goes and does not tell you anything about tomorrow if you are negative.
  2. Antibody testing would be important from an overall disease understanding point of view but is unclear how useful it is for treatment.
  3. The common sense approach is still the best drving force. If you feel sick, especially with respiratory issues and fever then either stay home (if the symptoms are mild) or call your physician and they will give you instructions in how to come in and get help…try not to just want walk into a drs office of hospital (exposing others) unannounced.


7 States with No Lockdown. Good idea or bad?

As we are half way through the month long national ‘lockdown’, attention is being focused on how we should return to life where we can leave our homes, go to work, shop etc.  One of the complications in deciding is the large differences between how the disease has impacted each state and that not all states have the same Covid 19 policies.  This is a discussion over 7 states.

There are 7 states that do NOT have a mandatory state wide ‘stay at home’ order.  These states are Iowa, Nebraska, North Dakota, South Dakota, Utah and Wyoming.  This does not mean there are no restrictions, but it means that the Governors or Legislaturs have not issued a mandatory stay at home or business shut down order.  Each state does have ‘mitigation’ policies such as closing schools and universities, and social distancing and testing programs.  Each state allows each city or county to add additional restrictions if they feel it is in their best interest.  The policy is to allow the most local government to make the decision that they feel is best for them.  In each state, there are cities are counties that have instituted a ‘shut down’ of all nonessential businesses, but the shut downs are not statewide.  There have been some areas which have placed limitations such as the maximum number of people in a store and other restrictions, but the restrictions are local.

To date, these states are 7 of the 16 states with the lowest number of Covid 19 deaths/million people.  Of these states, Iowa has the most deaths/million with 14.  It should be noted that 9 of these 14 deaths in Iowa were in one living facility.  Wyoming has the fewest deaths of any state with 1 attiributed to Covid 19.

Overall, the average statistics for these 7 states are far better than the national average:  There are fewer cases/million and fewer deaths/million.

Cases/million (average)

7 states: 598           50 states: 1410

Deaths/million (average)

7 states: 8           50 states: 51

It should be noted that the average death rate for the 50 states is dominated by results from 6 states which have over 124 deaths/million (NY 513 to Mass 124 deaths/million).  If you exclude these, the national average is 25 deaths/million.  In either case, the 7 no lockdown states have significantly lower death rates.

It is interesting to note that these states have been very aggressive in testing.


7 States: 9807         50 State: 9936

Utah and North Dakota are in the top 10 states with the most testing/million

The population of these states represent less than 3% of the US population.  However, these states seem to fair better than other states with similar populations.  Utah and Iowa have the largest populations of the 7 state with populations of about 3.2 million.  Some States with comparable or lower populations have significantly higher cases and deaths/million.

State Population Cases/million Deaths/million
Nevada 3.1 1026 41
Mississippi 2.98 884 33
Kansas 2.91 473 21
Rhode Island 1.08 2817 69
Delaware .97 1855 43
Vermont .62 1197 45
Wash DC .73 2856 76

Only time will tell if these 7 states made the right decision.  However, it does illustrate clearly that not all states have the same distribution of Covid 19 cases and deaths.  They are, on average, less socially distanced as many businesses remain open in these states.  If we could develop a better understanding of why the number of cases and deaths are low in these 7 states that did not lockdown, perhaps it will give insight into how to reopen the country in the other states.

There are couple of possibilities.  The good possibility is that a high number of people in these states have actually been infected but the infections have not resulted in a high number of deaths.  If this is the case, then a large population of these states are being immunized (herd immunization) and there will not be a spike in the number of infections.

The bad possibility is that unknown factors have delayed the onset of the infection and that infection and death rates will climb.  However, the numbers are so much better than the other states, that the situation would have deteriorate rapidly to reach the same levels.

This illustrates the complexity of decision making.  When the restrictions are lifted on businesses and people are free to go about, what policies should be instituted, when should they be instituted, do you institute the same policies everywhere?  Based on current information, different areas of the country differ greatly in the number of cases and number of deaths.