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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.

Tests/million

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.

 

 

 

How are we doing? Better

The number of new Covid 19 cases is still rising.  However, the number of new cases per day seems have ‘flattened’ in the past week .

It is also important to look at the data in a more ‘granular’ way.  These national numbers are driven over 70% by the data from 4 states New York, New Jersey, Michigan and more recently Pennsylvania.  New York has been the ‘hot spot’ for Covid 19 and dominates US statistics.  There have been 544,906 total cases reported and 188,694 (37%) were from New York.

These states also dominate the daily statistics.  Yesterday, there were 12027 new covid 19 cases reported across the US.  However, 63% of those cases (7550) were in New York and another 1029 were reported from Pennsylvania.  These two states accounted for 71% of all US new cases.  Maryland was third highest with 539.  Overall, the total number of new cases seems to have flattened around April 2.

Yesterday, there were 858 new deaths reported for the total US.  New York reported 758 of these accounting for 88% of the new deaths.  The second highest reported number of new deaths was Maryland with 29.  However, it should be noted that NJ reported 251 new deaths, and Michigan 111 which were NOT included in the 858.  This would make the nation total 1120 with New York contributing 68% of the new deaths.

Overall the national number of new deaths also seems to have ‘flattened’ around April 7.

The big question, of course, is when can we start to ‘relax’ the social distancing restrictions we have been living with?  More data will help – but that always takes time.  The effects on the economy have health effects too.  The estimates for the number of people who live paycheck to paycheck varies from 50-80% (most estimate are around 70%).  This is a lot of people who don’t have money to pay for their homes and food let alone medical expenses.  Each day, we are shut down, more and more people don’t have the money to minimally live.  The stimulus package of several trillion dolllars is an enormous amount of money but is not enough to feed, house and medically treat all those who need it.  So if we stay socially distanced, we ‘flatten’ the curve, but families at risk in many other ways.  If we go back to work too soon, we risk reigniting the Covid 19 infections.  The following is a photo of cars lined up at Food Bank on Friday.

Our best bet is more data.  We are getting more and more data each day here in the US and we will learn a lot from countries such as New Zealand, Norway which will begin to relax regulations this week.  The response to reopening schools, and businesses by these other countries will be closely watched by all.

In the mean time, things are all going in the right direction.  With the exception of a 4 or 5 states, the number of new cases and new deaths have either flattened or decreased depending on the state and city.  There does not appear to be a shortage of hospital beds or ventilators anywhere and the supply chain for medical equipment gets better each day.  This was a potential disaster that seems to have been averted (knock on wood).

Did Germany handle Covid 19 better?

Germany has been touted a standout nation due to it’s low fatality rate.  This of course, makes everyone wonder why we don’t handle the virus like Germany?  However, just little deeper dive shows that the reason is not clear and may not in fact hold up as time goes on.

Does Germany have more success managing Covid 19 and if so, how did they do it?

First, the summary data from a combination of WHO and the CDC as of April 7.

  US Spain Italy Germany France World
cases 404056 146690 135586 109329 109069 1,485,535
deaths 12988 14555 17127 2096 10328 87292
population (millions) 375 46.9 60.4 83 67 7,800
cases/million 1221 3137 2243 1305 1671 3,137
deaths/milliion 39 311 286 25 158 314

At first glance, Germany seems to look pretty good.  Compared to the US, Germany has 109,329 cases vs the 404056 in the US.  More importantly, Germany reported 2096 deaths vs the 12988 in the US.  However, the population of Germany is 83 million vs the 375 million of the US.  This means that Germany actually has more cases/million people than the US (1305 vs 1221) respectively.

Germany has 600% fewer deaths than the US, but only 56% lower based on deaths/million people.

Germany, to date has run the most number of tests/1000 people than any country in the world but the US has actually run more total tests.  As the US rate of testing increasing weekly, the Germany rate of testing is remaining constant.  The US will pass Germany in terms of tests/1000 patients in a few weeks.

It is also noted that Germany has tested the most asymptomatic or mild symptom patients of any country.  This would also lower their deaths/thousand cases.  There are also some reports that the Germans who are infected are significantly younger than those infected in the US.  As the disease is more deadly to the elderly, this would also skew the results.

In comparison with the other large countries of Europe, the US has the lowest number of cases/1000 patients and the second lowest fatality rate.

It is also interesting to note that although there were some targeted closings,  Germany’s national lockdown and social distancing regulations were put in place more than a week(March 22) after fellow EU members France (March 10), Austria, and Spain(March 14) had imposed similar policies.

There is no evidence that Germans are respecting shelter in place and social distancing more than any other country.

A large factor in Germany is that the ‘states’ have essentially more power than the central government.  Each German state made it’s own rule of what was an essential business and what you could and could not do.,  For instance in Berlin, bookshops were open but picnics were forbidden.  In Baden-Wuttenberg, it was exactly the other way around.  However, it allowed each state to do what it thought best for itself.  The German Public Health service is not one agency but rather by approximately 400 public health offices, run by municipality and rural district administrations.  This allowed each state to pick which test to use and when and how to use it.  The state did not have to wait for any national approval.  This seems chaotic but the end result seemed to be good or at least satisfactory.

The chart below shows that the daily deaths in Germany are still increasing.

The current data from Germany is relatively very good but only better in the category of deaths/million people than the US.  Although this is important, there may be other reasons for these numbers and the numbers are changing daily.  Who knows what the comparison will be in a week.

It does not seem like Germany has a special or different plan for managing Covid 19.

 

Covid 19 Models: Bad News/Good News

The models presented less than a week ago have turned out to be very wrong – which is good for us.

On April 2 (just 6 days ago), the Corona Virus task force showed a model that predicted that there would be 100,000-240,000 deaths due to Covid 19.  However, since that time, the predicted number of deaths have decreased steadily and significantly.  Today’s estimate is that the number of deaths is now projected to be 60,415.  This by the way, is the same number of people who died of the flu in 2018.

The decrease in predicted deaths is due to a reduction in the number of new cases, number of hospitalization and number of ICU patients in the past several days.  This was especially true in ‘hot spots’ such as New York, Los Angeles and Italy.  The projected fatality numbers will continue to drop if the trends continue.

The models are generated by the International Health Metrics and Evaluation (IHME) organization from the University of Washington.   They are recognized as a reputable and respected group that does this kind of modeling all the time.  However, models are only as good as the data that goes in and assumptions that the modelers make.  In the vast majority of cases, the actual numbers used and specific assumptions made are either never disclosed or are only disclosed at later dates.  In other words, we just have to take their word for it.

The IHME also predicted the number of hospital beds, numbers of ventilators etc. that each city might need.   The IHME models for any states were off by a factor of 5.  States that were predicted to have shortages are now predicted to have surplusses.  On April 2,  IHME predicted that Tennesse would have 3000 deaths.  The current IMHE estimate is 600.  Further on April 2, IMHE predicted that Tennessee would need 15,000 hospital beds.  This caused great concern as Tennessee only has 7812 beds.  However, it appears that they will actually only need 1232 beds.  IMHE also predicted Tennessee would need 2000 ventilators and it appears that they will only need 208.  Unfortunately, the IMHE greatly over estimated in many, many instances, including New York and California.  The good news is there seems to be plenty of capacity rather than a shortage.

This is not really the fault of modeling – the limitations of modeling are well known to those familiar with the process and procedure.  But these details are complicated and rarely communicated to public.  The problem comes when decisive action is taken based on models that are not validated and changing almost hourly due to new data.

Great efforts were made to construct makeshift hospital beds, icus and settting up the manufacturing of ventilators.  Fortunately, from the public health side this is all good news, but it could turn out to be a huge sum of money spent on equipment and facilities that are not needed – not mention the anxiety, fear and worry that was generated.

Models have their place, but we know the limitations of models.  It can not accurately predict the track of a hurricane more than a few hours ahead, it can not predict which stocks will go up or down, or if the market will go up or down.  In all these cases, we continue to use models because it is thought to be better than not having it.  However, that’s not always true.

California – Cautious Optimism

Two weeks ago, health models predicted that there would be over 6000 deaths by May. Last week, the model predicted a little more than 5000 deaths.   Today, the models again decrease the predicted of deaths to 1783 by mid April.  There is still uncertainty over when the ‘peak’ will be, but it is possible that it may come earlier than the current May estimate.  The next week will be an important time to watch the data.

The trends for the past 3 days show a lowering of the rates of hospitalization to 2.1% (was over 10% a week ago).  This was good enough that California loaned 500 ventilators to other states this week.

It’s too early to say with  certainty, but the policies of social distancing, hand washing etc. may be working and that is possible that the effects of the virus will be significantly lower than predicted just over a week ago for not just California but the nation.

It is more important now, even more than before that we continue to social distance…the virus is still infecting thousands of people/day and many people are infected and don’t know it.  Isolation is difficult but it keeps the infected and uninfected apart.

Sweden: A Different Covid 19 Plan

Sweden: A different Covid 19 Approach

The picture above was taken yesterday in Sweden.  Look: No Social Distancing.

Sweden has taken what is called a ‘different’ approach dealing with Covid 19.  They have been using minimal behavioral adjustments which relies of some selected precautions and only ‘lockdown’ the most vulnerable people.  Gatherings of more than 50 people are prohibited and high school and colleges are closed.  Sweden has kept it’s borders open.  Preschools, grade schools, bars, restaurants, parks and shop remain open.  A driving concept in Sweden’s approach is to use practices that can be continued for a long time.  More severe lockdowns are limited (even though we don’t know what the limits are) in they can not go on forever.

It is interesting to note that social distancing being practiced now is the first time that healthy people are being isolated as well as the sick.  In past epidemics, only the sick were isolated.  So in a way, Sweden is doing what is usually done and the rest of the world is really running an experiment.

The question is: How is Sweden doing?

To make the closest comparison possible, I compared the Scandavian Counties of Netherlands, Sweden, Finland, Norway and Denmark.  These other countries had nation wide social distancing policies like the US with nonessential operations and schools coming to a stop.

Here is an overview as of April 6, 2020.

Sweden Holland Finland Denmark Norway
deaths 477 1867 27 187 74
cases 7206 18803 2176 4681 5760
deaths/million 47 109 5 33 14
cases/million 713 1093 396 836 1067

Holland had the most cases, the most deaths, the most cases/million people and the most deaths/million people.  Sweden did remarkably well given the ‘minimum’ adjustments they made to daily living.  They had fewer cases/million people than Holland, Norway and Denmark.  Sweden did have a higher fatality rate but it is not clear what the reason is?  Differences in testing and the demographics of who was infected may have played a role in the results.

It is not known what the future will bring?  At this point, Sweden’s approach does not seem to give demonstrably worse results than countries more strict social distance policies.  However, it is not know what the future will bring?  It is possible that Sweden’s infection rate will go up or down  in the weeks to come.  They are offering an interesting comparative example of another approach to handling the disease.  Time will tell if they made the right decision or not.

Commentary:  There are many who criticize Sweden for not taking more action.  However, the data suggests that it’s infection and death rate are essentially the same as other countries who are imosing strict social distancing guidelines.  However, if an outbreak should occur anywhere in the country, the infection rate could be catastrophic.  They could look like they smart if things stay the way they are and they will be judged incompetent and perhaps even arrogant if Covid 19 should break out.

I wish them the all the best and they be spared from the strength of an epidemic, but their policy is quite a gamble.

Deaths/day of Sweden, Holland, Finland, Denmark, Norway

 

 

Covid 19: Italy Experience

Italy has recorded the highest number of Covid 19 deaths (15887) in the world.  It also has the second highest national fatality rate of 263 deaths/million people.  This in comparison to the US which has has 9652 deaths and a national fatality rate 29 deaths/million people.  It is not completely clear why the Italian and US experience is so different.  It is likely that the virus was spread during the 3 week period from the first detected case to the date that a nation wide quarantine was put in place.  Restaurants and bars remained open for another 2 days after the national quarantine was announced.

As of April 6, there has been a decline in the number of deaths for 3 straight days.  It is hoped that this signals that the ‘peak’ of the infection has passed and that quarantine efforts are having an effect.

Here is a timeline of events in Italy.

The first 2 cases of Covid 19 were made on Jan 31, 2020 when 2 Chinese tourists in Rome tested positive.  On the same day, Italy suspended all flights to and from China.

In February, 11 municipalities in northern Italy were identified as infection centers and placed under quarantine.

February 23.  Additional specific towns are placed under quarantine.  Carnival celebrations and some soccer matches were cancelled.

March 4.  Schools and university were closed but there were now over 3000 known cases.

March 8.  Quarantine expanded to all of Lombardy and 14 other northern provinces.

March 9. Quarantine exteded to all of Italy.

March 11.  All bars and restaurants closed.

March 22. Factories are closed and all nonessential production is halted (59,138 cases).