Author: Will Humble

As of this morning, S. Korea (the country with the best surveillance data) has 8,162 confirmed cases and 75 deaths (an average case fatality rate of 0.9%). 

But the case fatality rate varies a lot with age. Of the deaths in S. Korea, 25 have been over 80 years old, and 28 between 70-79 y/o. Fourteen were between 60-69 and 6 deaths have been among people 50-59 y/o.

Seventy-one percent (71%) of the deaths in S Korea are among people 70 years old and above and 89% are among those over 60. The case fatality rate for those over 80 is about 9%, and for all those over 70 it’s about 6.7%.

However, for people under 40 years it’s just 0.04% or 4 in 10,000. You can see from those data that COVID-19 is far more serious among those over 70 years old, and that for those under 40 it’s really not all that lethal.

The South Korean CDC updates their surveillance daily in English, and you can explore their data by going to this website.

Last Wednesday the governor declared a public health emergency to get enhanced authority to respond to the COVID-19 pandemic. This is the 2nd time that this governor has declared a public health emergency (the first one was to respond to the opioid epidemic).

So what does that mean?

It means that there are things that state government can do now that they couldn’t before last Wednesday.  That extra authority is in ARS 36-787. The governor’s press release about the Order provided some clues as to what extra authority he intends to use at least at the start. The Order specifically:

• Allows ADHS to waive licensing requirements during heightened demand;

• Gives the state to access $500,000 in emergency funds to buy stuff and provides the state with emergency procurement authority to buy it;

• Requires insurance companies to cover out of network providers;

• Waives co-pays and deductibles for consumers related to COVID-19 diagnostic testing;

• Implements consumer protections on COVID-19 of diagnosis and treatment-related services; and 

• Requires symptom checks of healthcare workers and visitors at skilled nursing facilities, nursing homes, and assisted living facilities.

Some of the additional authority in ARS 36-787 that wasn’t mentioned in the executive order provides authority for:

• Establishing a temporary waiver of the professional licensing requirements;

• Granting temporary waivers of health care institution licensing requirements; 

• Mandating medical examinations for exposed persons;

• Rationing medicine and vaccines; 

• Buying medicines and vaccines; and 

• Under more narrow circumstances, mandate treatment or vaccination of people and even order the isolation and quarantine of folks.

The US has had a Strategic National Stockpile of medical supplies that can be used when there’s a public health emergency. It’s released when state or local officials ask the fed’s to help support their response.

Back at the beginning of the H1N1 epidemic we asked for personal protective equipment for healthcare workers and antiviral medications from the stockpile. It was remarkable how fast the trucks arrived at our warehouse. The materials were released to hospitals and community health centers and others in anticipation of a surge in demand.

I haven’t heard whether the ADHS is considering asking for SNS materials or not.

Only hours after the governor signed the executive order, the legislature amended and passed SB 1050.  It had been a simple agency continuation bill for ADHS.  It quickly became a vehicle to transfer a whole bunch of money to the agency for the COVID-19 epidemic. 

It appropriates $5M from the rainy day fund to the ADHS Public Health Emergencies Fund right now and up to an additional $50M more from that fund. The ADHS is supposed to notify the Joint Legislative Budget Committee what they want to use it for.

This money is over and above the generous roughly $12M that it will soon be receiving from the CDC for the response.

The President signed an Executive Order declaring a National Emergency Friday. It basically gives the Secretary of HHS the ability to waive or modify regulations in Medicare, Medicaid, CHIP and HIPPA for the duration of the emergency. Presumably those would relate to the treatment of patients and the payments for those services.

He mentioned that there would be some kind of public-private partnership to expand testing capabilities (that would certainly be welcome)!

He also said that an additional $50B would become available to state and local governments for the response through the Stafford Act (although I don’t see that info in the actual declaration). That Stafford funding could be for “providing emergency medical care and temporary medical facilities; supplying food, water, medicine, and other supplies; and management control and reduction of immediate threats to public health and safety“.

Perhaps we will hear more about what these resources would be used for in the coming days from our state officials.

P.S. Last Friday the CDC released new guidance for folks to make decisions about whether or not to dismiss schools as a public health intervention.  it includes a visual decision tree.

Clinical Characteristics of Coronavirus Disease in China

INTRODUCTION

Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients.

METHODS

We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death.

RESULTS

The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%).

Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission.

CONCLUSIONS

During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)

This Post was last updated on March 15, 2020.

An important question regarding the etiology of the COVID-19 virus is outstanding… what’s the average case fatality rate?  

The case fatality rate is the number of folks that die from an illness divided by the number infected. The WHO has released a statement suggesting that the case fatality rate is 3.4%. This is inaccurate. Other sources have suggested that it’s 2%. This also is almost certainly a gross over-estimate of the average case fatality rate.

So are there any good data out there to get a better estimate?

Perhaps the best source is the S. Korean CDC, which has done robust testing. S. Korea has done far more testing than we have here in the US and have a much more broad testing protocol than we do.  Up until this week in the US, only severely ill patients with no alternative diagnosis, symptomatic folks with known contact with a case, or symptomatic people with travel history to an epidemic region are in the testing protocol.

As of this morning, S. Korea has 8,162 confirmed cases and 75 deaths (case fatality rate of 0.9%). Bottom line- the best data I can find is from S Korea and it suggests the average case fatality rate is 0.9%.

But the case fatality rate varies a lot with age. Of the deaths in S. Korea, 25 have been over 80 years old, and 28 between 70-79 y/o. Fourteen were between 60-69 and 6 deaths have been among people 50-59 y/o.

Seventy-one percent (71%) of the deaths in S Korea are among people 70 years old and above and 89% are among those over 60. The case fatality rate for those over 80 is about 9%, and for all those over 70 it’s about 6.7%.

However, for people under 40 years it’s just 0.04% or 4 in 10,000. You can see from those data that COVID-19 is far more serious among those over 79 years old, and that for those under 40 it’s really not all that lethal.

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To get a better picture of the percentage of confirmed cases that are asymptomatic let’s take a look at what happened on the Princess Cruise Ship – perhaps the best place to look for which there’s a good denominator (as they were a captive population).

A brand new study from that incident estimated that the delay-adjusted asymptomatic ratio of the positive COVID-19 infections on board the ship was 34.6%. In other words, about 35% of the folks on the Princess ship that were infected with the virus were asymptomatic. That’s an important factor, because it suggests that the S Korean CDC data (perhaps the best that’s out there right now) is an overestimate of the the case fatality rate.

We’ll get a better picture of how lethal the COVID-19 virus is in the coming weeks- but I felt compelled to include this data from S Korea and the cruise ship this week because there are a lot of people out there that are hanging their hat on the 3.4% and 2% case fatality rate numbers- and those are overestimates.

Also, remember that this discussion is about the average case fatality rate.  The fatality rate for certain sub-populations like the elderly and people with pre-existing conditions that put them at more risk will have a much higher case fatality rate than the average case fatality rate.