Forget about mortality rate, this is why you should be worried about coronavirus

2022 Edit: It still gets a few hundred views a month, so it’s worth a little foreword:

This was first written in January 2020 and immediately exploded. It reached over a million views within within the first three days and was republished in a few other places online.

As you can see from the comments I was accused of being alarmist and overstating the danger. It was shared so widely because people were reading it and panicking.

Two and a half years later, was the danger overstated?

Well, no, not really.

It’s a little arrogant to say, but I consider this piece to be one of the most accurate and prescient predictions of the impact that C-19 was going to have. There were only a handful of other people that got it this right, this early.

The US alone was suffering a 9/11 every two days at the height of the pandemic. My outlook wasn’t that negative, had I predicted something like that in this article I'd have been called a kook.

At the same time, the total healthcare collapse scenarios that were outlined as a distant possibility in this piece were avoided by the actions of our governments with rapid vaccine development, lockdowns and so on.

My analysis ended up being largely accurate, but also simultaneously both too pessimistic and too optimistic, interesting no?

— — — — — — — — — — — — — — — — — — — — — — — — — — — —

There’s been a huge amount of talk about the coronavirus on social and traditional media. Our governments are telling us not to worry, with a few key points being repeated:

“It’s just the flu”.

“The mortality rate is only 2%.”

“Only 3000 people have died so far”

“The only people dying are the old and people already sick”

If you’re young and healthy, what is there to worry about?

It turns out, an awful lot. Let me explain:

The main risk of the coronavirus outbreak isn’t that you’re going to get sick and die, it’s that so many people are going to get sick so quickly that our healthcare services and infrastructure are going to be completely overwhelmed.

Let’s look at the virus, it’s called SARS-CoV-2. The illness is called COVID-19.

This is the information we have so far, based on multiple sources:

Incubation period: 2–14 days 1

Transmission Methods:

• Respiratory droplets (coughing, sneezing) 2
• Fomites (infected clothes, furniture, sheets, hair, skin, vehicles, tools) 2
• Fecal-Oral (ingesting infected fecal matter, flies landing on your food, touching your mouth with your hand after contact with a public door handle) 3
• Possible airborne (different from droplets, airborne can be carried by dust in the air) 4
• The Virus may persist on surfaces for up to 9 days, on some surfaces up to 27 days 5

R0 is a measure of how infectious a virus is

• the R0 of the flu is 1.28 6
• the R0 of SARS-CoV-2 is assumed to be between 1.4 and 3.8, potentially much higher 7

Symptoms

• Fever 8
• Cough 8
• Shortness of breath 8
• Mean time from illness onset to hospital admission with pneumonia is 9 days 9
• 20% of patients require hospital treatment 9, 10
• 20–32% of patients hospitalised required intensive care for respiratory support 9
• Some people are completely atypical

Death Rate

The worrying parts:

The virus is highly infectious, potentially nearly twice as infectious as the flu. It might be far higher, there isn’t anywhere near enough data yet.

Infected people could spread the disease for up to two weeks before showing symptoms.

Some people don’t show any symptoms at all and could infect an enormous number of people.

In The Atlantic, Marc Lipsitch, a leading epidemiologist at Harvard reported that “that within the coming year, some 40 to 70 percent of people around the world will be infected with the virus that causes COVID-19”. This was last week and while ridiculed at the time, his assumptions are now the generally accepted position among epidemiologists.

As of this morning, there are 80,000 reported cases in China, 3000 in South Korea and 1000 in Italy.

In most western countries the number is much smaller, 68 in the USA, 23 in the UK. You can find up to date data for your country here.

The first thing to note is that Korea and Italy have been testing much more widely than other countries. Up until recently, most countries have only been testing people that have visited China.

The second thing to note is that “confirmed cases” is not the total number of cases in that country. “confirmed cases” is the lowest possible number of cases in that country. It’s the lower bound of an estimate.

The third thing to note is that while the number is relatively small right now, cases outside of china are doubling roughly every 5 days. The reported rate of infection in China is lower, but China has taken drastic quarantine measures, including welding people inside apartment buildings.

Ok, so it’s infectious. But it’s not a problem, it’s just like the flu…right?

Comparison to the flu

Each year the flu infects between 2 to 11% of the population. 11

The infectiousness of a virus is measured by its R0 value. R0 is a measure of how many people will catch a disease from one infected person. The R0 value of the flu is 1.28. The R0 of COVID-19 is assumed to be between 1.4–3.8

Dr Marc Wathelet, research leader at the only institute in the world dedicated exclusively to research on respiratory disease transmission wrote an article this morning claiming that the R0 is being severely underestimated and the real value could between 4.7 and 7. 12

Okay, okay so it might be much more infectious than the flu, but that’s fine because the mortality rate is only 2%, right?

Mortality Rate

Let’s assume the Chinese data is correct.

The formula China is using is current total deaths/current confirmed cases.

When this widely circulated mortality rate was calculated 97% of the country’s total deaths (414) were in the Hubei Province

Mortality rate in Wuhan was 4.9%

Mortality rate in the Hubei Province was 3.1%

Mortality rate in other provinces was 0.16%.

Mortality rate nationwide was 2.1%.

When asked why Wuhan was so much higher than the national level, the Chinese official replied that it was for lack of resources, citing as an example that there were only 110 critical care beds in the three designated hospitals where most of the cases were sent.

If you’re young and healthy, you’re probably going to fight the virus off just fine. 80% of the cases are mild and if our hospitals hold out, the mortality rate should be the same as the hospitals outside of Hubei, a manageable 0.16%

If you’re not young and healthy, you might want to be more careful. The death rate is far higher in older cohorts, it’s at least 14.8% in the over 80 group.

Why does that matter?

The UK has 2.8 million people over the age of 85.

The US has 12.6 million people over the Age of 80.

Trump told people not to worry because 60,000 people a year die of the flu. If just 25% of the US over 80’s cohort get infected, given current mortality rates that’s 466,200 deaths in that age group alone with the assumption that the healthcare system has the capacity to handle all of the infected.

The Problem

The danger doesn’t come from the virus, it comes from our under-prepared, fragile healthcare systems.

Western governments are responding by saying that they are prepared and ready to deal with the crisis, that it’s similar to the flu.

A recent paper suggested 80% of all cases are mild but 20% of those infected required hospitalization and 14% of those hospitalized require intensive respiratory treatment. 10

Can you guess the number of people that have contracted the flu this year that needed hospitalisation in the US? 0.9%

Let’s use Belgium as an example.

On the 26th of February, a minister answered a question about the preparedness of the country by saying

In Belgium, we have enough beds and sufficient treatment capacity. When we compare it to a winter flu and the number of elderly patients who are hospitalised, the situation is identical

In response, Dr Marc Wathelet, the expert I mentioned earlier wrote a letter to the Belgian government yesterday morning noting that the infectiousness and hospitalisation rates are much higher than the flu.

In my file, I cited the WHO, which on February 10 estimated that 16% of symptomatic patients were in a condition serious enough to require hospitalization. Influenza? 0.2% of cases.

The WHO released a report yesterday stating we now have more precise figures for symptomatic patients: 80% of mild cases, 13% of severe cases (hospitalization), 6% of critical cases (intensive care).

If the proportion of symptomatic cases due to the new coronavirus reaches 1% of the population, we would be on the verge of a hospital crisis due to lack of beds

Humans are pretty good at understanding threats to ourselves. We evolved to be on the lookout for prehistoric predators, and in the modern day we understand that the chances of being hit by lightning, or dying in a plane crash are pretty unlikely.

Evolving to be observant of direct dangers to ourselves seems to have left us terrible at predicting second and third-order effects of events.

When worrying about earthquakes we think first of how many people will die from collapsing buildings and falling rubble. Do we think of how many will die due to destroyed hospitals? How many will die because medicine can no longer be delivered on damaged roads?

The average mortality rate of 2% is with the caveat that our healthcare systems can manage severe cases.

We know that if the virus becomes widespread, they can’t.

We think the virus might be much more infectious than the flu, but let’s assume that only 8% of the UK population gets infected, the same as a severe flu season.

The UK population is 67 million people, that’s 5.4 million infected.

Currents predictions are that 80% of the cases will be mild.

If 20% of those people require hospitalization for 3–6 weeks?

That’s 1,086,176 People.

Do you know how many beds the NHS has?

140,000

If the present data about the virus is correct, even at conservative estimates we are going to have hundreds of thousands of people needing hospitalisation and intensive care. The strain that this will place on the healthcare system cannot be overstated. We are not prepared to deal with a pandemic.

This is a Coronavirus isolation facility at a hospital in Lincoln, UK:

No, not the building. The tent.

The potential for the healthcare system to be overwhelmed is very real.

If our hospitals are overwhelmed how many will die from unrelated conditions because they can’t get access to healthcare?

How many will die because of shortages of medication?

The limited availability of beds in Wuhan raised their mortality rate from 0.16% to 4.9%

This is why the Chinese government built a hospital in a week. Are our governments capable of doing the same?

The virus is not the main danger, our unprepared medical system and fragile supply chains are.

How many people are going to be prevented from going to work because of quarantine?

The FDA this morning reported the first Drug Shortage in the US caused by the coronavirus.

What can you do?

The CDC warned that disruption to everyday life might be severe

• Wash your hands. Alcohol based-handwash isn’t necessary, COVID-19 is an enveloped virus, meaning it steals some fat and oils from our cells to surround itself and prevent an immune response. All enveloped viruses are vulnerable to soap, which pops the membrane and kills the virus.
• If you need prescription medication, get it now.
• Stock up enough food to last you for a few weeks in case you get infected and need to quarantine yourself. Our supply chains are still functional and can account for the extra demand right now. This might not hold true, particularly if you don't live in the first world.
• Prepare for schools and businesses to close.
• If you have elderly relatives, try to prepare them for isolation until the outbreak is over.
• Psychologically prepare yourself, living in isolation isn’t easy. Tens of millions of people have been in lockdown in China for over a month. Get books, games, movies. Find some projects to work on. Issac Newton completed his Principia Mathematica when Cambridge university closed because of the plague.

What should our governments do?

Copy other governments.

Test entrants at the border.

An immediate increase in the patient capacity of Hospitals. Small regional hospitals especially are going to be under considerable pressure.

Increase the number and breadth of people being tested.

There needs to be preparations to monitor quarantined people.

Emergency purchase or rapidly increase manufacturing capacity for medical equipment.

In South Korea, there are drive-through testing sites. Somebody will call quarantined people twice a day to check they are following protocol and if they need assistance. The South Korean government is delivering food parcels to those in quarantine. Our national and local governments need to quickly organise the capacity and resources required to do this.

Japanese schools are scheduled to be closed for march. School and transport lockdowns should all be considered. Businesses need to encourage people to work from home where available. Sick pay should be considered for infected people to prevent them from leaving.

The Chinese and South Korean governments have been fast and effective in acting against the virus and are still struggling to contain it’s spread. Our governments should emulate where others have had success.

People need more information and they need to be told how serious it is to obey isolation measures.

People will show up to hospitals unnecessarily or dismiss the virus and violate quarantine. A man in Italy that was supposed to be quarantined showed up to court. A man in Israel ignored quarantine to go to a restaurant.

Criminal charges should be considered against those that endanger others by knowingly violating quarantine measures and putting lives at risk.

There is no treatment for the virus, people need to be told to stay at home unless their case is severe. It’s important that this information is widely known to minimise the spread of infection.

Tell others

If we act now, we can contain some of the damage this virus might cause to our families and our healthcare system. Secondary effects are extremely difficult to predict in complex systems. 80% of food in the UK is imported. How about your country? Your town?

This isn’t fearmongering, the data currently available suggests our systems are going to be overwhelmed. As individuals, the best we can do is prepare and encourage our loved ones to prepare. Listen to experts, not politicians. Ignore people saying that nobody is infected, only old people die or the death rate is “only” 2%.

Try to get people to think about the effects of mass hospitalisation and quarantine.

In the best-case scenario, the virus is delayed by warm weather, the fatality and hospitalisation rates are overstated because of the prevalence of smokers and poor healthcare in China and our hospitals are capable of dealing with the influx of people.

If nothing happens and the infectiousness and hospitalisation rates are overstated, you won’t have to go shopping for a few weeks and your friends might think you’re a bit of an idiot. Given the potential severity of an overwhelmed healthcare system, taking steps to protect yourself and your loved ones is the responsible thing to do.

If you enjoyed this article and want more you can find me on twitter here