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It turns out, when I am worried, I panic-data analyze. We are in truly unchartered territory with the COVID19 pandemic. There has never been a global pandemic of this magnitude in modern times. The current level of globalization and human movement makes us all more connected physically than ever before, which also increases pathogen transmission. At the same time, we also have the internet to connect us virtually which helps us connect with family members and work in ways that weren't possible before so I thought I would share some information. In my disease ecology course, I teach my students about the SARS almost-pandemic that occurred in 2003. None of my 20-something students have even heard of this disease.
Actions like fast diagnosis, quarantining infected individuals, and contact tracing were able to stop the emergence of that disease. But the current lack of global leadership has bungled the response to COVID19.
As many of you know, my family and I are in Madrid for the year on academic sabbatical. Madrid looks to be an emerging epicenter of COVID19. It's amazing how fast things are changing on almost an hourly basis here. Just last weekend, there were only about 100 confirmed cases of COVID19 in Spain. As of last night, there were 4,231. The death rate has also been mounting, from 5 deaths last weekend to 121 (based on WHO data) or 198 (based on local news data) last night. This is what exponential growth looks like. It looks like there is nothing to worry about one day, and then suddenly the risk goes up significantly. Therefore, the time to act and change behaviors is when things seem like no big deal.
Because there are not that many examples for us to look to for how things will progress and how effective certain policies will be, I've been looking at WHO data on COVID19 cases from situations a little ahead of where Spain and the USA are (reference below). That means Italy and China. We have also been instructed by the Fulbright commission to leave Spain due to the region being elevated to a level 3 health and safety threat by the CDC. Whether to leave is a very difficult decision since we are here with our family and uprooting our lives here is not simple or desirable. On the other hand, if things are going to get a lot worse here and travel becomes even more restricted (i.e. no one allowed out), we don't want to miss this window of opportunity to return home to California.
With the heightened measures in California and other areas of the US, I hear that many people are trying to figure out how to manage these changing conditions. I put together these data from the WHO from Italy and Spain showing the course of the epidemic and the government response. The epidemic in Italy started in the northern Lombardy region where, again, the epidemic started out slowly with only 3 cases on February 21 then jumped to 79 cases a couple days later and exponential growth in confirmed cases already happening. February 23rd was when schools were closed in Lombardy (light yellow shading) but this did little to slow the disease as shown by the increasing exponential growth. Stores were closed on March 8, just one week ago (orange shading) and a country-wide lockdown occurred just 3 days ago on March 12th (red shading). The epidemic rages on. The more severe measures may start to cause some decline in the number of new cases, but it will take at least 5-10 days to see.
Meanwhile, in Spain, the government was dangerously slow to act. Even as Italy was experiencing exponential growth in disease cases and closing down schools and stores last weekend, Madrid allowed several large events to occur in the city including a Woman's March with ~120,000 participants, a soccer game, and a far-right political rally with several key members that later tested positive for COVID19. Likely as a result of these gatherings, the number of cases in Madrid has swelled in the last week. Last weekend, there were about 400 cases in Spain and 56 deaths. As of last night, the number of cases has doubled nearly 4 times over in a matter of 7 days. Schools were closed in Madrid in March 11th but as the death toll continued to mount, Spain declared a state of national alert on Saturday, closing all stores and restaurants, and then 12 hours later, confined all residents to their homes. Supermarkets and pharmacies are still open but all over movements are not allowed anymore. The schools have been closed for 5 days, but again, there is no sign of the epidemic abating. The next week will show if the heightened measures will start to slow things.
Actions like fast diagnosis, quarantining infected individuals, and contact tracing were able to stop the emergence of that disease. But the current lack of global leadership has bungled the response to COVID19.
As many of you know, my family and I are in Madrid for the year on academic sabbatical. Madrid looks to be an emerging epicenter of COVID19. It's amazing how fast things are changing on almost an hourly basis here. Just last weekend, there were only about 100 confirmed cases of COVID19 in Spain. As of last night, there were 4,231. The death rate has also been mounting, from 5 deaths last weekend to 121 (based on WHO data) or 198 (based on local news data) last night. This is what exponential growth looks like. It looks like there is nothing to worry about one day, and then suddenly the risk goes up significantly. Therefore, the time to act and change behaviors is when things seem like no big deal.
Because there are not that many examples for us to look to for how things will progress and how effective certain policies will be, I've been looking at WHO data on COVID19 cases from situations a little ahead of where Spain and the USA are (reference below). That means Italy and China. We have also been instructed by the Fulbright commission to leave Spain due to the region being elevated to a level 3 health and safety threat by the CDC. Whether to leave is a very difficult decision since we are here with our family and uprooting our lives here is not simple or desirable. On the other hand, if things are going to get a lot worse here and travel becomes even more restricted (i.e. no one allowed out), we don't want to miss this window of opportunity to return home to California.
With the heightened measures in California and other areas of the US, I hear that many people are trying to figure out how to manage these changing conditions. I put together these data from the WHO from Italy and Spain showing the course of the epidemic and the government response. The epidemic in Italy started in the northern Lombardy region where, again, the epidemic started out slowly with only 3 cases on February 21 then jumped to 79 cases a couple days later and exponential growth in confirmed cases already happening. February 23rd was when schools were closed in Lombardy (light yellow shading) but this did little to slow the disease as shown by the increasing exponential growth. Stores were closed on March 8, just one week ago (orange shading) and a country-wide lockdown occurred just 3 days ago on March 12th (red shading). The epidemic rages on. The more severe measures may start to cause some decline in the number of new cases, but it will take at least 5-10 days to see.
Meanwhile, in Spain, the government was dangerously slow to act. Even as Italy was experiencing exponential growth in disease cases and closing down schools and stores last weekend, Madrid allowed several large events to occur in the city including a Woman's March with ~120,000 participants, a soccer game, and a far-right political rally with several key members that later tested positive for COVID19. Likely as a result of these gatherings, the number of cases in Madrid has swelled in the last week. Last weekend, there were about 400 cases in Spain and 56 deaths. As of last night, the number of cases has doubled nearly 4 times over in a matter of 7 days. Schools were closed in Madrid in March 11th but as the death toll continued to mount, Spain declared a state of national alert on Saturday, closing all stores and restaurants, and then 12 hours later, confined all residents to their homes. Supermarkets and pharmacies are still open but all over movements are not allowed anymore. The schools have been closed for 5 days, but again, there is no sign of the epidemic abating. The next week will show if the heightened measures will start to slow things.
Now onto the US. The y-axes are different, but the pattern of disease emergence is clearly exponential. Schools are starting to close in the US, but this is actually much later in the epidemic than when Lombardy or Madrid started closing their schools. It looks like school closures are not sufficient to stop this epidemic. The lockdown in Wuhan, similarly, occurred much earlier in the epidemic and was way more restrictive than anything that has happened in western Europe or the USA. Looking at these data, and based on epidemiologists' projections, beating this pandemic is going to require sacrifices that my generation has not been asked to do before. Yes, keeping your kids home is hard. But in the coming days, it will likely become necessary to halt a lot of other activities and gatherings like going to the gym, restaurants, bars, parties. I know it doesn't look serious now, but please look at the data from China, Italy, Spain, and other countries that are slightly ahead (only a couple of days, in some cases) of the US. The situation can change in a matter of days with an exponentially growing pandemic.
The good news is that there are examples of success. Wuhan, in particular saw a pronounced drop in cases once their lockdown went into effect. Likewise, South Korea has been effective using aggressive pathogen testing and contact tracing. Hong Kong and Taiwan did not forget the lessons from SARS 17 years ago and implemented measures early and aggressively to effectively hold the epidemic at bay within their borders. The estimated R0, number of secondary cases from a single individual, is around 2. Which means to stop this epidemic, we need to reduce transmission or contact rates by at least 50% (but preferably more) to bring the number to under 1, the threshold for sustained transmission. But it is increasingly looking like this needs to be a no holds barred approach: school closures, restricting large gatherings, widespread and efficient diagnosis, and contact tracing are all going to be necessary to stop this pandemic. It is time to take this seriously. A conservative fatality rate of 1% if applied to the entire US population would be 3.27 million. A recent Imperial College modeling study estimates that in the absence of any intervention, the death toll in the US could be 2.2 million. They estimated a death toll of 510,000 in Great Britain. We will all have to make adjustments to our daily lives and it will be uncomfortable, but the alternative is unthinkable.
References:
WHO case data, updated daily:
https://www.ecdc.europa.eu/en/publications-data/download-todays-data-geographic-distribution-covid-19-cases-worldwide
Preprint article (not peer reviewed, but written by scientists to get data out faster) showing estimates of R0 from various locations:
https://www.medrxiv.org/content/10.1101/2020.03.03.20029983v1
Imperial College COVID19 response team study:
https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
References:
WHO case data, updated daily:
https://www.ecdc.europa.eu/en/publications-data/download-todays-data-geographic-distribution-covid-19-cases-worldwide
Preprint article (not peer reviewed, but written by scientists to get data out faster) showing estimates of R0 from various locations:
https://www.medrxiv.org/content/10.1101/2020.03.03.20029983v1
Imperial College COVID19 response team study:
https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
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