55,000 DEAD IN MINNESOTA -BEST CASE

UNDER THE BEST CONDITIONS, MINNESOTA WILL SEE 50,000-55,000 COVID-19 DEATHS.
The StarTrib Headline Deliberately Downplays The Facts In Their Story
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Forecast for Minnesota predicts COVID-19 surge but fewer deaths, in summer
By Jeremy Olson and Christopher Snowbeck Star Tribune staff
March 27, 2020 — 8:49pm
https://www.startribune.com/4th-minnesotan-dies-from-covid-19-as-cases-rise-to-398/569161662/

Minnesota’s new “stay-at-home” strategy could reduce predicted COVID-19 deaths in the state by up to a third, according to the researchers who conducted the modeling.

Minnesota researchers provided the first detailed look Friday at the predictive modeling that influenced Gov. Tim Walz’s “stay-at-home” strategy — which began Friday at 11:59 p.m. — to slow the spread of a novel coronavirus that has caused four deaths in the state.

The good news is that the strategy could reduce predicted COVID-19 deaths by up to a third, according to the modeling, and even more if it buys the necessary time for researchers to come up with vaccines or drugs. But the death toll could still be steep, and the modeling still predicts a point this spring or summer when an overwhelming 2 million Minnesotans are infected all at once.

“My instinct was, ‘that can’t be right. That is so incredibly high it can’t be possible,’ ” said Stefan Gildemeister, the state health economist who conducted the modeling along with researchers from the U’s School of Public Health. While “shocking,” he said the results are only estimates based on assumptions about a still-unfolding global pandemic.

Health officials on Friday also reported two of the state’s four deaths from COVID-19, the respiratory illness caused by the virus. Both involved people in their 80s who lived in long-term care facilities in Hennepin and Martin counties. Minnesota’s confirmed case count is now 398 — with 34 people hospitalized with the illness and 17 receiving intensive care.

Walz issued a two-week stay-at-home order, with plans to follow that with three weeks of lesser restrictions — which will still include dine-in restaurant, bar and school closures. After that, restrictions could be reduced except for the elderly and people with other health problems who are most at risk of severe COVID-19 infection or deaths.

Two of the models by the state and university researchers compared the impact of this strategy vs. doing nothing at all and found that it could reduce deaths by as much as a third.

Both estimates are stark. The do-nothing model predicted 74,000 deaths in Minnesota over the entire course of the pandemic, but the model for the current state strategy still predicted 50,000 to 55,000 deaths, Gildemeister said.

State officials urged extreme caution in interpreting these figures, which are based on a number of assumptions, such as the amount of face-to-face time by Minnesotans that could spread the virus. Researchers also used the global average for the infection rate of the coronavirus, but it might not spread as quickly in Minnesota as in states or cities with more population density.

“We get nervous when we focus on the number,” said Shalini Kulasingam, one of the U researchers. “It’s an estimate based on the data we currently have in hand.

“What we’re all hoping for is at some point that we can actually deploy a vaccine” that dramatically changes the predicted outcomes, she added.

The goal of the “stay-at-home” intervention is to delay the peak of COVID-19 cases by as much as five weeks, which will buy hospitals time to acquire more supplies and ventilators and give researchers more time to study potential drugs and vaccines.

“The scenarios that had been run so far really do not reflect the precise mix of strategies the governor has chosen, and certainly don’t reflect the impact of any of those strategies,” said Jan Malcolm, state health commissioner.
Ventilators are of particular need. While 80% of those who contract corona¬virus infections have only mild to moderate symptoms, as many as 5% suffer severe symptoms and breathing problems that require intensive care.

While the state now has 1,268 ventilators for adults, Walz said that might not be enough at the peak and that “we are working on procuring what we think is going to be needed.”

Under the do-nothing model, the state would run out of intensive care beds in six weeks and see a peak in COVID-19 cases in nine weeks. Now, state officials hope the peak won’t come for 14 weeks.

Other national models haven’t predicted such severe outcomes, even for Minnesota, including those by the University of Washington Center for Health Trends and Forecasts, for the next four months. But each analysis is unique and based on different sets of assumptions.

Key assumptions by the Minnesota researchers included that face-to-face contact — the most likely method of virus transmission — will be reduced by 80% for the next two weeks due to the number of people staying at home and away from large gatherings.
Walz said Minnesotans have already practiced social distancing and that the results have shown up in various ways, including a 49% decline in traffic accidents.

Total predicted infection estimates for the state also rely on the current thinking that people are inoculated after initial infections and can’t get sick again — at least not right away.

Researchers in China recently infected monkeys with the virus, and then challenged them again and found no second cases of illness, said Michael Osterholm, director of the U’s Center for Infectious Disease Research and Policy. “We now have evidence to some immunity that occurs after infection, which is very important in terms of stopping ongoing transmission.”

Minnesota’s modeling shows a sharp decline in cases after the outbreak peaks, because so many people will have recovered and will no longer be infection risks. Osterholm said that presents an opportunity to mobilize people who have recovered.
So far, the state Health Department reports 180 confirmed cases of people who have recovered and are no longer required to be isolated.

“These are the people who can walk in the mouth of the lion and not worry about it,” Osterholm said.

State researchers have conducted dozens of models, including looking at ways to “flatten” the peak of cases through the extension of stay-at-home conditions for months. The researchers did not reveal those models on Friday, noting they are unrealistic in a U.S. democracy compared to countries with authoritarian governments that could force those conditions.

Osterholm said data modeling results can vary dramatically but still don’t change the looming impact of COVID-19 or the need for people to take it seriously right now.

Osterholm on Rogan Radio

Sterile Technique -PSA Safe Grocery Shopping in COVID-19 Pandemic

Drought Map for March 19th 2020

Testimony Of A Surgeon Working In Bergamo, In The Heart Of Italy’s Coronavirus Outbreak.

Dr Daniele Macchini, an Intensive Care Unit physician in Bergamo, Italy March 6th 2020

In one of the non-stop e-mails that I receive from my hospital administration on a more than daily basis, there was a paragraph on “how to be responsible on social media”, with some recommendations that we all can agree on. After thinking for a long time if and what to write about what’s happening here, I felt that silence was not responsible. I will therefore try to convey to lay-people, those who are more distant from our reality, what we are experiencing in Bergamo during these Covid-19 pandemic days.

I understand the need not to panic, but when the message of the danger of what is happening is not out, and I still see people ignoring the recommendations and people who gather together complaining that they cannot go to the gym or play soccer tournaments, I shiver. I also understand the economic damage and I am also worried about that. After this epidemic, it will be hard to start over.

Still, beside the fact that we are also devastating our national health system from an economic point of view, I want to point out that the public health damage that is going to invest the country is more important and I find it nothing short of “chilling” that new quarantine areas requested by the Region has not yet been established for the municipalities of Alzano Lombardo and Nembro (I would like to clarify that this is purely personal opinion).

I myself looked with some amazement at the reorganization of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly “emptied”, elective activities interrupted, intensive care unit freed to create as many beds as possible. Containers arriving in front of the emergency room to create diversified routes and avoid infections. All this rapid transformation brought in the hallways of the hospital an atmosphere of surreal silence and emptiness that we did not understand, waiting for a war that had yet to begin and that many (including me) were not so sure would never come with such ferocity (I open a parenthesis: all this was done in the shadows, and without publicity, while several newspapers had the courage to say that private health care was not doing anything).

I still remember my night shift a week ago spent without any rest, waiting for a call from the microbiology department. I was waiting for the results of a swab taken from the first suspect case in our hospital, thinking about what consequences it would have for us and the hospital. If I think about it, my agitation for one possible case seems almost ridiculous and unjustified, now that I have seen what is happening. Well, the situation is now nothing short of dramatic. No other words come to mind. The war has literally exploded and battles are uninterrupted day and night.

One after the other, these unfortunate people come to the emergency room. They have far from the complications of a flu. Let’s stop saying it’s a bad flu. In my two years working in Bergamo, I have learned that the people here do not come to the emergency room for no reason. They did well this time too. They followed all the recommendations given: a week or ten days at home with a fever without going out to prevent contagion, but now they can’t take it anymore. They don’t breathe enough, they need oxygen. Drug therapies for this virus are few.

The course mainly depends on our organism. We can only support it when it can’t take it anymore. It is mainly hoped that our body will eradicate the virus on its own, let’s face it. Antiviral therapies are experimental on this virus and we learn its behavior day after day.

Staying at home until the symptoms worsen does not change the prognosis of the disease. Now, however, that need for beds in all its drama has arrived. One after another, the departments that had been emptied are filling up at an impressive rate. The display boards with the names of the sicks, of different colors depending on the department they belong to, are now all red and instead of the surgical procedure, there is the diagnosis, which is always the same: bilateral interstitial pneumonia. Now, tell me which flu virus causes such a rapid tragedy.

Because that’s the difference (now I get a little technical): in classical flu, besides that it infects much less population over several months, cases are complicated less frequently: only when the virus has destroyed the protective barriers of our airways and as such it allows bacteria (which normally resident in the upper airways) to invade the bronchi and lungs, causing a more serious disease.

Covid 19 causes a banal flu in many young people, but in many elderly people (and not only) a real SARS because it invades the alveoli of the lungs directly, and it infects them making them unable to perform their function. The resulting respiratory failure is often serious and after a few days of hospitalization, the simple oxygen that can be administered in a ward may not be enough. Sorry, but to me, as a doctor, it’s not reassuring that the most serious are mainly elderly people with other pathologies. The elderly population is the most represented in our country and it is difficult to find someone who, above 65 years of age, does not take at least a pill for high blood pressure or diabetes.

I can also assure you that when you see young people who end up intubated in the ICU, pronated or worse, in ECMO (a machine for the worst cases, which extracts the blood, re-oxygenates it and returns it to the body, waiting for the lungs to hopefully heal), all this confidence for your young age goes away. And while there are still people on social media who boast of not being afraid by ignoring the recommendations, protesting that their normal lifestyle habits have “temporarily” halted, the epidemiological disaster is taking place.

And there are no more surgeons, urologists, orthopedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us.

The cases multiply, up to a rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing. Emergency provisions are issued: help is needed in the emergency room. A quick meeting to learn how the to use to emergency room EHR and a few minutes later I’m already downstairs, next to the warriors on the war front. The screen of the PC with the chief complaint is always the same: fever and respiratory difficulty, fever and cough, respiratory insufficiency etc …

Exams, radiology always with the same sentence: bilateral interstitial pneumonia. All needs to be hospitalized. Some already needs to be intubated, and goes to the ICU. For others, however, it is late. ICU is full, and when ICUs are full, more are created. Each ventilator is like gold: those in the operating rooms that have now suspended their non-urgent activity are used and the OR become a an ICU that did not exist before.

I found it amazing, or at least I can speak for Humanitas Gavazzeni (where I work), how it was possible to put in place in such a short time a deployment and a reorganization of resources so finely designed to prepare for a disaster of this magnitude.

And every reorganization of beds, wards, staff, work shifts and tasks is constantly reviewed day after day to try to give everything and even more. Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted. I saw fatigue on faces that didn’t know what it was despite the already grueling workloads they had. I have seen people still stop beyond the times they used to stop already, for overtime that was now habitual.

I saw solidarity from all of us, who never failed to go to our internist colleagues to ask “what can I do for you now?” or “leave that admission to me, I will take care of it.” Doctors who move beds and transfer patients, who administer therapies instead of nurses. Nurses with tears in their eyes because we are unable to save everyone and the vital signs of several patients at the same time reveal an already marked destiny. There are no more shifts, schedules.

Social life is suspended for us. I have been separated for a few months, and I assure you that I have always done my best to constantly see my son even on the day after a night shift, without sleeping and postponing sleep until when I am without him, but for almost 2 weeks I have voluntarily not seen neither my son nor my family members for fear of infecting them and in turn infecting an elderly grandmother or relatives with other health problems. I’m happy with some photos of my son that I look at between tears and a few video calls.

So you should be patient too, you can’t go to the theater, museums or gym. Try to have mercy on that myriad of older people you could exterminate. It is not your fault, I know, but of those who put it in your head that you are exaggerating and even this testimony may seem just an exaggeration for those who are far from the epidemic, but please, listen to us, try to leave the house only to indispensable things. Do not go en masse to make stocks in supermarkets: it is the worst thing because you concentrate and the risk of contacts with infected people who do not know they are infected. You can go there without a rush. Maybe if you have a normal mask (even those that are used to do certain manual work), put it on. Don’t look for ffp2 or ffp3. Those should serve us and we are beginning to struggle to find them. By now we have had to optimize their use only in certain circumstances, as the WHO recently recommended in view of their almost ubiquitous running low.

Oh yes, thanks to the shortage of certain protection devices, many colleagues and I are certainly exposed despite all the other means of protection we have. Some of us have already become infected despite the protocols. Some infected colleagues also have infected relatives and some of their family members are already struggling between life and death. We are where your fears could make you stay away. Try to make sure you stay away.

Tell your family members who are elderly or with other illnesses to stay indoors. Bring him the groceries please. We have no alternative. It’s our job. Indeed what I do these days is not really the job I’m used to, but I do it anyway and I will like it as long as it responds to the same principles: try to make some sick people feel better and heal, or even just alleviate the suffering and the pain to those who unfortunately cannot heal.

I don’t spend a lot of words about the people who define us heroes these days and who until yesterday were ready to insult and report us. Both will return to insult and report as soon as everything is over. People forget everything quickly. And we’re not evTop of Form

en heroes these days. It’s our job. We risked something bad every day before: when we put our hands in a belly full of someone’s blood we don’t even know if they have HIV or hepatitis C; when we do it even though we know they have HIV or hepatitis C; when we stick ourselves during an operation on a patient with HIV and take the drugs that make us vomit all day long for a month. When we read with anguish the results of the blood tests after an accidental needlestick, hoping not to be infected.

We simply earn our living with something that gives us emotions. It doesn’t matter if they are beautiful or ugly, we just take them home. In the end we only try to make ourselves useful for everyone. Now try to do it too, though: with our actions we influence the life and death of a few dozen people. You with yours, many more. Please share and share the message. We need to spread the word to prevent what is happening here from happening all over Italy.»

Sources:

Original Facebook post

Italian newspaper (Corriere della Sera, edizione di Bergamo) transcript

BBC 4 Coronavirus expert Dr. Richard Hatchett: ‘War is an appropriate analogy’ – YouTube

CEO of the Coalition for Epidemic Preparedness Innovations Dr Richard Hatchett explains the long-term dangers of the Covid-19 coronavirus – saying it’s the scariest outbreak he’s dealt with in his 20-year career
https://www.youtube.com/watch?v=dcJDpV-igjs

Covid-19 and Systemic Healthcare Failure,March 6th 2020

by Dr. Liz Specht -from her twitter feed

I think most people aren’t aware of the risk of systemic healthcare failure due to #COVID19 because they simply haven’t run the numbers yet. Let’s talk math. 1/n

Let’s conservatively assume that there are 2,000 current cases in the US today, March 6th. This is about 8x the number of confirmed (lab-diagnosed) cases. We know there is substantial under-Dx due to lack of test kits; I’ll address implications later of under-/over-estimate. 2/n

We can expect that we’ll continue to see a doubling of cases every 6 days (this is a typical doubling time across several epidemiological studies). Here I mean *actual* cases. Confirmed cases may appear to rise faster in the short term due to new test kit rollouts. 3/n

We’re looking at about 1M US cases by the end of April, 2M by ~May 5, 4M by ~May 11, and so on. Exponentials are hard to grasp, but this is how they go. 4/n

As the healthcare system begins to saturate under this case load, it will become increasingly hard to detect, track, and contain new transmission chains. In absence of extreme interventions, this likely won’t slow significantly until hitting >>1% of susceptible population. 5/n

What does a case load of this size mean for healthcare system? We’ll examine just two factors — hospital beds and masks — among many, many other things that will be impacted. 6/n

The US has about 2.8 hospital beds per 1000 people. With a population of 330M, this is ~1M beds. At any given time, 65% of those beds are already occupied. That leaves about 330k beds available nationwide (perhaps a bit fewer this time of year with regular flu season, etc). 7/n

Let’s trust Italy’s numbers and assume that about 10% of cases are serious enough to require hospitalization. (Keep in mind that for many patients, hospitalization lasts for *weeks* — in other words, turnover will be *very* slow as beds fill with COVID19 patients). 8/n

By this estimate, by about May 8th, all open hospital beds in the US will be filled. (This says nothing, of course, about whether these beds are suitable for isolation of patients with a highly infectious virus.) 9/n

If we’re wrong by a factor of two regarding the fraction of severe cases, that only changes the timeline of bed saturation by 6 days in either direction. If 20% of cases require hospitalization, we run out of beds by ~May 2nd. 10/n

If only 5% of cases require it, we can make it until ~May 14th. 2.5% gets us to May 20th. This, of course, assumes that there is no uptick in demand for beds from *other* (non-COVID19) causes, which seems like a dubious assumption. 11/n

As healthcare system becomes increasingly burdened, Rx shortages, etc, people w/ chronic conditions that are normally well-managed may find themselves slipping into severe states of medical distress requiring intensive care & hospitalization. But let’s ignore that for now. 12/n

Alright, so that’s beds. Now masks. Feds say we have a national stockpile of 12M N95 masks and 30M surgical masks (which are not ideal, but better than nothing). 13/n

There are about 18M healthcare workers in the US. Let’s assume only 6M HCW are working on any given day. (This is likely an underestimate as most people work most days of the week, but again, I’m playing conservative at every turn.) 14/n

As COVID19 cases saturate virtually every state and county, which seems likely to happen any day now, it will soon be irresponsible for all HCWs to not wear a mask. These HCWs would burn through N95 stockpile in 2 days if each HCW only got ONE mask per day. 15/n

One per day would be neither sanitary nor pragmatic, though this is indeed what we saw in Wuhan, with HCWs collapsing on their shift from dehydration because they were trying to avoid changing their PPE suits as they cannot be reused. 16/n

How quickly could we ramp up production of new masks? Not very fast at all. The vast majority are manufactured overseas, almost all in China. Even when manufactured here in US, the raw materials are predominantly from overseas… again, predominantly from China. 17/n

Keep in mind that all countries globally will be going through the exact same crises and shortages simultaneously. We can’t force trade in our favor. 18/n

Now consider how these 2 factors – bed and mask shortages – compound each other’s severity. Full hospitals + few masks + HCWs running around between beds without proper PPE = very bad mix. 19/n

HCWs are already getting infected even w/ access to full PPE. In the face of PPE limitations this severe, it’s only a matter of time. HCWs will start dropping from the workforce for weeks at a time, leading to a shortage of HCWs that then further compounds both issues above. 20/n

We could go on and on about thousands of factors – # of ventilators, or even simple things like saline drip bags. You see where this is going. 21/n

Importantly, I cannot stress this enough: even if I’m wrong – even VERY wrong – about core assumptions like % of severe cases or current case #, it only changes the timeline by days or weeks. This is how exponential growth in an immunologically naïve population works. 22/n

Undeserved panic does no one any good. But neither does ill-informed complacency. It’s wrong to assuage the public by saying “only 2% will die.” People aren’t adequately grasping the national and global systemic burden wrought by this swift-moving of a disease. 23/n

I’m an engineer. This is what my mind does all day: I run back-of-the-envelope calculations to try to estimate order-of-magnitude impacts. I’ve been on high alarm about this disease since ~Jan 19 after reading clinical indicators in the first papers emerging from Wuhan. 24/n

Nothing in the last 6 weeks has dampened my alarm in the slightest. To the contrary, we’re seeing abject refusal of many countries to adequately respond or prepare. Of course some of these estimates will be wrong, even substantially wrong. 25/n

But I have no reason to think they’ll be orders-of-magnitude wrong. Even if your personal risk of death is very, very low, don’t mock decisions like canceling events or closing workplaces as undue “panic”. 26/n

These measures are the bare minimum we should be doing to try to shift the peak – to slow the rise in cases so that healthcare systems are less overwhelmed. Each day that we can delay an extra case is a big win for the HC system. 27/n

And yes, you really should prepare to buckle down for a bit. All services and supply chains will be impacted. Why risk the stress of being ill-prepared? 28/n

Worst case, I’m massively wrong and you now have a huge bag of rice and black beans to burn through over the next few months and enough Robitussin to trip out. 29/n

One more thought: you’ve probably seen multiple respected epidemiologists have estimated that 20-70% of world will be infected within the next year. If you use 6-day doubling rate I mentioned above, we land at ~2-6 billion infected by sometime in July of this year. 30/n

Obviously I think the doubling time will start to slow once a sizeable fraction of the population has been infected, simply because of herd immunity and a smaller susceptible population. 31/n

But take the scenarios above (full beds, no PPE, etc, at just 1% of the US population infected) and stretch them out over just a couple extra months. 32/n

That timeline roughly fits with consensus end-game numbers from these highly esteemed epidemiologists. Again, we’re talking about discrepancies of mere days or weeks one direction or another, but not disagreements in the overall magnitude of the challenge. 33/n

This is not some hypothetical, fear-mongering, worst-case scenario. This is reality, as far as anyone can tell with the current available data. 34/n

That’s all for now. Standard disclaimers apply: I’m a PhD biologist but *not* an epidemiologist. Thoughts my own. Yadda yadda. Stay safe out there. /end

Addendum: to anyone who found this useful or interesting, highly recommend you follow

@trvrb who actually does modeling and forecasting for a living. This thread is a great place to start: https://twitter.com/trvrb/status/1

ABOUT Liz Specht, PhD

As Associate Director of Science & Technology with GFI, Liz analyzes areas of current and future technological need within plant-based and cell-based meat innovation, catalyzes research to address these needs, and supports start-ups and investors who are moving the field forward.

Liz has a bachelor’s degree in chemical and biomolecular engineering from Johns Hopkins University, a doctorate in biological sciences from the University of California San Diego, and postdoctoral research experience from the University of Colorado Boulder. Liz is a Community Fellow with CU Boulder’s Sustainability Innovation Lab and a Guest Lecturer for Singularity University. She has a decade of academic research experience in synthetic biology, recombinant protein expression, and development of genetic tools.