Monday, March 2, 2020

Have We Cracked the Coronavirus Conundrum?

[We've been grappling with understanding the coronavirus ("WuFlu") puzzle since late January with the help of @pdxsag, who wrote two guest posts about it. Tyler Cowen has also noticed the conundrum, asking "what gives?" The essay below is by pdxsag and reflects our collaborative effort to understand what is going on here.]

Hopefully this will be the final installment on the WuFlu conundrum. I believe the epidemic will resolve itself over the next 2-3 weeks. There will be an exponential growth in cases as testing is more widely performed, but there will not be exponential growth in mortality. Nor will there be more than a handful -- if any -- of small concentrated clusters of infections.

Since the last essays, infections have popped-up across dozens of countries. Italy and Iran have been notable for going from zero reports to hundreds in the matter of days, having high case-fatality rates (CFR), and, it must be said, non-Asian populations.

In the US the news is occupied with community transmissions (ie. person-to-person with no known Chinese connection) in Washington, Oregon, and California. Additionally, in Washington a male in his 50’s co-morbid for cardiovascular disease died over the weekend, prompting a press-conference by President Trump.

Following the report from Italy on February 21 was the largest 5-day stock market sell-off since the GFC in 2008. Although, I would be remiss not to mention the February options expiration also coincided with the market’s sudden concern with, and sell-off over, Coronavirus. It was almost as if some very deep pockets in January had gone long February call contracts, then in February had flipped and gone long March put contracts.

However, our concern at CreditBubbleStocks has not been exclusive to mercenary financial market prognostication. We’ve also been trying to determine what is the real threat to the US population, ourselves, and our loved ones. To that purpose, there has been considerable conflicting accounts leading to confusion and uncertainty as to what the real story surrounding it is.

The biggest conflict was from China itself, the source of the outbreak. On the one hand they shutdown their entire economy for 2 weeks and quarantined upwards of 600 million people. On the other hand, the reported infection counts and mortality rates were far below what one would expect to warrant shutting down the world’s second largest economy; and, more so, the infection counts China reported perfectly fit an exponential growth and recovery model that one twitter user discovered and shared on the 2nd of February. Over the ensuing 4 weeks of February, excepting one conspicuous shift in the Y-axis, the daily numbers were always reported within 10-20 individuals from the model. Such precision does not exist in the real-world, especially in the midst of a raging epidemic.

Outside of China, neither of the two clusters of non-trivial “N” infections -- Singapore and a cruise ship docked at a port in Japan -- showed anywhere near the severity being reported inside of China. For that matter, within China the severity inside the city of Wuhan and the province of Hubei was markedly greater than the rest of the country, which was reporting a severity not out of the ordinary for the seasonal flu.

The additional information helped to winnow our theories down, and at one point we were working on three hypotheses:

  • Real, but largely harmless virus — the severity and resultant quarantines were a propaganda campaign on the part of the CCP.
  • Severe and deadly virus, but with an incubation period closer to 6 weeks than the typical 2 weeks — this would explain for the otherwise mysteriously slow spreading to neighboring countries.
  • Two virii — a severe virus, escaped from a research lab in Wuhan and a largely benign one planted as a cover-story for the one raging in Wuhan.
As events unfolded I was at pains trying to discount one theory over another. Almost any given day I changed my mind as to what was most likely. Eventually, with no additional deaths in Japan or the cruise ship after an initial headline grabbing one or two, and given literally no deaths in Singapore, and the clock running down on even the 6 week incubation period in the rest of the world, I was thinking either propaganda campaign or two virii were the likelihood.

The problem with two virii, is that genetic sequencing would make that all put impossible to hide. As much as it explained the discrepancy inside Wuhan and the rest of the world, it seemed almost impossible to keep hidden over the long-term. There were too many foreigners and foreign travelers that could have picked up the Wuhan virus and spread it elsewhere. It only takes one or two transmissions for the cat to get out of the bag that there is another virus.

Also, I had seen and not forgotten an interesting tweet mentioning that Covid-19 shared the fecal-oral infection pathway of SARS. I’d also seen someone mention that intestinal transmission could cause considerably more severe symptoms than inhalation of air-borne particles. Indeed, in the first days of January when the outbreak hit the news I remembered from the 2003 SARS outbreak that the biggest cluster and the location of most of the deaths was an apartment complex (Amoy Gardens) with shoddy bathroom plumbing. I quickly dismissed it though, as it would be impossible for an entire city and surrounding province to have shoddy plumbing. It then occurred to me there might be one virus, but two infection pathways causing two different severities. The more I thought about it, the more likely this scenario became.

What finally settled it for me was seeing that the Italian cluster was centered around the hospital. Until then, I thought possibly whatever was in Wuhan, could also have gotten into Iran. The hot-spot in Iran was Qom, which is the site of their military industrial complex and presumably the most likely place for Chinese military advisors to be found. However, as the Italian cluster exceeded multiple hundreds, and there was no mention of a second virus, I decided the two virii theory was just too improbable.

That brought me back to one virus, but two severities. What would be consistent with two severities?

The evidence is that most people are asymptomatic for most if not all of their infections. One of the Americans that was repatriated from the cruise ship barely had 24 hours of fever and admitted he wasn’t sure if his physical condition wasn’t mostly attributable to jet-lag. Countries without broad population testing might not know they even had an epidemic going on. If they started a testing campaign, they would see an alarming number of infected people, yet the average severity among all those carriers would be a non-event, almost indistinguishable from the seasonal flu. That certainly described South Korea.

What if one were to assume two pathways of infection?
  • Ingestion of contaminated food — direct exposure to intestinal cell walls with a potentially large virus load since viruses are not limited to relatively small quantities necessary to remain in an aerosol state.
  • Inhalation of airborne particles — most common contact is within mucus membranes; deep-lung inhalation may occur but would be less frequently, though result in far more severe infections
If those are true, we would expect a few, incredibly severe outbreaks reminiscent of a food poisoning episode. These would most likely be where 1) infected people are to be found and 2) where a large number of people eat from the same cafeteria. Hospitals and long-term care facilities would be the most likely places. As would places with poor sanitation habits and infrastructure. Italy and Iran fit into this scenario perfectly.

Outside of the hot-spots experiencing transmission by contaminated food, for typical airborne transmission we’d expect to see random, generally low-grade infections with occasionally severe results owing to idiosyncratic cases of compromised immunity and other comorbidities. Also with airborne transmission, we’d expect to see an environmental component where cities or regions with poorer air quality experience worse outbreaks in both severity and scale. Again, Qom and Wuhan fit the latter scenario perfectly, but also South Korea was far worse than Singapore. As well, Vietnam, Thailand, and Cambodia, no strangers to Chinese tourists, had not reported any conspicuous clusters of infections.
What have we seen, where we’ve seen the WuFlu?
  • The original outbreak was traced to a Wet Food Market (ie. contaminated food).
  • When a hospital is overwhelmed, the staff never leaves. They eat & sleep at the hospital. (ie. contaminated food).
  • Early in Hubei’s outbreak family clusters were common (I felt at the time that this was also consistent with the "WuFlu as hoax / propaganda campaign" theory, as political dissidents would also cluster in families).
  • The Singapore cases tracked back to a small number of churches and a holiday party (ie shared food consumption).
  • Wuhan has notoriously poor air quality, even for China.
  • Qom, Iran, the one place with an infection rate and severity comparable to Hubei also has notorious poor air quality.
  • In the rest of the world, we hear about isolated cases of infections: 1 in Ireland, 2 in Iceland, a few in Vancouver & Toronto, 1 in Oregon, a few in California, 1 in Mexico. (ie. airborne particles causing mild infection in most cases except a random few).
Now about those comorbidities…
Covid-19 has been called "BoomerPox" for the fact it kills those over 50 at twice the rate of those over 40, and kills those over 60 at 10 times the rate. Also, the comorbidity with CVD and diabetes was often mentioned and warned about.

It occurred to me, in the heat of an epidemic how would doctors know about a patient’s CVD unless it had been previously diagnosed? If it had been previously diagnosed, what is the almost universal result? Statin prescription.

What is non-existent among 30 & 40 year-olds, begins rising among 50 year-olds and is virtually a foregone conclusion among 60 year-olds? Statin prescription.
What do we know about statins? They function by decreasing LDL. Among LDL’s purposes is infection fighting. Additionally, how do statins actually decrease LDL? They block CoQ10 synthesis. What is CoQ10 needed for? Myocarditis recovery. It’s one big vicious cycle.

My Prediction
To be sure, Covid19 is a serious, highly contagious flu. However, in the next couple weeks we are going to find out it’s already been running wild for around six weeks on the West Coast, and for the most part under the radar as a nasty, non-specific flu season. As I said at the beginning, there will certainly be more random reports of infected individuals. If no hospitals get overwhelmed, I think total deaths will be less than 100. Maybe that sounds like a lot, but out of a population of 330 million, it’s not even noise. There may even be a handful of clusters around long-term care facilities. There is one in Washington State already. (Though I suspect for the next few weeks management and staff will be atypically careful -- it would be a supreme irony if hospital & nursing home infection complication rates make a significantly measurable drop over the next 3-4 months.)

Coincidentally, by the time we figure out that Covid19 has been here and most often is not any worse than seasonal flu, the weather will be improving, air quality will be improving, as will sun exposure with increased ultraviolet light killing germs and increased vitamin D making people more resistant to infection in the first place. San Francisco and LA will feel like they dodged a bullet with regard to their homeless communities, and maybe they did. If this had become an epidemic in the fall instead of the waning months of winter, the outcome maybe would have been far different.

Trump supporters and detractors will respectively marvel and fume at his seemingly flippant take that “it will all be fine by April when the weather gets warm,” being right, presumably for the wrong reason. Again.

The second order economic effects will certainly be more interesting. Do Central Banks use the opportunity to engage in coordinated easing? I can’t see why not. They always want to. They just feel they need a fig leaf. Nothing is so vulgar, or so demeaning as being beholden to politicians. As fig leafs go, a global pandemic is a pretty good one.

Costco has a notoriously generous return policy. I wonder how that’s going to work out in the weeks ahead. Airlines, hotels, convention centers, and amusement parks are going to have a tougher time of it for sure. Lost revenue in those businesses is lost forever. Hopefully supply shocks to US manufacturers and retailers are brief and well contained.


Anonymous said...

I talked to several doctors and an ER nurse this weekend. The spine surgeon didn't care about NCoV. The concierge medicine internist seemed to know little about it. The ER nurse was sketching. Finally, I talked to another internist who told me the true death rate was probably flu-level. She said that most people are not going into the doctor with NCoV because symptoms are mild, thus they're never counted against the infection/lethality rates. Moreover, in China, why the hell would you tell the government you're sick? You'll get hauled-off to quarantine so that your immune system has to deal with everything going around in China with no supportive medical care.

She said she thought that NCoV had probably gone around in our county and had been for a month and that it's NBD. She said there's two US Marshals guarding one quarantined patient in our county around the clock and that this was an absurd, CYA response. She also didn't think closing schools was necessary.

I explained that the "news" we get from our government waffles between, "This is NBD" to "THIS IS A PANDEMIC!" She responded that "pandemic" just means, "widespread illness." I said that it's almost like our government doesn't have much experience talking to normal people. OTOH, people want to blame the government when anything goes wrong rather than take personal responsibility and accept bad outcomes as part of God's providence (we Americans are functional atheists) so the government has every incentive to sell the worst case possibility to tell Americans to prepare. At the same time, flights still seem to be coming to/from China and no schools are closed. That makes sense since we couldn't handle any halt to global commerce and the Press would melt-down about it.

All this is adding up to a sclerosis and incompetence to handle something as deadly as Spanish flu, but that hasn't happened yet.

Anonymous said...

I am very confused by the statin comments, which are quite declarative but provide minimal reasoning or citation of figures. If statin use were the issue, and CVD merely a statin indicator, what of Chinese statin users without CVD? And what will that imply for the United States in which statin usage is much higher than in China, with 17% of 40-54yo, up to 48% of those >75 (source: NCHS)?

Allan Folz said...

It's my informed opinion, which is what any blog is.

Nor will I be writing another 2000 words showing that the lipid theory of heart disease and statins are fraud. It's well-established among critical thinkers on the internet, which is the audience of this site, that I feel warranted to simply assert it.

If it's a radical new idea to you, I encourage you to investigate it further.

MrGotham said...

I think the risk that is glossed over in this analysis is whether the health care system can withstand the load place on it by COVID. Statistics from Italy suggest COVID patients are using 3X the beds of peak flu patients and they've accounted for 4X the peak deaths so far vs the flu. The mortality rate in Wuhan seems driven by an overwhelmed health system as well.

Seattle bought a motel for $5MM last week to house less severe patients and is reportedly going to set up "man camps" typically used in remote oil & gas fields to house others.

Reports from Italy are that ICUs are now being set up in the hallways of hospitals.

While the aggregate mortality rate may be no worse than flu, for those north of 60, it appears to be far deadlier on average.

The key now seems to be slowing down the progression of cases so that the health care system does not become swamped with cases it can't address.

Allan Folz said...

I wouldn't say it was glossed over. It was orthogonal to the question of why the wildly divergent severity seen between individual case reports and over-flowing hospitals in Wuhan, Iran, and Italy.

But it is timely of you to bring up. My next post (and definitely final) will address the public health vs. private health aspects, and how it accounts for the glaring conundrum.

CP said...

What was the answer here - two strains?

Or one strain that wasn't that bad, but China exaggerated it in order to get competitors to weaken themselves with lockdowns AND help China Joe rig the election?

Allan Folz said...

One strain that wasn't that bad.

It's definitely worse than regular flu. It is more communicable and 5-15 times more virulent in a log-linear relationship with age. There also remains a unexplained serious immune system over-reaction among some people, probably caused by a genetic component.

But the fact is it was wildly politicized, initially with China, and following-up with the Davos-Globalization group. It is far deeper than China Joe and one US election.

Most suspiciously treatments have been politicized. Any and every cheap prophylaxis has been ignored and proponents of them attacked for being anti-science. To my mind, this is the peek behind the curtain. If Covid was an existential threat to those in power, they would not be picky about the cure or where it came from. Instead, they inserted themselves between doctor and patient in an entirely unprecedented fashion. HQZ was treated like it was a schedule 1 narcotic.

To my mind this much politicization belies another agenda is at work. It was no less than a world war as far as the singular focus it had for the entire planet.

Allan Folz said...

Ops. Meant 2-15 times. And actually it's even more divergent than that because the sub-14 cohort has less morbidity risk from Covid-19 than from regular flu.