Pandemic Update March 28

CV19 Pandemic Update for 2020-03-28 (Saturday Night).

I’m thinking that the increase in testing that we have done may simply be what’s required to keep up with our infection spread rate, and maybe does not actually dilute our results. The US mortality rate actually just started to go up again.

The numbers are close to estimates, but non-PRC is 6k low, Texas is 2% high, and Maine is 1.5% high. Either the rest of the world is slowing down, with the future estimates coming back in line, or this was an anomaly which will self-correct soon, with an over-sized day.

2020-03-28 Saturday
1-Day Projection: WW 666020/30928; PRC 82012/3301; NON 584008/27627; IT 92840/10156; US 123266/2067; TX 2400/32; ME 182/1
1-Day Distancing: WW 666020/30928; PRC 82012/3301; NON 584008/27627; IT 92840/10156; US 123859/2000; TX 2390/33; ME 182/1
Actual Numbers:   WW 660706/30652; PRC 81999/3299; NON 578707/27353; IT 92472/10023; US 121478/2026; TX 2455/30; ME 211/1

I only include the numbers for PRC because it fits my chart. I am fairy cetrain those numbers are bogus after seeing that their funeral homes appear to be cremating 4-8 times the normal number of bodies. That matches the supposition that we only get 14% of their numbers.

ERR US Testing:   POS 107,568 NEG 561,770 PEND 59,784 HOSPITAL 23,397 DEAD 2,585
1-Day US Testing: POS 107,345 NEG 569,288 PEND 64,889 HOSPITAL 19,587 DEAD 2,013
Actual Testing:   POS 118,234 NEG 617,470 PEND 65,712 HOSPITAL 16,729 DEAD 1,965

I had a formula error and pasted the wrong line for the estimate. Not too far off from the updated estimate, but the real numbers are much further off than I expected.

2020-03-29 Sunday Estimate
1-Day Projection: WW 736981/34604; PRC 82101/3302; NON 654880/31302; IT 98859/10999; US 145164/2596; TX 3112/35; ME 265/1
1-Day Distancing: WW 736981/34604; PRC 82101/3302; NON 654880/31302; IT 98859/10999; US 144607/2494; TX 2934/37; ME 265/1
1-Day US Testing: POS 126,269  NEG 659,435  PEND 70,178  HOSP 23,397  DEAD 2,585
2020-04-01 7-day Projection April 1
7-Day Projection: WW 1,169,645/61,852; PRC 82,134/3,338; NON 1,087,512/58,514; IT 157,313/19,560; US 477,863/6,398; TX 9,131/162
UPDATE            WW 1,097,956/54,118; PRC 82,357/3,321; NON 1,015,599/50,796; IT 132,717/16,052; US 333,315/5,929; TX 7,263/90; ME 468/5

The worldwide numbers are lower by 70k.  The US 477k is from a one-day 175% several days ago, and it has not rolled out of the average. If I dilute that, the estimate is 300k Note that the US is not tracked as part of the world here.

7-Day Distancing: WW 1,169,645/61,852; PRC 82,134/3,338; NON 1,087,512/58,514; IT 157,313/19,560; US 232,880/4,603; TX 5,875/72
UPDATE            WW 1,097,956/54,118; PRC 82,357/3,321; NON 1,015,599/50,796; IT 132,717/16,052; US 237,600/4,513; TX 5,003/68

The distancing algo still tracks close, with 1.5% difference.

7-Day US Testing: POS 134,035 NEG 728,160 PEND 100,028 HOSP 68,262 DEAD 4,770 Overrun: 04-06 335k
UPDATE            POS 150,376 NEG 785,328 PEND  83,576 HOSP 64,012 DEAD 5,886 Overrun: 04-06 342k

The US testing chart looks like hospital overrun may still be April 6 (32% of US hospital beds).

Texas projections are the same except the 1.2m point moves out 1 day.

04-07 29k TEXAS ICU OVERRUN STAGE 1
04-06 36k TEXAS VENT OVERRUN STAGE 1
04-13 146k TEXAS ICU STG3
04-14 178k TEXAS VENT STG3 & Hosp STG1
04-17 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
04-18 532k TEXAS HOSP STG3
04-22 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08

The distancing formula update shows TX ICU one day earlier, and hospital stage 3 one day later.

04-10 2929 TEXAS ICU OVERRUN STAGE 1
04-12 1787 TEXAS VENT OVERRUN STAGE 1
04-20 2929 TEXAS ICU OVERRUN STAGE 3
04-21 1787 TEXAS VENT OVERRUN STAGE 2
04-21 26633 TEXAS HOSPITAL OVERRUN STAGE 1
04-25 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
04-27 4550 TEXAS VENT OVERRUN STAGE 3
04-28 26633 TEXAS HOSPITAL OVERRUN STAGE 2
05-02 47441 TEXAS HOSPITAL OVERRUN STAGE 3
05-02 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08

Here are the milestones from 04-23 data for comparison to track our progress flattening the curve:

04-06 33k TEXAS ICU OVERRUN STG 1
04-07 45k TEXAS VENT OVERRUN STG 1
04-10 150k TEXAS VENT/ICU STG 2 & Hosp STG 1
04-13 366k TEXAS VENT/ICU STG 3 & Hosp STG 2
04-15 660k TEXAS Hosp STG 3

Milestones are based on guesstimates: TX 28.7m pop; 2.9 beds per 1000 in TX (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787); 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)

Testing has ramped up substantially, every 2 days another 20k per day. We are at 110k per day as of 2020-03-28 16:00 EDT. We are expecting another 50k/day from Abbott Labs. That probably is just going to help keep up with demand, and not dilute deaths by confirmations. US mortality rates are up again, at 1.67%,

Our mortality rate is still about a third of the rest of the world, with TX going down to 122%, and the US going up again today to 167% (155% yesterday, 144% prior).

Inflection point for outbreaks with an R0 of 2.2 is 60% of the population, not 60% of the confirmed cases. If we are catching a third of the cases, then uncontrolled, exponential climb would stop when confirmed cases were 20% of the population. If we are catching a 6th, then 10%.

Social distancing data lags by 3 days. Statistics lag by 1 day. Detection lags by 9-12 days. Impact delay of SD on Confirmations MAY BE 9 days, or it may be longer. The correlation is hard to suss out, but it may be that it will become more evident as we get more days of data.

Spreadsheet is updated, and downloadable here:
https://drive.google.com/file/d/1vocCN445AZyVBBLsv0kJR8ZDP9DM0UST/view


Pandemic Update March 27

CV19 Pandemic Update for 2020-03-27 (Friday)’s final numbers. I waited long enough, it is almost time for another update. But, I got some sleep. That helped me feel better. Also, it’s Erica’s birthday!
 
03-27 Friday
1-Day Projection: WW 601509/27192; PRC 81903/3297; NON 519605/23895; IT 87309/8995; US 106851/1552; TX 1988/29
1-Day Distancing: WW 601509/27192; PRC 81903/3297; NON 519605/23895; IT 87309/8995; US 103554/1554; TX 1971/27
Actual Numbers: ww 593291/27198; PRC 81897/3296; NON 511394/23902; IT 86498/9134; US 101657/1581; TX 1937/26
 
1=Day US Testing: POS 89,618 NEG 486,863 PEND 66,880 HOSPITAL 13,923 DEAD 1,471
Actual Numbers: POS 99,413 NEG 527,220 PEND 60,094 HOSPITAL 13,718 DEAD 1,530
 
The numbers are really close to estimates, except Italy had a few more deaths. Almost everything else was on par or a little lower than estimated.
 
 
2020-03-28 Saturday 20:00ish
1-Day Projection: WW 666020/30928; PRC 82012/3301; NON 584008/27627; IT 92840/10156; US 123266/2067; TX 2400/32
1-Day Distancing: WW 666020/30928; PRC 82012/3301; NON 584008/27627; IT 92840/10156; US 123859/2000; TX 2390/33
1-Day US Testing: POS 107,568 NEG 561,770 PEND 59,784 HOSPITAL 23,397 DEAD 2,585
 
I only include the numbers for PRC because it fits my chart. I am sure thei are bogus, since their funeral omes are cremating thousands of bodies per week. Dear China, I respect honesty, not obedience. I know, I am not 10,000 years old. I know, keeping people from panicking is important.
 
 
2020-04-01 7-day Projection
7-Day Projection: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 477863/6398; TX 9131/162
7-Day Distancing: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 232880/4603; TX 5875/72
7-Day US Testing: Positive: 134,035 Negative: 728,160 Pending: 100,028 Hospitalized: 68,262 Dead: 4,770 Overrun: 04-06 295-335k
 
For April 1, we are trending to have more confirmed (mostly from Italy), fewer dead (more than the testing stat dead though), fewer in the hospital, and a lot more tests run. We are clearing 110k tests per day.
 
The US testing chart looks like hospital overrun may be April 6 (32% of US hospital beds).
 
Texas projections move one more day further out on every estimate.
04-07 29k TEXAS ICU OVERRUN STAGE 1
04-06 36k TEXAS VENT OVERRUN STAGE 1
04-13 146k TEXAS ICU STG3
04-14 178k TEXAS VENT STG3 & Hosp STG1
04-17 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
04-18 532k TEXAS HOSP STG3
04-21 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08
 
The distancing formula overrun estimates are pulled way back closer to the others, because social distancing got worse again. It is only -20% right now.
04-11 2929 TEXAS ICU OVERRUN STAGE 1
04-12 1787 TEXAS VENT OVERRUN STAGE 1
04-20 2929 TEXAS ICU OVERRUN STAGE 3
04-21 1787 TEXAS VENT OVERRUN STAGE 2
04-21 26633 TEXAS HOSPITAL OVERRUN STAGE 1
04-25 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
04-27 4550 TEXAS VENT OVERRUN STAGE 3
04-28 26633 TEXAS HOSPITAL OVERRUN STAGE 2
05-01 47441 TEXAS HOSPITAL OVERRUN STAGE 3
05-02 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08
 
 
Here are the milestones from 04-23 data for comparison to track our progress flattening the curve:
04-06 33k TEXAS ICU OVERRUN STAGE 1
04-07 45k TEXAS VENT OVERRUN STAGE 1
04-10 150k TEXAS VENT/ICU STG2 & Hosp STG 1
04-13 366k TEXAS VENT/ICU STG3 & Hosp STG 2
04-15 660k TEXAS Hosp STG 3
 
Milestones are based on guesstimates.
TX 28.7m pop; 2.9 beds per 1000 in TX (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787); 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)
 
Testing has ramped up substantially, every 2 days another 20k per day. We are at 110k per day as of 2020-03-28 16:00 EDT.
 
Our mortality rate is still about a third of the rest of the world, with TX going down, and the US going up just a little today.
 
Inflection point for outbreaks with an R0 of 2.2 is 60% of the population, not 60% of the confirmed cases. If we are catching a third of the cases, then uncontrolled, exponential climb would stop when confirmed cases were 20% of the population. If we are catching a 6th, then 10%.
 
Social distancing data lags by 3 days. Statistics lag by 1 day. Detection lags by 9-12 days. Impact delay of SD on Confirmations MAY BE 9 days, or it may be longer. The correlation is hard to suss out, but it may be that it will become more evident as we get more days of data.
 
Spreadsheet is updated, and downloadable here:

NYTimes McNeil Shameful Foment

There’s an NYTimes article claiming the US is hardest hit by CV19, and implying that our lack of autocracy, and our slow-to-respond government is to blame. This is based on us now having the highest confirmed rate.
 
 
That’s bollocks, and Donald G. McNeil, Jr. should be ashamed of misleading and promoting fear and amplifying distrust.
 
First, there is no way autocracy is acceptable. Even if he didn’t realize that’s what he said or implied, he should have a stern talking to. We struggle like any country, but we have a pretty decent amount of personal liberty. Declaring emergencies and taking executive power is spooky, and should stay limited.
 
Yes, our confirmed case number is highest, but that has no bearing on how hard we’ve been hit. We have tested more people than any other country by hundreds of thousands of tests. Our mortality rate is lower than most other countries, on par with SK.
 
Yes, we could have snapped out of it sooner, while China was still misleading the world about what was really going on over there, and we could have done more, sooner. But tests don’t grow on trees. It took time to ramp up testing. We could have probably gotten two weeks extra, not two months extra. Like TX said last weekend, we had money if anyone could provide us the tests.
 
The thing to check for “how hard are we hit” is the mortality rate. We cannot use deaths per confirmed case, because that number is affected by percentage of positive cases found. We do not have that metric for any country. We have some guesses. We can also factor in hospital overload vs not, but that’s not consistent either. There are a few really hot places in the US, but we’re not collapsing them yet.
 
The thing we can look at reliably is deaths per capita from the disease. That tells us how hard we’re hit. For instance, if China had 1000 people dead, and we had 500 dead, China would not be harder hit. Their population is huge.
 
Our total deaths as of yesterday were:
Italy 10k (one per 5.9k)
France 5000 (one per 13.4k)
Worldwide is 122k (one per 64k).
US 1200 (one per 273k)
SK 131 (one per 393k)
PRC 3300 (one per 420k)
 
CAVEAT EMPTOR:
We’re pretty sure a lot of people in China died and never got counted, but everyone else is better about testing people who died with respiratory distress.
 
We’re pretty sure Italy’s rates are a little high, because death from any cause while infected is attributed to CV19 death rate. Mostly, they are just getting hammered due to population age, hotspot distribution, and some procedural errors that allowed intra-hospital disease spread.

MD ERD Notes COVID-19

MD ERD notes RE COVID-19 from TX Ags (aggies forum). He’s giving info for other healthcare professionals. Don’t go self-prescribing or self treating if you’re not a trained professional.
 

From: nawlinsag
Date: 1:27a, 3/25/20

I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.
I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias (general muscular pain; back pain indicated as common), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.Day 5 of symptoms- increased SOB (shortness of breath), and bilateral viral pneumonia (double pneumonia) from direct viral damage to lung parenchyma (the portion of the lung involved in gas transfer – the alveoli, alveolar ducts and respiratory bronchioles.)

Day 10- Cytokine storm (overproduction of immune cells and their activating compounds (cytokines), signaling an inflammatory response flaring out of control) leading to acute ARDS (Acute respiratory distress syndrome) and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (poor oxygen saturation; below 90%) even 75% without dyspnea (labored breathing). I have seen Covid patients present with encephalopathy (brain injury, headache), renal (kidney) failure from dehydration, DKA (Diabetic ketoacidosis: occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic). I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF (Congestive heart failure) and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs (ST-Elevation Myocardial Infarction; serious heart attack) at all of our facilities are getting TPA (Tissue plasminogen activator used to dissolve blood clots) in the ED (Emergency Department) and rescue PCI (Percutaneous Coronary Intervention; aka angioplasty with stint) at 60 minutes only if TPA fails.

Diagnostic
CXR (Chest X-Ray)- bilateral interstitial pneumonia (anecdotally starts most often in the RLL (lower lobe of the right lung) so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC (white blood cell count) low, Lymphocytes low, platelets lower than their normal, Procalcitonin (substance produced in response to bacterial infections but also in response to tissue injury) normal in 95%.
CRP (C-Reactive Protein Test: A plasma protein that rises in the blood with the inflammation from certain conditionsand Ferritin (blood protein that indicates iron level) elevated most often. CPK (creatine phosphokinase: elevated levels indicate muscle trauma, including heart), D-Dimer (a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis), LDH (Lactate dehydrogenase: plays an important role in cellular respiration, the process by which glucose (sugar) from food is converted into usable energy for our cells.), Alk (Anaplastic lymphoma kinase: plays a pivotal role in cellular communication and in the normal development and function of the nervous system), Phos (Phosphorus level: key to kidney function)/AST (Aspartate aminotransferase: released into blood when the liver or heart is damaged)/ALT (alanine transaminase: high levels can indicate a liver problem) commonly elevated.
Notice D-Dimer- I would be very careful about CT PE (CT pulmonary angiography used to detect pulmonary embolisms) these patients for their hypoxia. The patients receiving IV contrast are going into renal (kidney) failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil (type of white blood cell) count to absolute lymphocyte (type of white blood cell) count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6: stimulates the inflammatory and auto-immune processes in many diseases) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia (low blood platelet count) and LFTs (liver function test) 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won’t make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the “lockdown”, our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

Worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2  (angiotensin-converting enzyme) blockade doesn’t appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil’s potential QT prolongation  (refers to an interval seen in an electrocardiogram (EKG) test of heart function) and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.  400mg bid day one then 400mg qd for 4 more days is the goal. But my goal is for the patient to be managed by someone else after the first dose. Although our ER group is helping with floor intubations, central lines, and art line placements so I am seeing some of the longer term treatments.  Advisory on the use of Hydroxychloroquin as prophylaxis for SARS-CoV-2 infection  / HYQ Prophy Dosing Chart

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient’s standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap (Bilevel Positive Airway Pressure, and is very similar in function and design to a CPAP machine )- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI (Metered-dose inhaler). you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn’t often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI (upper respiratory infection)/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 (saturated O2 level in the blood) of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.

 

From: Infection_Ag11

 
I agree that it is striking how fast they crash when they do. It happens right in front of you in very short order.  

The rate of superimposed bacterial PNA is very low, less than 1% based on Chinese data, and so I really don’t feel there is any benefit to azithromycin. Especially given even strep pneumo in major population centers laughs at azithro these days.CXR findings in general have little correlation with disease severity in pneumonia, and that goes for COVID as well. A patient <65 who isn’t hypoxic or hypotensive with a RR <30 essentially never needs to be admitted for pneumonia outside of unique circumstances (regardless of imaging), and even then it’s usually “just in case”. I will say this disease does make one hesitate because of its unique course, but there are predictors other decompensation as you said that can guide you.

I don’t love the Plaquenil option and the data sucks to be honest, but I have used it some. Remdesivir really seems to work well in the severe cases from my anecdotal perch.

 

Also, some of these patients have incredible IL-6 levels. I’ve never seen numbers this high even in my AIDS patients with KICS. One guy had a level above assay which were pretty sure has never been reported by our lab before.

Obviously we dont know what they were for Spanish flu patients 100 years ago but the cytokine storm was the hallmark of that disease. We’re seeing something similar here.

 
Patients requiring supplemental oxygen beyond regular nasal cannula, which in COVID usually ends up being a ventilator. We don’t really try NIPPV as the OP said because it doesn’t help much and risks aerosolizing the virus. I’ve had one patient saved from a vent by high flow nasal cannula, which in terms of pure oxygen delivery is the most we can provide prior to intubation, but generally these people are either on NC or getting intubated because the hypoxia becomes so profound so quickly if they crash.
 
Thanks for posting this. I’m working at a rural Texas ER currently, but I trained EM in Baton Rouge so I have been following the South Louisiana situation. It hasn’t hit here yet but I am sure it’s coming. It’s in every county around us. We have no ICU at my hospital so we will be tubing and attempting transfers. This may prove difficult once all the ICU beds in Houston and Austin are filled to capacity before it even hits out here. Do you have any experience with how rural ED that are critical access without ICU care are handling things in your area? As a typically transfer accepting hospital what is your situation regarding transfers for higher level care?
 
Previous ER medical director at a rural Texas site here. IMO, got to hope that social distancing plus differences in population density allow for recovery in metro areas before rural areas get hit hard. Otherwise, I think you’re going to be managing those intubated patients in your ER indefinitely. Hope to be wrong of course.
 

For those with the elevated levels of IL6, are any of the IL-6 receptor blockers being administered? If so, any results to speak of?

This editorial written yesterday has some inisghts….
https://www.sitcancer.org/research/covid-19-resources/il-6-editorial

Quote:

Emerging evidence suggests that high levels of CRP and IL-6 are observed in patients infected with COVID-19 [1, 8]. Anecdotal experience on the use of tocilizumab at doses comparable to those used for the management of CRS from investigators in Italy [9] and from China [10] has reported rapid improvement in both intubated and non-intubated patients. In these reports, expeditious administration of anti-IL-6R therapy for patients in acute respiratory distress has been critical. A recent study protocol to evaluate the efficacy of tocilizumab in COVID-19 induced pneumonitis accrued over 300 patients worldwide in less than 24 hours. Additionally, Genentech will also provide 10,000 vials of tocilizumab to the U.S. Strategic National Stockpile [11]. Tocilizumab was also approved in China in March 2020, for the treatment of patients with COVID-19 with serious lung damage and elevated IL-6. Sponsors, investigators, and regulators have moved with unprecedented speed and collaboration to initiate protocols to formally study the safety and efficacy of antiviral agents and vaccines, as well as various anti-IL-6 antibodies in patients with COVID-19. In the US, a trial of sarilumab in the COVID-19 setting is ongoing [12].

 
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.

From: Dr. Not Yet Dr. Ag

 
Can’t rely on the chief complaint to be the typical viral syndrome, as I have had one who came in for abdominal pain and another was an older gentleman with altered mental status. Many of them don’t have fever. Several of them have pretty unremarkable lab work, although many have several of the typical lab or imaging abnormalities. Many of these patients are being seen by healthcare workers w/o proper PPE due to atypical complaints. One of the confirmed patients was brought in by EMS without any PPE on whatsoever, although I don’t think they realized that this patient was at risk for having it. Unfortunately, after talking with some of my local EMS friends, they are getting absolutely no education regarding ways to protect themselves, and who they should suspect this in, at least according to them.
 

I am ER, trained at the Lake in BR

We are doing plaq/azithro in the ICU….obviously we have the ability to keep them on the monitor if they go into Torsades. Agree, I am not testing anyone unless they are admitted. I am sorry, but I am not putting my nursing staff at risk for a mildly symptomatic patient to whom the treatment does not change,

Intubation wise, trying to minimize risk as best as possible. I have the vent set up before hand, minimize bagging, have them on 100% NRB until RSI. Then I am pushing paralytic before hand to minimize sedation time. Tube them w glidescope and immediately put them on vent to decrease open circuit time. Can do this <90 sec if prepared.

 

CV19 US Hospitalization Rates

CV19 Pandemic Update!

US has stepped up testing rapidly, and so while social distancing is at -40%, we still show +1% of the new model prediction.

03-26 Thursday
1-day Projection: WW 524523/24175; PRC 81731/3289; NON 442792/20886; IT 79988/8254; US 80513/1257; TX 1582/19 non+IT 1.2%, US 5.1%
1-Day Distancing: WW 524523/24175; PRC 81731/3289; NON 442792/20886; IT 79988/8254; US 82170/1244; TX 1632/20 TX 5% high, US 2% low
Actual Numbers: WW 529591/23970; PRC 81782/3291; NON 447809/20679; IT 80589/8215; US 83836/1209; TX 1563/21

The rapid rise in US testing (127% per day average) may numerically counter the decrease in disease spread from social distancing (-40%). I hope that is factored into the policy plans, because it may look a lot more spooky over the next week than it really is.

03-27 Friday
1-Day Projection: WW 601509/27192; PRC 81903/3297; NON 519605/23895; IT 87309/8995; US 106851/1552; TX 1988/29
1-Day Distancing: WW 601509/27192; PRC 81903/3297; NON 519605/23895; IT 87309/8995; US 103554/1554; TX 1971/27
1=Day US Prototype: Positive: 89,618 Negative: 486,863 Pending: 66,880 Hospitalized: 13,923 Dead: 1,471

I added the Number of Tests and number hospitalized in the US to the spreadsheet. This is somewhat complete for the US and TX, but other countries are hit or miss. Those checkpoint earlier in the day than other stats, but that is fine. Those are much better numbers to track hospital overload than trying to extrapolate from confirmed cases, but much less data. I am still tweaking it all.

Midday Thursday, the US had 10131 hospitalized, and 1163 dead from COVID-19. The rates of increase of these are still climbing at the typical 135% per day. There is not yet a clear correlation between social distancing and death or hospitalization rates, but I am still testing ideas.

Since I only have that for the whole US, I am still tracking confirmed, death, and projecting with social distancing in the main sheet.

2020-04-01 7-day Comparison
7-Day Projection: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 477863/6398; TX 9131/162
7-Day Distancing: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 232880/4603; TX 5875/72
7-Day US Prototype: Positive: 134,035 Negative: 728,160 Pending: 100,028 Hospitalized: 68,262 Dead: 4,770 Overrun: 04-06 295-335k

The old formula pushes Texas overrun slightly further out for late-stage events:

04-06 29k TEXAS ICU OVERRUN STAGE 1
04-07 36k TEXAS VENT OVERRUN STAGE 1
04-12 146k TEXAS ICU STG3
04-13 178k TEXAS VENT STG3 & Hosp STG1
04-16 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
04-17 532k TEXAS HOSP STG3
04-20 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08

The new distancing prototype formula looks like this after tweaking:

04-15 2929 TEXAS ICU OVERRUN STAGE 1
04-17 1787 TEXAS VENT OVERRUN STAGE 1
05-02 2929 TEXAS ICU OVERRUN STAGE 3
05-03 1787 TEXAS VENT OVERRUN STAGE 2
05-04 26633 TEXAS HOSPITAL OVERRUN STAGE 1
05-09 4550 TEXAS VENT OVERRUN STAGE 3
05-09 400k may be the inflection point for Texas if 14% like China, but our death rate is lower than theirs or the world.
05-16 26633 TEXAS HOSPITAL OVERRUN STAGE 2
06-05 47441 TEXAS HOSPITAL OVERRUN STAGE 3
05-21 1.2m Inflection point for R0 of 2.2 is 60% with detection rate of 39.08

The growth in hospitalizations puts overrun at 04-06. I do not know what to believe.

Here are the milestones from 04-23 data for comparison to track our progress flattening the curve:

04-06 33k TEXAS ICU OVERRUN STAGE 1
04-07 45k TEXAS VENT OVERRUN STAGE 1
04-10 150k TEXAS VENT/ICU STG2 & Hosp STG 1
04-13 366k TEXAS VENT/ICU STG3 & Hosp STG 2
04-15 660k TEXAS Hosp STG 3

Milestones are based on guesstimates: TX 28.7m pop; 2.9 beds per 1000 in TX (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787); 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)

Testing has ramped up substantially, and the US has a capacity around 350k tests per week, or 50k per day. The increased testing, and the shift in social distancing makes these numbers more fuzzy. I tweaked my multipliers for regression testing.

Our hospital load may be 31.86% of the world average for the same number of confirmed. Korea had 8652 confirmed from 316664 tests on 03-20 with 94 deaths. Their death rate is 1.42%. Ours is 1.44% with 579k tests, 83836 confirmed, 1209 deaths. The world rate is 4.52% I suppose that the death to confirmed case is tied to the test percentage.

Inflection point for R0 of 2.2 is 60% of the population, times the percentage of infected people who get confirmed. It was estimated elsewhere that China at 4.02% mortality rate per confirmed was 14% tested. That means our hospital load will be 35.82% for the same number of confirmed, or that our confirmed cases are 39.08% of our total cases.

TX has 28.7 million, and 39.08% of that is 1.12 million as our inflection point.

Unknown accuracy because testing inputs are changing, and I am just making things up.

Social distancing data lags by 3 days. Statistics lag by 1 day. Detection lags by 9-12 days. Impact delay of SD on Confirmations is 9 days.

https://drive.google.com/file/d/1vocCN445AZyVBBLsv0kJR8ZDP9DM0UST/view


Results and New Formula

Infection rate and death rates for US and TX match predictions, so that is disappointing. I was hoping they would be lower.

03-25 Wednesday
1-day Projection: WW 461807/21005; PRC 81686/3288; NON 381238/17782; IT 74856/7654; US 66137/903; TX 1203/16
Actual Numbers: WW 467594/21181; PRC 81661/3285; NON 385933/17896; IT 74386/7503; US 65778/942; TX 1229/15

I found a data source that tracks social distancing in the US via mobile phones. I have included a preliminary result for that (US and TX ONLY!) for tomorrow. I do not know if this will be valid.

03-26 Thursday
1-day Projection: WW 524523/24175; PRC 81731/3289; NON 442792/20886; IT 79988/8254; US 80513/1257; TX 1582/19
1-Day Distancing: WW 524523/24175; PRC 81731/3289; NON 442792/20886; IT 79988/8254; US 82170/1244; TX 1632/20

I also changed the WW projections to be NON + PRC, since rounding was really messing up the 7-day projections (WW was less than non-PRC). This new 7-day projection will be a real test of the new distancing formula for US and TX.

2020-04-01 7-day Comparison
7-Day Projection: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 477863/6398; TX 9131/162
7-Day Distancing: WW 1169645/61852; PRC 82134/3338; NON 1087512/58514; IT 157313/19560; US 232880/4603; TX 5875/72

The new numbers push Texas overrun one day later than predicted yesterday.

04-06 29k TEXAS ICU OVERRUN STAGE 1
04-07 36k TEXAS VENT OVERRUN STAGE 1
04-11 146k TEXAS ICU STG3
04-12 178k TEXAS VENT STG3 & Hosp STG1
04-15 400k may be the inflection point for Texas
04-16 532k TEXAS HOSP STG3

The new distancing formula is a different story. Overrun is much further out. Also, the spread makes recovery rate important, so I subtract 10 days prior from current confirmed, and subtract the current dead as well. Again, too new to be reliable, and I did not do a regression test.

04-12 2929 TEXAS ICU OVERRUN STAGE 1
04-14 1787 TEXAS VENT OVERRUN STAGE 1
04-26 2929 TEXAS ICU OVERRUN STAGE 3
04-28 26633 TEXAS HOSPITAL OVERRUN STAGE 1
04-28 1787 TEXAS VENT OVERRUN STAGE 2
05-04 400k Inflection point for R0 of 2.2 is 60%
05-09 4550 TEXAS VENT OVERRUN STAGE 3
05-11 26633 TEXAS HOSPITAL OVERRUN STAGE 2
05-17 47441 TEXAS HOSPITAL OVERRUN STAGE 3

Here are the milestones from 04-23 data for comparison to track our progress flattening the curve:

04-06 33k TEXAS ICU OVERRUN STAGE 1
04-07 45k TEXAS VENT OVERRUN STAGE 1
04-10 150k TEXAS VENT/ICU STG2 & Hosp STG 1
04-13 366k TEXAS VENT/ICU STG3 & Hosp STG 2
04-15 660k TEXAS Hosp STG 3

NOTE that the very first milestone was 04-02 based on 570 ICU beds, and was abandoned as a predictor.

Milestones are based on guesstimates, because the exact number of ICU beds and placement of ventillators is proprietary data that is hard to find and confirm. My estimates are based on: TX 28.7m pop; 2.9 beds per 1000 in TX (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787); 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)

Testing infrastructure may fail before the inflection point, leading to a false decrease in numbers reported. If that happens, we may not numerically reach the inflection point, which is 60% of the population for R0 of 2.2. Remember, we only confirm 12-15% of the actual cases, as many are mild or even asymptomatic, but are still infectious to others.

Inflection point for R0 of 2.2 is 60% of the population, times the percentage of infected people who get confirmed. Current reporting rate is 12-15%. Assuming we keep testing by same criteria, the TX inflection point is 400k confirmed. We may not reach this numerically due to testing/infrastructure failure. eg, we may reach stage 3 while our confirmed rate is much lower, but still around the same days.

Unknown accuracy at this point, because testing inputs are changing.

Social distancing data lags by 3 days. Statistics lag by 1 day. Detection lags by 9-12 days.

https://drive.google.com/file/d/1vocCN445AZyVBBLsv0kJR8ZDP9DM0UST/view


Social Distancing Dashboard

This site uses anonymous mobile phone data to calculate the change in miles traveled, and the change in number of mobile phone encounters. It is an earlier predictor of how well social distancing is working, without having to wait 12 days for the confirmed cases stats to change, nor worry about changes in testing frequency or methodology.
 
It’s really a green-light instantaneous dashboard kind of thing. They don’t expose trending data, or even numerical data, so you cannot chart, trend, or predict off of this.
 

CV19 no big deal

A good question I saw and responded to is “Hardly anyone is sick, and hardly anyone has died. Why is everyone all panicky about CV19? What’s missing?”
 
TLDR: It spreads exponentially, and while you have no symptoms. Listen to the experts if you don’t understand. Don’t be a party to manslaughter.
 
NARRATIVE: The missing part is that it’s an exponential spread. It’s like the old puzzle, there’s one lily pad on a pond, and every day, each lily pad becomes two. It takes 30 days to cover the pond. When is the pond half covered? 29 days.
 
Today, the absolute numbers look very mild right now, and that’s what we like. We want them to stay mild, but any action we take will not have an effect for 12 days. Also, number reporting lags by 1 day. 13 days before the end looks like just any other day in paradise. We’re not doubling every day. We’re doubling every 2.2 days.
 
For the US, we are 10 days from overloading hospital capacity, and 14 days from overloading even reserve, crappy capacity. When we overload the hospital capacity, the death rate quadruples. That’s why it became such a panic.
 
Luckily, the declaration of pandemic was on the 11th, which just started to show up in the numbers yesterday. We’ll know by late Thursday if the declaration of national emergency made an impact. The goal is to keep the number of people in the hospital below the threshold where a lot of extra people die. Right now, that looks so far off, but if we didn’t drastically slow the spread, that would start to look grim for the worst survivable cases around April 5, and by April 15 would be just letting the really sick asphyxiate. I say “didn’t” rather than “don’t” because the time to take action has already passed.
 
It’s easy to ignore when 85% of the people infected simply are not counted, and when only 10% of the counted people are at risk of dying from a hospital overload. However, that amounts to 2-5 million people in the US potentially dying from this. With that many, chances are one of them would be a close friend or family member. If it happens to you, then you would definitely care, and you would not care that it was because a bunch of people didn’t understand exponential math.
 
The panic is because a bunch of us care even when it’s not someone close to us, or we can see that it could happen to us. There are a lot of asymptomatic carriers, spreading the disease. So “I feel fine, I don’t need to quarantine” has already lead to deaths, and will lead to many more deaths.
 
It wouldn’t be God’s Will, or bad luck. It would be a willful choice of people to ignore the experts because the non-experts didn’t understand, and therefore decided the experts were not actually experts. Reckless action leading to the death of others is called manslaughter, and negligent action leading to death is called negligent homicide. Purposefully infecting someone would be called murder.
 
Lag times per Feb 7 study in JAMA from Wang et al:
Median time from first symptom to dyspnea was 5.0 days
to hospital admission was 7.0 days
to acute respiratory distress syndrome was 8.0 days.
For survivors, the median hospital stay was 10 days.
https://jamanetwork.com/journals/jama/fullarticle/2761044
 
Lag times per Jan 22 report by China National health:
Median days from first symptom to death were 14 (range 6-41)
70 year old or above (11.5 [range 6-19] days)
below 70 year old (20 [range 10-41] days.
https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25689?af=R
 
The average is 12 days to show up in the stats, and 20 days start to finish, so that’s what most stats focus on. Policy changes consistently take 12 days to show up in the stats. I’m not sure where that first started, but you can look at the raw numbers and see it. It is self evident.

SARS-2 March 24 Update

First, the update:

03-24 Tuesday
1-day Projection: WW 425953/18600; PRC 81595/3283; NON 346031/15382; IT 69104/6744; US 57310/731; TX 916/10
Actual Numbers: WW 417966/18615; PRC 81591/3281; NON 336375/15334; IT 69176/6820; US 53740/706; TX 955/12

03-25 Wednesday
1-day Projection: WW 461807/21005; PRC 81686/3288; NON 381238/17782; IT 74856/7654; US 66137/903; TX 1203/16

Infection spread appears to be reducing in US and TX, even though TX was above projections for yesterday.
US shows 134% instead of 135%, and the last 3 days were 130%, 131%, and 123%.
TX shows 135% instead of 147%, and the last 3 days were 108%, 121%, and 126%.

This implies that the declaration of pandemic may have had positive effect.

The numbers from tonight or tomorrow will start reflecting any changes caused by the declaration of national emergency.

Milestones would have pushed out a day, but my methodology was poor. I now show the number for the condition in the left of the note, not the estimated number for that day. Also, I dropped stage 2 here, and just show worst case reserve (smallest number) and best case reserve (largest number). I do not have proper numbers to separate stage 1 (over standard) vs stage 2 (over minimum reserve).

04-05 29k TEXAS ICU OVERRUN STAGE 1
04-06 36k TEXAS VENT OVERRUN STAGE 1
04-10 146k TEXAS ICU STG3
04-11 178k TEXAS VENT STG3 & Hosp STG1
04-14 400k may be the inflection point for Texas
04-15 532k TEXAS HOSP STG3

Milestones are based on guesstimates, because the exact number of ICU beds and placement of ventillators is proprietary data that is hard to find and confirm. My estimates are based on: TX 28.7m pop; 2.9 beds per 1000 in TX (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787); 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)

Testing infrastructure may fail before the inflection point, leading to a false decrease in numbers reported. If that happens, we may not numerically reach the inflection point, which is 60% of the population for R0 of 2.2. Remember, we only confirm 12-15% of the actual cases, as many are mild or even asymptomatic, but are still infectious to others.

I expect these to move further out each of the next few days, and then it will probably look like it levels off a bit for several days before reducing further.

We are not out of the woods. Hospital usage is 1-4 weeks. Average infection course is 20 days with no hospitalization, but once people are bad enough to need O2 or ventilation, it takes longer to recover well enough to not need it anymore.  If we were to fall to 112% today (unrealistic extreme) and stay there, the milestone dates become 04-23, 04-25, 05-07, 05-09, 05-16, 05-18. That spreads out enough that we may gain an extra couple of days on each due to early cases resolving (people do not stay in the hospital forever).

The current milestones for the US, since TX is about 9% of the US:
03-31 29k -> 322k US ICU OVERRUN STAGE 1
03-31 36k -> 400k US VENT OVERRUN STAGE 1
04-05 146k -> 1622k US ICU STG3
04-06 178k -> 1977k US VENT STG3
04-08 400k -> 4444k US inflection point
04-09 532k -> 5800k US HOSP STG 2

These are MUCH more fuzzy, since it is not exactly 9%, and ICU, Vent and bed capacities vary. That adds 1-2 days uncertainty. This also will be affected by any changes in the numbers as discussed above.

Here are the milestones from 04-23 data for comparison to track our progress flattening the curve:
04-06 33k TEXAS ICU OVERRUN STAGE 1
04-07 45k TEXAS VENT OVERRUN STAGE 1
04-10 150k TEXAS VENT/ICU STG2 & Hosp STG 1
04-13 366k TEXAS VENT/ICU STG3 & Hosp STG 2
04-15 660k TEXAS Hosp STG 3

NOTE that the very first milestone was 04-02 based on 570 ICU beds, and was abandoned as a predictor.

When testing and behavior are nonchanging:
Model is +/- 25% per week
That is +/- 1.5 days for stage 1
That is +/- 2.5 days for stage 2
That is +/- 3.5 days for stage 3

Inflection point for R0 of 2.2 is 60%.
Current reporting rate is 12-15%.
Assuming we keep testing by same criteria, the Tx inflection point is 400k confirmed.
We may not reach this numerically due to testing/infrastructure failure.
eg, we may reach stage 3 while our confirmed rate is much lower, but still around the same days.

This is all bistromath, and both reporting rates, and trends are changing daily at this point.

Also note that the numbers lag by up to 24 hours based on reporting systems.

Also Also note that it still takes around 12 days for action changes to affect trends, since people infected today will not be detected for a while.

Also Also Also note that there are many people who have NO symptoms at all, but are still infecting others. This, along with poor testing, explains the 12-15% confirmation rate.

https://drive.google.com/file/d/1vocCN445AZyVBBLsv0kJR8ZDP9DM0UST/view


Overrun Planning

Stats for Sunday, Monday, and predictions for Tuesday, and Texas hospital overruns.

03-22 Sunday

  • 7-day Projection: WW 262771/11285; PRC 81266/3324; NON 259371/14696; IT 78550/8986; US 25567/280; TX 521/21. plus or minus 25%.
  • 1-day Projection: WW 340729/14895; PRC 81360/3265; NON 260988/11728; IT 61049/5774; US 34015/386; TX 857/5.
  • Actual Numbers: WW 335955/14632; PRC 81397/3265; NON 254558/11367; IT 59138/5476; US 33272/417; TX 627/8

03-23 Monday

  • 1-day Projection: WW 370630/16503; PRC 81489/3271; NON 290297/13301; IT 65275/6215; US 43432/566; TX 627/13. TX Deaths is Still early and erratic
  • Actual Numbers: WW 378287/18600; PRC 81496/3274; NON 296791/13223; IT 63927/6077; US 43667/552; TX 758/9. IT is slowing, which is good. JHU new dataset.

03-24 Tuesday

  • 1-day Projection: WW 425,953/18,600; PRC 81,595/3,283; NON 346,031/15,382; IT 69,104/6,744; US 57,310/731; TX 916/10
  • Actual Numbers: To be determined.  Infection spread for US is fluctuating slightly.

The following major milestones assume no gross change in testing rates nor confirmed infection rates.  Stage 1 is over standard capacity.  Stage 2 is over worst case reserve capacity.  Stage 3 is over best case reserve capacity.  This does not cover additional production, but does cover identified lower-function and out-of-date equipment from federal, military, and major hospital stockpiles.  At Stage 1, alternative locations are getting converted for use by patients, such as closed medical buildings.  At stage 2, we’re relying on medical and nursing students as front-line caregivers, and MASH style pop-up tent hospital expansions start getting deployed where possible. At stage 3, we’re draping parking garages, and getting scouts with first-aid badges to help.  Elderly or anyone with comorbidities will be comforted, but won’t get access to mechanical ventilation.  Only those with the best chance of survival with, and a high risk of death without, would get advanced care.

  • 04-05 33k TEXAS ICU OVERRUN STAGE 1 / 28.7m pop; 2.9 beds per 1000 (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787) and 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)
  • 04-06 45k TEXAS VENT OVERRUN STAGE 1 / 28.7m pop; 2.9 beds per 1000 (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787) and 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)
  • 04-10 150k TEXAS VENT/ICU STG2 & Hosp STG 1 / 28.7m pop; 2.9 beds per 1000 (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787) and 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)
  • 04-13 366k TEXAS VENT/ICU STG3 & Hosp STG 2 / 28.7m pop; 2.9 beds per 1000 (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787) and 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)
  • 04-15 660k TEXAS Hosp STG 3 / 28.7m pop; 2.9 beds per 1000 (83230); 32% unoccupied (26633) / 11% are ICU (2929); 6.7% ventilators (1787) and 10% limited function ventilation (2663) / 5-15% conf need hosp(532k-177k @ overrun); 2-10% ICU (29k-146k); 1-5% need vent (36k-178k)

The inflection point for R0 of 2.2 is 60%. Current reporting rate is 12-15%. Assuming we keep testing by same criteria, the Tx inflection point is about 400k confirmed. We may not reach this numerically due to testing/infrastructure failure. eg, we may reach stage 3 while our confirmed rate is much lower, but still around the same day, and still around the same number of actual infected.  Also, there are different groups between spreaders and isolators.  I don’t know the balance of those two groups. They could be 20/80 or 50/50.

Barring major changes, the model is +/- 25% per week.  That is +/- 1.5 days for stage 1. That is +/- 2.5 days for stage 2. That is +/- 3.5 days for stage 3.

If the Pandemic declaration helped, then 03-24 will be at least 2% low for US and TX. If the Emergency declaration helped, then 03-25 will be at least 2% low for US and TX.  Either of those should show a continual downward trend.  We have had a lot of people ignoring expert and government recommendations, so I do not expect an abrupt change.

If we did abruptly fall to, say, 112% on 03-24 and stay there, then Stage 1 starts April 23-26; then Stage 2 starts May 7-11; Stage 3 may never happen due to average disease cycle of 20 days, and ICU cycle of 30 days.  This would be a dream scenario, and is unlikely.  More likely to see a 5% drop several days in a row.  It’s unlikely to see the clam-down go below 110% until it looks really bad (and then it’s too late).

Texas is about 9% of the US capacity and slightly more capacity than average.  Look for 11x numbers in the US column for similar problems.

  • 33k -> 363k on 03/30 Stage 1 ICU
  • 45k -> 495k on 03/31 Stage 1 Vent
  • 150k -> 1650k on 04/04 Stage 2 / Stage 1 Hosp
  • 366k -> 4026k on 04/07 Stage 3 / Stage 2 Hosp
  • 660k -> 7260k on 04/09 Stage 3 Hosp

112% projections:

  • 112% ICU Stage 1 is 04/10
  • 112% Vent Stage 1 is 04/12
  • 112% V2 / Hosp Stage 1 is 04/23
  • 112% V3/H2 is 05/01
  • 112% H3 is 05/06
  • 112% numbers are +/- 3, 5, and 7 days.

This is all bistromath, and really, anything more than a week out is just guesswork. A lot can change in a week, and I’m expecting substantial changes over the next 3 days based on the activities 10-14 days ago.

The Spreadsheet has been updated. JHU replaced some data sources, so it was a little annoying, and a little more manual entry.

https://drive.google.com/file/d/1vocCN445AZyVBBLsv0kJR8ZDP9DM0UST/view