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Discussion - Estimating the CFR for 2019-nCoV

The above issues are of course part of the uncertainty. But the big elephant in the room is the unknown denominator of how many undiagnosed cases there have been. It's obvious that more than just the 600 or so confirmed cases have been infected. Is it twice than number? Then this virus might have the CFR of SARS. Is it 6000? Then this virus probably has about the CFR of the 1918 pandemic virus. Is it 600,000? Then this virus might have a CFR closer to that of seasonal flu.

One good sign is that we're not seeing family clusters of fatalities like we did for SARS, Ebola, and H5N1.
 
The above issues are of course part of the uncertainty. But the big elephant in the room is the unknown denominator of how many undiagnosed cases there have been. It's obvious that more than just the 600 or so confirmed cases have been infected. Is it twice than number? Then this virus might have the CFR of SARS. Is it 6000? Then this virus probably has about the CFR of the 1918 pandemic virus. Is it 600,000? Then this virus might have a CFR closer to that of seasonal flu.

One good sign is that we're not seeing family clusters of fatalities like we did for SARS, Ebola, and H5N1.

Alert, thanks for reminding us that we don't known what we don't know. You point about watching for deaths among among small clusters is a good one. It appears that most clusters of H5N1 from 1997 to about 2014 were small, about 3 persons per cluster. However, the CFR for these clusters is about .52. Whether these numbers are applicable to the 2019-nCoV outbreak is unknown at this time.
 
In addition to confirmed deaths, there have likely been pneumonia deaths from corona virus that were never tested. I’m particularly concerned about the incubation period and H2H transmission. Even if the cfr is low, if it transmits efficiently, there could be large numbers of deaths globally.
 
A novel coronavirus (2019-nCoV) causing severe acute respiratory disease emerged recently in Wuhan, China. Information on reported cases strongly indicates human-to-human spread, and the most recent information is increasingly indicative of sustained human-to-human transmission. While the overall severity profile among cases may change as more mild cases are identified, we estimate a risk of fatality among hospitalised cases at 14% (95% confidence interval: 3.9–32%).

full article


https://www.eurosurveillance.org/con...#html_fulltext
 
These were some more deaths as of yesterday:
105 New Pneumonia Cases Infected by New Coronavirus in Hubei Province

According to the CCTV News client news, from 00:00 to 24:00 on January 23, 2020, 105 new cases of pneumonia with new coronavirus infection were added in Hubei Province (70 new cases in Wuhan, 7 new cases in Jingmen City, and Jingzhou City 2 cases were newly added, 22 cases were found for the first time in Xiaogan City, 2 cases were found for the first time in Xiantao City, 1 case was found for the first time in Yichang City, and 1 case was found for the first time in Shiyan City). There were 7 new deaths in the province (including 6 in Wuhan and 1 in Yichang). Three cases were cured and discharged from Wuhan.



As of 24:00 on January 23, 2020, Hubei Province has reported a total of 549 cases of pneumonia caused by new coronavirus infection (including 495 in Wuhan, 22 in Xiaogan, 12 in Huanggang, 8 in Jingzhou, 8 in Jingmen, 2 cases in Xiantao City, 1 case in Yichang City, 1 case in Shiyan City), 31 cases have been cured and 24 cases have died. At present, 494 patients are still being treated in the hospital, of which 106 are critically ill and 23 are critically ill. They are all under isolation treatment at designated medical institutions. A total of 3,653 close contacts have been tracked, 877 medical observations have been lifted, and 2776 people are still receiving medical observations.


Zhao Moumou, female, 85 years old, had orthostatic hypotension, hypothyroidism, systemic osteoarthritis, ischemic necrosis of the femoral head, etc. On November 26, 2019, because of intermittent palpitation for 1 year, and his symptoms worsened, he was admitted to the Provincial Hospital of Traditional Chinese Medicine for treatment. On January 21, 2020, the patient's condition further deteriorated, and the rescue was invalid at 18:50 and he was declared dead.


Yin Moumou, female, 69 years old, had no previous special medical history. She was admitted to Wuhan Union Medical College Hospital on January 14, 2020 due to "fever, cough and muscle soreness". Later, due to the detection of a new type of coronavirus nucleic acid positive, she was transferred to Wuhan Jinyintan Hospital on January 20, 2020. After admission, she was in critical condition, was in intensive care, was given high-flow oxygen, and her condition did not improve. On January 22, 2020, nocturnal respiratory failure aggravated, and clinical rescue was announced at 3:25.


Li, male, 36 years old, was admitted to the hospital on January 9, 2020 for "fever with fatigue for 3 days". At the time of admission, the patient had a high fever. A chest radiograph showed bilateral lung infection, elevated white blood cells, and was diagnosed with viral pneumonia. He was given symptomatic treatment of oxygen inhalation, anti-virus, anti-infection, phlegm elimination, and anti-inflammatory treatment. At 12:20 on January 23, a sudden decrease in heart rate, cardiac arrest, and blood pressure decreased. At 13:45, a cardiac arrest occurred and clinical death was announced to the patient's family.


Zhang Moumou, male, 73 years old, was admitted to the Intensive Care Unit of the Western Union Hospital on January 5, 2020 because of "fever, cough, and dyspnea for 7 days." Admissions were mainly diagnosed with pulmonary infection and respiratory failure. Mechanical ventilation for tracheal intubation was performed on January 16. On January 22, the family signed off to abandon the rescue, pulled out the tracheal intubation, and stopped using the ventilator. Clinical death was announced at 18:23 on January 22.


Shao Moumou, female, 70 years old, became ill on January 18, 2020, and was admitted to Wuhan Youfu Hospital for Respiratory Medicine due to "fever for 3 days". Admitted to the hospital to diagnose pulmonary infection and schizophrenia. Admitted to the hospital for oxygen, anti-infection, phlegm and asthma, antiviral and other symptomatic supportive treatment. At 22 o'clock on January 22, the patient's condition worsened. At 0:25 on January 23, a sudden bleeding from the mouth and loss of consciousness occurred. At 0:45, the rescue was invalid and clinical death was announced.


Mr. Liu, male, 81 years old, had previous coronary heart disease, hypertension, diabetes and tuberculosis. On January 13, 2020, he was admitted to the hospital with a 4-day fever. At 6 o'clock on January 18, the patient suddenly had dyspnea, and was continuously given oxygen and ECG monitoring. On January 21, the patient began to experience a decrease in heart rate, and oxygen saturation and blood pressure could not be measured. At 9:38, clinical death was declared due to various diseases such as viral pneumonia, multiple organ failure, septic shock, and pulmonary infection.


Zhang Moumou, female, 65 years old. On January 13th, he was admitted to the third department of Yuan'an County Traditional Chinese Medicine Hospital on his own. He was diagnosed with "primary bone marrow fibrosis and pulmonary infection" on admission. There was no remission after anti-infection treatment. On January 15th, he was transferred to the city center hospital to be admitted to the hospital's hematology department for treatment. After being consulted by the city expert group on January 19, he was transferred to the third city hospital for isolation and treatment. On January 23, the Hubei Provincial Center for Disease Control and Prevention had a positive nucleic acid test result, and a new coronavirus-infected pneumonia was confirmed. At 18:00 on January 23, a sudden decrease in finger pulse oxygen and respiratory arrest occurred, and clinical death was announced at 18:26 after rescue.
 
I was beginning to be concerned by the fact that most of the cases are still ill, but according to the above link, only 7 of the first 41 cases are still ill (with 6 deaths and 28 recoveries). The reason that a majority of cases nationwide (or worldwide?) appear to still be ill seems to be that most cases have more recent onset. Six deaths in 34 cases with known outcome would be a 18% CFR, which is right around what SARS had in places like Hong Kong or Toronto, but it's obvious that those 41 are just the most severe cases found to that point. How many human infections would it take to reduce those six deaths to a more reasonable CFR? Probably two orders of magnitude (i.e. it would require those cases to be the most severe of 3,400 human infections)….

Let's not also forget that in 2003 SARS, there were a few cases with very long hospitalizations (>2 months) that survived, usually the result of complications such as hospital-acquired co-infections. When the July 14, 2003 blackout hit Toronto, more than a month after the isolation date of the last case, something like 6 or 7 patients were still ill in isolation. It's not clear what would happen to such cases in the event of a pandemic where that degree of care was not available to most.
 
I was beginning to be concerned by the fact that most of the cases are still ill, but according to the above link, only 7 of the first 41 cases are still ill (with 6 deaths and 28 recoveries). The reason that a majority of cases nationwide (or worldwide?) appear to still be ill seems to be that most cases have more recent onset. Six deaths in 34 cases with known outcome would be a 18% CFR, which is right around what SARS had in places like Hong Kong or Toronto, but it's obvious that those 41 are just the most severe cases found to that point. How many human infections would it take to reduce those six deaths to a more reasonable CFR? Probably two orders of magnitude (i.e. it would require those cases to be the most severe of 3,400 human infections)….
.

Serious question - wouldn’t the CFR increase there are more deaths due to unavailable respirators..etc. when health services are overrun? Seems an increase of infections starts to increase CFR at some point when finite resources are included.
 
On Jan 10, 2020 Confirmed cases was 41... From records of the first 17 deaths, the average days from contraction to death was about 17 days...On Jan. 25, fifteen days after Jan 10 when 41 cases were confirmed, 41 were reported dead from the virus. We know it's not killing 100% of the confirmed cases but this also tells us that a lot more people are sick than are being listed as confirmed carriers. At one time I was under the impression that there were only 15 confirmed in the original cluster. I can't find that story anymore. Most stories say there were 27 cases of pneumonia on Dec. 31 2019 in Wuhan. (i couldn't find out how many of those cases were confirmed Wuhan virus). Either way we're looking at a death rate that is so high that it will drive the world economy to it's knees, somewhere between 12% and 30% could die after contracting this virus. This is a farmers math project, so don't hate me if I'm wrong.
 
On Jan 10, 2020 Confirmed cases was 41... From records of the first 17 deaths, the average days from contraction to death was about 17 days...On Jan. 25, fifteen days after Jan 10 when 41 cases were confirmed, 41 were reported dead from the virus. We know it's not killing 100% of the confirmed cases but this also tells us that a lot more people are sick than are being listed as confirmed carriers. At one time I was under the impression that there were only 15 confirmed in the original cluster. I can't find that story anymore. Most stories say there were 27 cases of pneumonia on Dec. 31 2019 in Wuhan. (i couldn't find out how many of those cases were confirmed Wuhan virus). Either way we're looking at a death rate that is so high that it will drive the world economy to it's knees, somewhere between 12% and 30% could die after contracting this virus. This is a farmers math project, so don't hate me if I'm wrong.

WR-
AP is saying 27. You can use Google’s date range filters and search news. For example, the search input I used was:

wuhan after:2019-12-15 before:2019-12-31
 
On Jan 10, 2020 Confirmed cases was 41... From records of the first 17 deaths, the average days from contraction to death was about 17 days...On Jan. 25, fifteen days after Jan 10 when 41 cases were confirmed, 41 were reported dead from the virus. We know it's not killing 100% of the confirmed cases but this also tells us that a lot more people are sick than are being listed as confirmed carriers. At one time I was under the impression that there were only 15 confirmed in the original cluster. I can't find that story anymore. Most stories say there were 27 cases of pneumonia on Dec. 31 2019 in Wuhan. (i couldn't find out how many of those cases were confirmed Wuhan virus). Either way we're looking at a death rate that is so high that it will drive the world economy to it's knees, somewhere between 12% and 30% could die after contracting this virus. This is a farmers math project, so don't hate me if I'm wrong.

I understand your frustration Wilderness Retreat. It is important to remember that on any given day the number of reported deaths has ZERO relationship to the number of newly reported confirmed cases of a disease (unless of course the newly reported case is already a deceased individual). Unfortunately, epidemiologist do a poor job of makings this clear in discussions and graphs. Even now the WHO will include individual who survived with individuals who died within a stack bar graph on a specific date, yet these cases are mutually exclusive; they only share being reported on the same day. Reporting these deaths and survivors in the same graph implies that all these individuals contracted the disease the same number of days before they survived or succumbed to death. It is difficult to interpret such confusing data.
 
SCMP just reported a case that I linked in the news thread with onset December 1 (one week before the earliest case linked to that market) and no links to the seafood market. That means this virus did not first jump to humans in that market and was instead already circulating. Notably, none of his contacts became ill (at least ill enough to be hospitalized). Perhaps the outbreak at the market was due to an ill human going to work and may have represented a superspreading event.

The origin of this outbreak is now completely unclear.

That drastically increases the number of people who have likely been infected by now, and reduces the likely CFR. This looks more like Mexico 2009 than SARS 2003.

I don't think the CFR is going to get all the way down to that of seasonal flu, but it wouldn't surprise me if it got lower than the 2% that is cited for the 1918 virus.
 
would they quarantine >30M with just a few thousand cases ? The damage from the quarantine would be larger.
So I speculate that there are >100K cases and the CFR is low.
 
A 1% attack rate in Wuhan itself is 110k cases. One percent attack rate in all of Hubei would be more like 600k. These are very densely populated areas. People have been saying since the start of the outbreak that there is a huge amount of background ILI, some or most of which may be due to this virus.

The question is how low is low? The 1918 pandemic was about 2-2.5% CFR. I think there's a good chance this virus is less than that. But that's still 20-25x the death rate of seasonal flu.
 
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China
Prof Chaolin Huang, MD *
Yeming Wang, MD *
Prof Xingwang Li, MD *
Prof Lili Ren, PhD *
Prof Jianping Zhao, MD *
Yi Hu, MD *
et al.
Show all authors
Show footnotes
Published:January 24, 2020DOI:https://doi.org/10.1016/S0140-6736(20)30183-5
...
By Jan 2, 2020, 41 admitted hospital patients were identified as laboratory-confirmed 2019-nCoV infection in Wuhan. 20 [49%]) of the 2019-nCoV-infected patients were aged 25–49 years, and 14 (34%) were aged 50–64 years (figure 1A). The median age of the patients was 49?0 years (IQR 41?0–58?0; table 1). In our cohort of the first 41 patients as of Jan 2, no children or adolescents were infected. Of the 41 patients, 13 (32%) were admitted to the ICU because they required high-flow nasal cannula or higher-level oxygen support measures to correct hypoxaemia. Most of the infected patients were men (30 [73%]); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]).
...
As of Jan 22, 2020, 28 (68%) of 41 patients have been discharged and six (15%) patients have died.
...
Untitled.webp

...
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext

Comment - The above paper pushes the onset of the disease back to Dec 1 with no contact with the market. It also suggests that half of those hospitalized where aged under 50. Given the demographics of the fatal cases this indicates that younger individuals are recovering. But the overall recovery rate of hospitalized cases is still only 68% after a minimum of 3 weeks from onset with 17% of cases still under care. - Ro
 
they (Pybus et.al.) were estimating that the time of common anchester of the viruses was in late December,
so one first strain had possibly died out
 
Serious question - wouldn’t the CFR increase there are more deaths due to unavailable respirators..etc. when health services are overrun? Seems an increase of infections starts to increase CFR at some point when finite resources are included.

5 of the 7 cases, in Shilohs post above, specifically mention oxygen therapy. The lack of equipment can only make the outcomes poorer.
 
5 of the 7 cases, in Shilohs post above, specifically mention oxygen therapy. The lack of equipment can only make the outcomes poorer.

Thank you. Then it would seem that the CFR can increase over time as health networks become saturated.
 
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