Concerning the Recent 2019-Novel Coronavirus Outbreak

This straightforwardly got the novel coronavirus (now "covid-19") on the radar of many EAs who were otherwise only vaguely aware of it, or thought it was another media panic, like bird flu. 

The post also illustrates some of the key strengths and interests of effective altruism, like quantification, forecasting, and ability to separate out minor global events from bigger ones.

For a long time, I've believed in the importance of not being alarmist. My immediate reaction to almost anybody who warns me of impending doom is: "I doubt it". And sometimes, "Do you want to bet?"

So, writing this post was a very difficult thing for me to do. On an object-level, l realized that the evidence coming out of Wuhan looked very concerning. The more I looked into it, the more I thought, "This really seems like something someone should be ringing the alarm bells about." But for a while, very few people were predicting anything big on respectable forums (Travis Fisher, on Metaculus, being an exception), so I stayed silent.

At some point, the evidence became overwhelming. It seemed very clear that this virus wasn't going to be contained, and it was going to go global. I credit Dony Christie and Louis Francini with interrupting me from my dogmatic slumber. They were able to convince me —in the vein of Eliezer Yudkowsky's Inadequate Equilibria —that the reason why no one was talking about this probably had nothing to do whatsoever  with the actual evidence. It wasn't that people had a model and used that model to predict "no doom" with high confidence: it was a case of people not having models at all.

I thought at the time—and continue to think—that the starting place of all our forecasting should be using the outside view. But—and this was something Dony Christie was quite keen to argue—sometimes people just use the "outside view" as a rationalization; to many people, it means just as much, and no more than, "I don't want to predict something weird, even if that weird thing is overwhelmingly determined by the actual evidence."

And that was definitely true here: pandemics are not a rare occassion in human history. They happen quite frequently. I am most thankful for belonging to a community that opened my mind long ago, by having abundant material written about natural pandemics, the Spanish flu, and future bio-risks. That allowed me to enter the mindset of thinking "OK maybe this is real" as opposed to rejecting all the smoke under the door until the social atmosphere became right.

My intuitions, I'm happy to say, paid off. People are still messaging me about this post. Nearly two years later, I wear a mask when I enter a supermarket. 

There are many doomsayers who always get things wrong. A smaller number of doomsayers are occasionally correct—good enough that it might be worth listening to them, but rejecting them, most of the time. 

Yet, I am now entitled to a distinction that I did not think I would ever earn, and one that I perhaps do not deserve (as the real credit goes to Louis and Dony): the only time I've ever put out a PSA asking people to take some impending doom very seriously, was when I correctly warned about the most significant pandemic in one hundred years. And I'm pretty sure I did it earlier than any other effective altruist in the community (though I'm happy to be proven wrong, and congratulate them fully).

That said, there are some parts of this post I am not happy with.  These include,

• I only had one concrete prediction in the whole post, and it wasn't very well-specified. I said that there was a >2% probability that 50 million people would die within one year. That didn't happen.
• I overestimated the mortality rate. At the time, I didn't understand which was likely to be a greater factor in biasing the case fatality rate: the selection effect of missed cases, or the time-delay of deaths. It is now safe to say that the former was a greater issue. The infection fatality rate of Covid-19 is less than 1%, putting it into a less dangerous category of disease than I had pictured at the time.

Interestingly, one part I didn't regret writing was the vaccine timeline I implicitly predicted in the post. I said, "we should expect that it will take about a year before a vaccine comes out." Later, health authorities claimed that it would take much longer, with some outlets "fact-checking" the claim that a vaccine could arrive by the end of 2020. I'm pleased to say I outlasted the pessimists on this point, as vaccines started going into people's arms on a wide scale almost exactly one year after I wrote this post.

Overall, I'm happy I wrote this post. I'm even happier to have friends who could trigger me to write it. And I hope, when the next real disaster comes, effective altruists will correctly anticipate it, as they did for Covid-19.

This is the boring take, but it's worth noting that conditional on this spreading widely, perhaps the most important things to do are mitigating health impacts on you, not preventing transmission. And that means staying healthy in general, perhaps especially regarding cardiovascular health - a good investment regardless of the disease, but worth re-highlighting.

I'm not a doctor, but I do work in public health. Based on my understanding of the issues involved, if you want to take actions now to minimize severity later if infected, my recommendations are:

• Exercise (which will help with cardiovascular health)
• Lose excess weight (which can exacerbate breathing issues)
• Get enough sleep (which assists your immune system generally)
• Eat healthy (again, general immune system benefits)

Incubation period and Chinese government coverup efforts are relevant to this question, but roughly speaking if the actual number of infections is ~35x the reported number, and there's no uptick in mysterious deaths in hospitals, then the actual mortality rate is ~1/35 the reported number, more in line with normal flu than 1918 Spanish flu.

Estimates of the mortality rate vary, but one media source says, "While the single figures of deaths in early January seemed reassuring, the death toll has now climbed to above 3 percent." This would put it roughly on par with the mortality rate of the 1918 flu pandemic.

It should be noted that the oft-cited case-fatality ratio of 2.5% for the 1918 flu might be inaccurate, and the true CFR could be closer to 10%: https://rybicki.blog/2018/04/11/1918-influenza-pandemic-case-fatality-rate/?fbclid=IwAR3SYYuiERormJxeFZ5Mx2X_00QRP9xkdBktfmzJmc8KR-iqpbK8tGlNqtQ

EDIT: Also see this twitter thread: https://twitter.com/ferrisjabr/status/1232052631826100224

https://www.worldometers.info/coronavirus/

I find the analysis from this link very interesting. It suggests that Ro is higher than initially estimated at 3-4 (rather than 1.4-2.5 by WHO) but the national China mortality rate drops to 0.3% if the province of Hubei is excluded (the reported mortality rate of Wuhan alone is 5.5%). This would be consistent with the theory that the number of cases are underreported in Wuhan, due to a shortage of testing capacity and perhaps under reporting. A recent Lancet report by Professor Gabriel Leung from University of Hong Kong https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30260-9/fulltext estimates 76,000 cases in Wuhan as of Jan 25th based on a Ro of 2.68, more than 30x reported, which would put the mortality rate at well under 0.5%.

This suggests the pandemic could be more difficult to control than expected but mortality rate is also much lower (perhaps in the region of 3x flu).

This may also mean the main damage could be through economic impact.

I am an EA living in China right now. Thanks for sharing this post on the Coronavirus. I am also very interested in these questions.

We do not know what percentage of people experience symptoms so mild that they do not seek medical attention and so do not appear in the 'Suspected' or 'Confirmed' case statistics.

here: https://ncov.dxy.cn/ncovh5/view/pneumonia

and here: https://www.worldometers.info/coronavirus/

Here’s Google Translate if you need it: https://translate.google.com/

Nevertheless, as you mentioned, attempts have been made to model the spread of the infection and to estimate the number of people carrying the virus so far.

I have created a very simple spreadsheet with three scenarios here:

https://docs.google.com/spreadsheets/d/1qSNLQC5BpA-Gah0INyolFpPvTAGFphKUwTxQZN7FWI4/edit?usp=sharing

The Red scenario = 50% of infections go undiagnosed (unrecorded).

The Yellow scenario = 70% of infections go undiagnosed (unrecorded).

The Green scenario = 85% of infections go undiagnosed (unrecorded).

Each scenario has different estimates of the ‘real’ number of infections and percentages that progress to either a serious/critical condition or to death.

I found the serious/critical condition numbers here: https://twitter.com/BNODesk

We can perhaps use these scenarios to roughly 'frame' whether this virus is similar or much worse than the seasonal flu. Thoughts?

There are potential inaccuracies with the numbers in the three scenarios.

On the potential positive (good) side, perhaps the high critical condition and death rates reflect the early stages of treating a novel virus and it's possible that the rate will not be so high in future as better treatment protocols are followed. Certainly the rates seem much worse in Hubei Province compared to the rest of China and the rest of the world.

On the negative (bad) side, the death rate and serious/critical condition rate may turn out to be higher than the number reflected here. This is because many of the 'suspected and confirmed' cases will later progress to a serious/critical condition or death. There is likely to be a time lag in this progression which we do not yet see in the stats.

Moreover, perhaps the virus could become more deadly if medical services were to become overwhelmed.

Perhaps the questions could be summarised:

What percentage of cases go unrecorded (undiagnosed)? What is the real number of people with infections right now?

Which scenario: Green, Yellow or Red is closest to the truth? What confidence would you assign to the probability of each of the three scenarios?

What is the ‘true’ risk of progressing to a serious/critical condition or death once infected with Coronavirus?

I would love to hear any thoughts from others on any of the points made here.

Thanks for the article. One thing I'm wondering about that has implications for the large scale pandemic case is how much equipment for "mechanical ventilation and sometimes ECMO (pumping blood through an artificial lung for oxygenation)" does society have and what are the consequences of not having access to such equipment? Would such people die? In that case the fatality rate would grow massively to something like 25 to 32%.

Whether there is enough equipment would depend upon how many get sick at once, can more than one person use the same equipment in an interleaved fashion, how long each sick person needs the equipment, are their good alternatives to the equipment, and how quickly additional equipment could be built or improvised.

So the case I'd be worried about here would be a very quick spread where you need rare expensive equipment to keep the fatality rate down where it is currently.

A study published today attempts to estimate the nCoV incubation period:

Using the travel history and symptom onset of 34 confirmed cases that were detected outside Wuhan, we estimate the mean incubation period to be 5.8 (4.6 – 7.9, 95% CI) days, ranging from 1.3 to 11.3 days (2.5th to 97.5th percentile).

As the authors note, this estimate indicates an incubation period remarkably similar to that of the Middle East respiratory syndrome.

I wonder what sort of Fermi calculation we should apply to this? My quick (quite possibly wrong) numbers are:

• P(it goes world scale pandemic) = 1/3, if I believe the exponential spreading math (hard to get my human intuition behind) and the long, symptom less, contagious incubation period
• P(a particular person gets it | it goes world scale pandemic) = 1/3, estimating from similar events
• P(a particular person dies from it | a particular person gets it) = 1/30, and this may be age or preexisting condition agnostic and could, speculatively, increase if vital equipment is too scarce (see other comment)

=> P(death of a randomly selected person from it) = ~1/300

What are your thoughts?

FYI - study of outcomes a/o Jan 25 for all 99 2019-nCoV patients admitted to a hospital in Wuhan between Jan 1 and Jan 20.

Many caveats apply. Only includes confirmed cases, not suspected ones. People who end up at a hospital are selected for being more severely ill. 60% of the patients have not yet been discharged so haven't experienced the full progression of the disease. Etc.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext#%20

For a week or so I have been fearing this potentially deadly disease spreading to most people on Earth (space-station and antarctic bases excepted), since the doubling time has been about half a week, and simple calculations show that even with a 1 week doubling time, half the Earth's population would get it by June.  My fears were confirmed by reading of the John Hopkins Event 201 simulation last year, in which a 1 week doubling time virus spread throughout the world and killed tens of millions of people:

https://www.abc.net.au/news/2020-02-01/coronavirus-outbreak-researchers-simulated-severe-pandemic/11906562

http://www.centerforhealthsecurity.org/event201/videos.html

There is no precedent for a virus spreading as fast and far as this one:

https://graphics.reuters.com/CHINA-HEALTH-VIRUS-COMPARISON/0100B5BY3CY/

I still believe the Wuhan coronavirus will infect half the population by the middle of this year, but I now have cause for hope that the variants which do this will be far less virulent than the one or ones which caused the deaths in Hubei in January.

I am not an epidemiologist, but here goes.  I am suggesting that the virus is mutating rapidly into less virulent strains which compete successfully against the original, December and early January, more virulent form(s).  However, I know of no reports of such mutations. 

From the John Hopkins ticker (necessarily long URL):

https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

here are the figures from Hubei, the province containing Wuhan, and the ten provinces with the highest death rates, all of which were infected in mid to late January, about 5 or 6 weeks after the disease began in Wuhan.  (The following is a table, to be viewed in a fixed width font.)

   Province   Confirmed  Deaths         Recovered        
   Hubei         11,177     350  3.1%         295  2.6%        
   Guangdong        725       0                15  2.1%     
   Zeijiang         724       0                36  5.0%      
   Henan            566       2  0.3%          14  2.5%     
   Hunan            521       0                22  4.2%     
   Anhui            408       0                11  2.7%     
   Jiangxi          391       0                18  4.6%     
   Chongquing       312       2  0.6%           8  2.7%     
   Jaingsu          271       0                 8  3.0%     
   Shandong         259       0                 6  2.3%     
   Sichuan          254       1  0.4%          14  5.5%       
   Average of                    0.113%            3.430%      
   these 10 provinces 

The lower death rate in the provinces which were first infected well after the initial spread in Hubei is striking: it is 1/27th the death rate in Hubei.

The reasons for this might include:

1. Cases in the other provinces are, on average, more recent than those in Hubei, meaning the death rate will rise over time to resemble that of Hubei (and the Hubei death rate could rise too, for the same reason.)

2. Saturation of hospitals and testing in Hubei and Wuhan in particular.

3. The provinces being infected more with a less symptomatic and so less deadly variant of the virus than those which caused the initial spread in Hubei, though hopefully the same process would be occurring in Hubei too, so the death rate for recent infections would be lower too. (I hope this is happening.)

4. Nursing leading to people surviving to the extent that a significantly lower proportion of people have no immunity. (I think this does not yet play a significant role.)

5. Poorer quality of care, including people not being able to get into hospital, in Hubei compared to the other provinces

However, I can’t imagine that 1, 2 or 4 would make anything like the difference we see - a striking 27:1 ratio in the death rate. 5 might explain some of it. This makes me think that 3 is true to a significant degree.

Now turning to the recovery rates. The other provinces have a significantly higher recovery rate than Hubei. Assuming the diagnostic standards do not vary significantly, this cannot be explained by 1, 2 or 4. It would be very well explained by 3.

In the other provinces, the recognised infections seem to be less damaging, with quicker recovery. Assuming that quality of care is about the same, the only explanation I can think of is that these more recent cases in the other provinces are with variants of the virus which cause less symptoms and perhaps lead to an earlier recovery - while still being contagious enough to compete successfully against the original and/or any more recently mutated, more virulent strains.

This analysis gives me hope that by the time the virus reaches about half the people on Earth - as I believe it will by the middle of this year - that the variants most people get will be much less damaging than at the start of the pandemic.

If this analysis is true, then the true rates of infection in the other provinces - and recently in Hubei - may be much higher in proportion to the number of confirmed cases than was the ratio a few weeks ago. This would be due to a greater proportion of infected people having no or only mild symptoms - so they are never tested or recognised much by the medical system.

If this is occurring, then it may work out well . . . unless there are mutants which remain highly infectious but which have sufficiently different spike and envelope proteins that the antibodies developed in response to the current strains are ineffective. Then those strains might start a whole second wave of infection, since immunologically, they would be a different virus.

If this analysis is correct, then while the Chinese lockdown (which is unsustainable) may slow the spread of the virus more effectively than the post-symptom quarantine arrangements of the West (which is the best they can do, not being a dictatorship), the Western approach is actually more helpful.  This would be due to the Western approach enabling strains of the virus which have few or no symptoms to spread very rapidly, while significantly reducing the replication of strains which produce strong enough symptoms for people to be hospitalised and tested.

If there were no such helpful mutations, then the Western approach would be less effective than the Chinese approach, but the Chinese approach is unsustainable for more than a few weeks. There's no hope of a conventional vaccine by the middle of this year, or even the end. However, if my analysis is correct, then by the good fortune of the virus mutating without altering its envelope and spike proteins significantly, the most successful strains become less damaging and work like a vaccine against the more damaging strains.

Some slightly positive evidence: By the 24th, 19 cases had been reported outside of China, with onset of symptoms usually before that. Given the most recent estimate of a mean incubation period of 5 days, it seems surprising that only 1 of the 19 cases has infected another person that we know of so far (a man traveling from Wuhan to Vietnam infected his son, who shared a hotel room with his father for 3 days). Since monitoring of people the infected came into contact with is high, finding infected people should be fairly quick.

Seems that effective containment, a lower R0 than expected (both good), or a longer incubation period than previously assumed (bad) could be the reason.

Source for the 19 cases by the 24th: https://docs.google.com/spreadsheets/d/1yZv9w9zRKwrGTaR-YzmAqMefw4wMlaXocejdxZaTs6w/htmlview?usp=sharing&sle=true#

How confident are you that it affects mainly older people or those with preexisting health conditions? Are the stats solid now? I vaguely recall that SARS and MERS (possibly the relevant reference class), were age agnostic.