Alright, it's Wendy so here from Science Vs. I am now working from home, and  my package of food for the pandemic has arrived.. Let’s open it up Wow that’s a lot of cans of chickpeas… 

Even though we’ve been reporting on this for a couple months… I can’t believe it’s here.How dumb am I

Yeah, so we're in the middle of a coronavirus pandemic[1]. The W-H-O officially called this a pandemic[2]..  Over 100 countries now have confirmed cases[3]. and life for millions of us is changing really fast[4] Attention is shifting away from China a bit ... to the U.S. and Europe ... as the virus takes hold there.  In countries like  Spain, France and Italy[5] -- new, strict rules have just been brought in to keep people away from each other. Italy has been hit particularly hard by the virus[6]. Fabio Gaeta in Milan told us about what was happening around him.

FG You are only allowed to go out with kind of document in which you have to state why you're going out

WZ Oh you're not allowed to leave the house without a document?

FG Yes

His job - in the manufacturing industry - means he can still go to work. But other than that… he’s only allowed to go to the supermarket and the pharmacy. And the police are patrolling the streets.

FG If they stop you, they will ask you where you live, and based on the location they can assess whether you are really going to the supermarket

And so they can fine you with up to 200 euros[7]

WZ oh wow

WZ: Did you ever imagine this would happen?

FG Honestly no, you have always the impression that this is stuff that happens in other parts of the world, never in the efficient western culture, but in this case we are all of us very fragile no?

FG How many weeks will pass until we get to our normal life? That's the question

WZ i know it's so hard to know, are we? im looking at my office home set up and like we’re at the beginning, right, we’re not even close to the end, this is the beginning

FG hope for you that i'm wrong but i think it's the beginning. it started like this in italy with politicians saying this is not a problem… only a few people, no worries. But in the end it was not like this. So I really hope for you this is not the case... but it could be>>

And over here . In the U.S., things are changing every day. 

Just today the President made recommendations for all Americans. He said for the next 15 days…

DT My admin is recommending all Americans incl young and healthy work to engage in schooling from home when poss, avoid gathering in groups of more than 10 people, avoid discretionary travel, avoid eating and drinking at bars, restaurants, and public food courts.

And earlier, Trump announced a 30-day travel ban from Europe and declared a national state of emergency. Sporting events, like the Boston Marathon, have been postponed.  Broadway went dark, Disneyland is shuttered. Schools were being shut across the country, and bars and businesses were told to close.[8] Meanwhile, many people in the US don’t know if they're sick with this virus or not - because it’s been really difficult to get tested. And experts - like our old pal Anthony Fauci - are saying we should expect more and more cases.

AF We will see more cases, and things will get worse than they are right now

So what can we do now to stop this? As we’ve been following what is going on around the world - and here in the US -- two big things have been swirling around: The first is about testing. The U.S. seems to have really bungled this from the start … what’s happening there? And how can you know if you have this coronavirus?  The second thing: social distancing  we’re hearing that we need to be avoiding other people, but how far do we really need to take this?

Science Vs Coronavirus Part III. Rise of the Machines. Is coming up just after the break.

BREAK

Welcome back. Right now in the U.S. there is a ton of talking … and arguing … about testing for the Coronavirus…

The testing thing we obviously screwed that up royally as a country

Why don’t we have a test

Tell us the truth about testing!

And our man on the ground - Anthony Fauci - has had to acknowledge to Congress

AF That is a failing, a failing, let’s admit it

We're hearing all these reports of people who are sick[9]  ... they think they have the virus  ... but can't get tested … The situation in the U.S.  is such a mess… that it's often not clear how to get a test... or even how many people have been tested... Best we could find were stats saying that it’s probably around 40,000[10].  People point to other countries and say --  look how far ahead they are on this.

Music In “PL_SV_cue_Superposition_v02”

For example, South Korea. They had their first reported case on Jan. 20,[11] right around the same time the U.S. had theirs.[12] Since then, South Korea has tested more than a quarter of a million people[13] …

One of them is Grace Moon, a Korean American who moved to Seoul, South Korea... 8 months ago… Had a nasty cough - went to get tested. And she told us - look - it’s not perfect there… Grace told us she had to go to a booth outside a hospital to get tested. She had to wait there for hours next to a bunch of people who could have been sick …

Music Out

GM When I went there, I was just so scared, I was like wow I'm going to get coronavirus, just by being here, by going to the hospital. Because people around me were like, coughing, I just tried to stay in the corner. 

Finally it was her turn to get tested. And Grace says that part was quick.

GM it was just 5 minutes, the first part was 2 people in the suits asked me what are the symptoms why are you here today?

WZ In the suits as in quarantine suits?

GM Yes, the quarantine suits. Everyone there was wearing quarantine suits --  you go into this narrow space that closes and they kind of like shove this piece, this long stick up my nose.[14] Omigosh it hurt I was crying but it was very fast

GM And then,  they took my information, I paid, can't remember how much i paid, it was definitely under $30. I think in 24 hours I got my results via text.

WZ  Via text?

GM it was like hey, these are your results, your results are negative

        

So that's South Korea -- but here in the U.S. it’s very different. Which is a big problem, partly because the symptoms of coronavirus are really vague.  A lot of people who have it get a fever and cough, and you might have fatigue or shortness of breath too[15][16][17].. But really These tests are key to knowing if you have the coronavirus[18].

To find out why this has been so hard to work out in the US…  we called up Josh Sharfstein. Josh is a professor at Johns Hopkins and he used to be the secretary of the Maryland Health Department.[19]  Last week he wrote a paper about what went wrong in the U.S.[20] And Josh told us ...

JS this really shouldn't be this challenging from a scientific perspective to stand up-01

Back in early February[21], the CDC sent out a batch of tests .. And? They didn’t stand up. You see… these tests are supposed to just be detecting bits of this virus’s genetic code but instead they were picking up other stuff as well … and confusing that for virus. Scientists realised this pretty quickly in quality control…. And then knew they had a problem.[22][23] [24] 

JS the test didn't work as well as intended, state labs many of them had to send it back-04

RR so the test was a lemon

JS i would say that would probably be a fair statement

That was producer Rose Rimler. So some of the initial CDC tests? They were bung. That problem was pretty easy to fix. Unfortunately there was another problem.

JS even if it had worked,still we'd be complaining about not enough tests-03

Not enough tests. Now that happened partly that’s because at first the CDC were the only folks allowed to make this test...so weeks went by with this little trickle ... until the regulations loosened...letting companies and universities make the tests too[25] [26] [27] [28] [29] [30] ..  And by then the coronavirus had already moved fast. Josh says that what we were missing in those key first weeks...was a sense of urgency …

 

JS if you go back to the beginning in mid to late January, you know, the general sentiment was this might not affect the United States that much-01

And on one hand there were some good reasons for thinking this: some other epidemics like SARS[31] and Ebola[32] they didn’t gain traction in the U.S. But still, … this positive polly attitude - we’ll be all right here in the U.S. - it needed to change faster than it did.    

RR I’ve been really surprised that the US bungled this so badly I feel disappointed in the response the country has had. Do you feel that way?

JS Oh, I think it's enormously frustrating, the situation we're in is frustrating.. I think surprised and disappointed would describe a lot of people about this

And all these testing problems had consequences -- because while we were waiting to get more tests--- the coronavirus kept spreading. We didn't know the people who had it ... and couldn’t tell them to isolate... and so they stayed out there infecting more people… And meanwhile… we are kinda in the dark about infection rates all across the U.S.

OK, so what is happening now?[33][34]  Well on Sunday, the government said[35]  -- that it’s basically gonna throw a bunch of stuff at this problem. The Trump administration says it’s working with 2,000 labs to get tests made … and it says testing centers will be soon set up across the country. It’s still not clear how many people will be able to get tested, though … or how soon. One official said they’ll be able to test 10s of thousands … or hundreds of thousands of people a week. Let’s wait and see.  

Because it is currently difficult to get tested. We’re in this position. If you have some symptoms - any symptoms - coughing, fever, you need to stay away from other people. Isolate yourself. Just in case. And we know...this sucks.

JS now i totally appreciate that is enormously frustrating position to be in if you're sick and wondering whether you have something and can't find out that is enormously frustrating-01

Josh says that soon ... or soonish - he thinks this testing situation will be sorted - but even then there will be one more thing to keep in mind. These tests aren’t perfect. And one place where they’re not super accurate is early on in your infection.[36][37][38][39] If there’s not enough viral bits in your body - the test won’t pick it up - and it could tell you, CONGRATS, you’re fine, no coronavirus! When actually that’s wrong.

JS And I would worry in that case about people feeling if negative good to go

WZ Don't wave your negative test in the air and say huzzah - cough cough - i'm fine

JS That's exactly right and there's a real risk of that. Not only huzzah i'm fine now i can go bowling or the big party or whatever

WZ i love that you picked bowling as if this pandemic was set in the ’90s

JS i'm dating myself

So bottom line: the tests were and are a big mess. And the U.S. still has not cracked it. But Josh says tests aren’t the only trick up our sleeve when it comes to stopping this pandemic.

JS I think that we shouldn't just play a game of waiting for tests, everybody should be thinking about what they can do.

And one big thing is … is avoiding other people. Even if you feel fine. It’s called social distancing. So … will it work? And if we really want to slow down this pandemic … exactly how much of a hermit do I have to be? That’s coming up after the break.

BREAK

Welcome back. We’ve just talked about how testing for the coronavirus is still a struggle in the U.S.

And that means we don’t have a good idea of who is infected. Worse still, according to a big report from WHO, on average - infected people are walking around for 5-6 days before they start showing symptoms. Almost a week![40]  Even though it doesn’t look like this virus is super contagious, compared to say, measles[41][42] ...  We are living in a world where basically any of us could - potentially - be infected. So what should we do? Well one idea has been getting a lot of attention…

The buzz phrase of the moment is social distancing

That means avoiding group gatherings plus crowded subways and buses

Illinois, Ohio, Massachusetts closing all bars and restaurants

New York has the look and feel of a ghost town!

BOOO! It’s not exactly a ghost town things are quieter, though[43]So how far we should be taking this social distancing? And will it work?

WZ Hi Hi hi, Sorry I was having some technical difficulties

VR Oh that shouldn’t be with all your Gimlet money…Hehe

Ahh that Gimlet Money… down the drain with the stock market. This is Professor Vincent Racaniello a virologist at Columbia University in New York[44]. Ever since the outbreak, Vincent has been talking to other scientists across the country about this coronavirus for his podcast - This week in Virology.[45] Basically, Vincent, is the perfect person to ask…

WZ Does social distancing actually work?

VR Absolutely! There will be fewer infections and fewer serious infections. That’s the key here.

Vincent says that with this coronavirus, for every infected person - on average - they are spreading this to around 2 more people.[46] Those 2 people… on average … spread it to 4 … who spread it to 8 people… If we could slow this down... so that maybe each infected person only spreads this to one person… or no one ... then it could lower the total number of people who become infected -- that’s what happened with the  1918 flu pandemic, the Spanish flu.[47] Cities that reacted fast-- closing churches, businesses and schools …had less infections and saved lives[48][49] One paper estimated that in San Francisco and St Louis - strict interventions might have dropped infection rates by a third.[50].[51][52] [53]

And fast forwarding a hundred years to this pandemic? A paper just out estimated that after Japan - canceled sports and entertainment events[54] - among other things - it did drop infection rates.

So what’s happening across the US right now - all the closures and banning big gatherings - it’s expected to help. But did we take these actions fast enough and have we gone far enough?

The thing we are trying to avoid are hospitals getting overrun.

VR Because the real issue - 80% of the infections are mild, 20% are not  and some of those will require hospitalisation, and a fraction of those will require -  intensive care and if we have too many people needing ICU, then at some point we are going to overburden the system.

Social distancing slowing down the spread of the disease[55]so vulnerable people don’t get sick and land in the hospital all at once[56] [57] [58] [59]. [60] 

VR Then the hospital has to triage and make a decision, and that's really a problem01

And this is exactly the problem in Italy right now[61][62] -- their hospitals are overrun.

VR They don't have enough beds, ICU beds-01

Recommendations are being sent to Italian doctors telling them if they need to make a choice - give the beds younger and healthier people[63].[64] So Italy?  They acted too late..

So when did THEY start social distancing? After only a few people died[65][66] some towns started closing schools, as well as businesses and train stations.[67][68][69] But Italy’s big regional shutdown … when life changed dramatically for people like Fabio … who you met at the beginning of the show … that didn’t happen until more than 200 people had died of coronavirus.[70][71][72] As best as we can tell, about 70 people[73] have died so far in the U.S. … Now, it’s not a perfect comparison … the outbreaks are different, the U.S. has a much bigger population…  But given that we’re just now starting to do some serious social distancing measures… what could this mean for our hospitals?    

Well, just to take New York State as an example…  the Governor said that the State currently has around 3000 ICU beds -- and including new coronavirus patients, and patients already using the ICU for other things. He says we’re 80% full[74]. And he thinks we’re not going to have enough bed[75]. So unless we can ramp up capacity fast, we can expect our hospitals to get full pretty soon

And the thing is… other places around the world - they acted much faster. For example, in Hong Kong, within a week of their first case[76] workers were encouraged to telecommute, they closed schools, libraries, museums, courts and sports centers.[77][78][79] And now, 2 months later, they’ve had only some 140 confirmed cases and 4 deaths[80]. Acting fast worked in other places in Asia too[81][82][83] .

VR Which was really remarkable…  everyone listened, stayed home, that's what it takes, it really takes a commitment

Some places in the US have closed restaurants and bars - and with the new recommendations, we’ll probably start to see a lot more of that. But you can still get a cheeky beer in Australia! And many other parts of the world. So what should you do if you live in a place that has coronavirus patients where businesses haven’t been closed?

So this is the time, it's a critical time. To start avoiding interacting with other people. .

VR All non essential movement don’t do it. People have asked me can I go to a restaurant and meet friends- I would not do that. A student wanted to come see me today and talk. She would have to take the subway, I said it's better if you don’t do that. Let’s do a zoom. As much as you can.

Vincent says that working from home is a great idea right now - but he gets it. Not everyone makes a podcast in Brooklyn…

VR Yes I understand. Some people have to go to work, you have to take precautions, wash your hands, don't touch your face, sneeze and cough in your elbow, move away from sick people, do things to reduce the likelihood of transmitting the infection.

And this really important if you’re over 60[84] … or you have a condition like diabetes or heart disease[85] …

VR I have an elderly podcaster here in New Jersey and I said to him stay home, please don't go out because he’s 80 and is at risk for serious infection. His grandson typically visits from Brooklyn, I said don't do that, just don’t do that it's too much of a risk-01

If you do decide to go for a walk, or bike ride, Vincent said it’s a good idea to try to keep your distance.

VR 6 feet[86][87][88] is the minimum, the droplets you produce by breathing, coughing typically drop to the ground within 6 feet[89]

WZ Literally if you're walking down the street - should you cross the street?

VR I just move away from them

This, 6ft? It’s  kind of a rule of thumb… like, studies have found that when you sneeze droplets can travel further.[90][91] But to Vincent the broader point is that in countries where there is community transmission - so that means that this virus is spreading from person to person within the country - we need to be minimising contact with other people. And the more cases are in your area, the more careful you need to be … though Vincent did hear this story suggesting that some people didn’t get the memo.

VR My friend in Italy told me they were restricting the number of people that could get in a  supermarket at any given time, in principle it’s  a good idea, except she says queueing up outside by the hundreds. I think a supermarket you should just let people go. 

We reached out to a bunch of scientists - and they all agreed that these were the right steps. And they said it was really important.

ER There's not that many times you'll be able to spend a weekend at home, relaxing, and binge watching, and call it a public service and I think this is a rare case that we can…

This is Elizabeth Radin, public health professor at Columbia in New York[92]

WZ If we don't social distance and people keep living their lives as normal, then what could happen?-04

ER It’s sort of we don't really know but let’s not find out. I think, if no one practices social distancing, we can almost guarantee that the spread continues to increase-01

Something else we need to keep doing is washing our hands and disinfecting stuff with things like alcohol[93]. Viruses can stick around on surfaces for hours, sometimes for days-- so if you touch something that has viral particles on it, you could pick it up. We know this from other coronaviruses like SARS, and a study out last week into this new virus shows the same thing.[94][95][96]  

But…  Vincent says one thing is for sure: one thing's for sure..  it’s too late to just rely on doing things like travel bans or trying to track every new case….

VR: Restricting flights from Europe into the U.S., that’s not the solution[97], the virus is already here!! We need to be stopping the spread in the country02

WZ : We made a fictional pandemic, and we published it several months ago, before we knew about coronavirus … and there's this scene in it - where the host, me, is working from home, mandated working from home - and the scientist says "it's already here" - which you just said - I can't believe it.  I can't believe it

VR It is already here. VR People shouldn't panic. Someone asked me yesterday, are we all going to die? NO! You're not going to die. 80% of the cases are mild, most of the deaths are in people over 60, someone over 60 said that doesn't make me feel better, I understand that. Only a fraction will die and that fraction is smaller and smaller if you can get care in a hospital[98]. We cannot overburden the hospital. If we have enough beds for everyone who’s sick, we can take care of them!

WZ: I gotta ask, Vincent, why are people stocking up on toilet paper?! No one needs that much toilet paper right?

VR I guess people want to have toilet paper right?-02

WZ The virus doesn't make you crap!

VR No, it doesn’t give you diarrhea most of the time as far as we know, I think it's just a hoarding thing. My wife said the milk was gone too. I don’t understand it. Well my wife bought a 30-pound bag of beans and she said we’ll just have rice and beans for a month - fine with me

WZ Maybe then you will need the toilet paper I guess

VR That's right!

Look - I know this is new, and scary and weird. But for a lot of us, we can do this social distancing thing. And it looks like ... we just have to.

That’s Science Vs.

Check out our transcript, it’s in the show notes! We have all of our citations. There’s more than 100. And Josh Sharfstein who talked to us about testing, he has a podcast! It’s called Public Health on Call. It’s all about the coronavirus. Check out too. And Vincent’s podcast is - This Week in Virology. One more podcast recommendation: our friends over at The Journal podcast are reporting on this as well - so you can check out their work for more.

This episode was produced by Wendy Zukerman, Michelle Dang, Meryl Horn, Sinduja Srinivasan, and Rose Rimler. We’re edited by Blythe Terrell and Caitlin Kenney. Fact checking by Lexi Krupp. Mix and sound design by Sam Bair. Music written by Peter Leonard, Emma Munger, and Bobby Lord. A big thanks to all the researchers we got in touch with for this episode, including Dr Neeltje van Doremalen, Prof. Nigel McMillan, Prof. Jeffrey Shaman, Prof. Stephen Morse,

And special thanks to Salvatore Incontro, the Zukerman family and Joseph Lavelle Wilson.

I’m Wendy Zukerman, fact you next time.


[1] See “Actual” and “Daily Cases” chart on John Hopkins resource page. Number of new confirmed cases shot up on 3/13 and 3/16: https://coronavirus.jhu.edu/map.html

[2] “We have therefore made the assessment that COVID-19 can be characterized as a pandemic” from March 11 WHO speech 

[3] Johns Hopkins lists 155 countries/regions as of 3/16: https://coronavirus.jhu.edu/map.html

[4] Government in 100 countries school closures https://en.unesco.org/themes/education-emergencies/coronavirus-school-closures

[5]“...Spain on Saturday became the second country in Europe to impose sweeping restrictions on the public, telling everyone to stay indoors, with limited exceptions.” - NYT

 “In France, cafes and restaurants — central to the country’s soul and social life — were ordered closed along with most other nonessential businesses.” - NYT

 “Italy on Monday became the first European country to announce severe nationwide limits on travel as the government struggled to stem the spread of a coronavirus outbreak” - NYT

[6] Italy on Sunday reported 368 new deaths from the coronavirus outbreak as the country's death toll hit 1,809 while the number of positive cases rose to 24,747 from 21,157 on Saturday, the country's civil protection authority said.

Italy on Sunday reported its biggest one-day increase in cases and deaths during the coronavirus outbreak.

“Italy, the hardest-hit country outside China, reported a death toll of 1,809, a 25 percent increase over the day before.”

[7] According to Al Jazeera, national news outlets in Italy have said that “161 individuals had been sanctioned by police in a single day for violating a decree” … “Those found guilty face a three-month prison sentence or a fine of 206 euros ($230) as authorities sought to enforce the new rules.”

[8]https://www.statnews.com/2020/03/11/trump-europe-travel-ban/ 

“Trump declares coronavirus outbreak a national emergency” - Washington Post, March 13

https://www.washingtonpost.com/sports/2020/03/13/boston-marathon-postponed-coronavirus/

 https://www.nytimes.com/2020/03/12/theater/coronavirus-broadway-shutdown.html

https://www.marketwatch.com/story/disneyland-in-california-closed-through-end-of-month-amid-coronavirus-outbreak-2020-03-12

https://www.nytimes.com/2020/03/15/world/coronavirus-live.html?action=click&module=Spotlight&pgtype=Homepage

 As of March 16, 2020, 12:52 p.m. ET: 35 states have decided to close public schools. Combined with district closures in other states, at least 69,000 U.S. schools are closed, are scheduled to close, or were closed and later reopened, affecting at least 35.9 million public school students.of March 15, 2020, 9:29 p.m.

New York City is closing schools on Monday, and restaurants, bars and other venues a day later in an effort to halt the spread of the deadly coronavirus.

https://www.chicagotribune.com/coronavirus/ct-coronavirus-pandemic-chicago-illinois-news-20200315-tn4rchjbazb73h6x2i4vz7v3xq-story.html

https://www.cleveland.com/healthfit/2020/03/all-bars-restaurants-to-close-9-pm-sunday-due-to-coronavirus-carryout-still-allowed-ohio-gov-mike-dewines-sunday-briefing.html 

 In California, the governor orders home isolation of all senior citizens, calls for bars and nightclubs to close and for restaurants to reduce capacity by 50%

[9] According to WP reporting, “in interviews, people from states as varied as Wisconsin, North Carolina, Washington, Indiana and New York said their doctors sought but were unable to get testing approval from local or state health officials.”  ““It’s really been unbelievably infuriating,” said Remy Coeytaux, a North Carolina physician with a doctorate in epidemiology who tried to get tested for covid-19 but was turned down by the state public health department.”

In this case, reported by Vox, at first a PA was told her patient didn’t qualify for testing. Once the CDC relaxed their guidelines on who is eligible, she was still unable to get patient tested (basically a bunch of red tape)-- first she couldn’t reach her local health department, so she ordered a private test. Then the health department said she wasn’t allowed to use the test kits without their permission. Then she couldn’t reach the CDC. And meanwhile, the commercial test she ordered still hasn’t arrived.

 https://twitter.com/acarvin/status/1237864733786566658?s=20

https://www.marketwatch.com/story/one-womans-miserable-experience-trying-to-get-tested-for-the-coronavirus-2020-03-03

 https://act.nationalnursesunited.org/page/-/files/graphics/NU-Quarantine-RN-press-conf-statement.pdf

[10] According to the The COVID Tracking Project there have been 41,552 people tested as of 5:29 p.m. EDT 3/16.

[11] https://www.cdc.go.kr/board/board.es?mid=&bid=0030&act=view&list_no=365797&tag=&nPage=12 first case on Jan 20, 2020

[12] First case in the U.S. was on Jan 21. By a month later,  Feb 21, 2,561 “specimens tested” for virus according to CDC data  --although probably far fewer patients.

[13] As of 3/16, 274,504 people tested in South Korea

12,000 new cases tested between 3/13 and 3/14 according to Korean data: https://www.cdc.go.kr/board/board.es?mid=&bid=0030

https://www.npr.org/sections/goatsandsoda/2020/03/13/815441078/south-koreas-drive-through-testing-for-coronavirus-is-fast-and-free

[14] "For initial diagnostic testing for COVID-19, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal swab)."

[15] Symptoms of COVID-19 are non-specific and the disease presentation can range from no

symptoms (asymptomatic) to severe pneumonia and death. As of 20 February 2020 and based on 55924 laboratory confirmed cases, typical signs and symptoms include: fever (87.9%), dry cough (67.7%), fatigue (38.1%), sputum production (33.4%), shortness of breath (18.6%), sore throat (13.9%), headache (13.6%), myalgia or arthralgia (14.8%), chills (11.4%), nausea or vomiting (5.0%), nasal congestion (4.8%), diarrhea (3.7%), and hemoptysis (0.9%), and conjunctival congestion (0.8%).

[16] https://www.cdc.gov/coronavirus/2019-ncov/faq.html#symptoms 

[17] Big Systematic Review from China (From March 12) The most common symptom of COVID-19 was fever (2878 [83.0%]), followed by cough (2102 [61.0%]), fatigue (942 [37.9%]), sputum production (720 [28.7%]), dyspnea (412 [14.5%]), muscle aches (477 [18.6%]).  NEJM paper The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). From table: Fatigue 38%, Sputum production (33.7%) [phlegm], Sore throat/headache both 14%, shortness of breath 18.7%.2 other papers also from China saying most common symptoms are fever and cough. From WHO “The most common symptoms of COVID-19 are fever, tiredness, and dry cough.” From CDC  “The following symptoms may appear 2-14 days after exposure. Fever, Cough, Shortness of breath

[18]“Miami Mayor Francis Suarez has COVID-19, though you wouldn’t know it if you were sitting next to him.”

Most cases were classified as mild (81%; ie, non-pneumonia and mild pneumonia).

WHO Report 16-24 Feb Most people infected with COVID-19 virus have mild disease and recover. Approximately 80% of laboratory confirmed patients have had mild to moderate disease

[19] https://www.jhsph.edu/faculty/directory/profile/1781/joshua-m-sharfstein

[20]https://jamanetwork.com/journals/jama/fullarticle/2762951?guestAccessKey=0221d908-88c2-44d7-9e78-d95f5c67cea5&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=030920 

[21] https://www.cdc.gov/media/releases/2020/p0206-coronavirus-diagnostic-test-kits.html

[22] CDC finally started to send kits to state and local health labs on 5 February. But on 12 February, it revealed that several labs had difficulty validating the test because of a problem with one of the reagents.,,, The key problem with the kits is what’s known as a negative control, says Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories (APHL). CDC’s test uses the polymerase chain reaction (PCR) assay to find tiny amounts of the SARS-CoV-2 genome in, say, a nose swab. To make sure a test is working properly, kits also include DNA unrelated to SARS-CoV-2. The assay should not react to this negative control, but the CDC reagents did at many, but not all, state labs.

[23] https://cen.acs.org/analytical-chemistry/diagnostics/Faulty-probes-blame-CDC-coronavirus/98/i9 

[24] As soon as the test kits arrived, however, many state laboratories encountered difficulty verifying the results; some of the expected results came back as inconclusive or invalid due to failure of the negative control. The source of these problems remains under investigation.

[25]https://www.fda.gov/media/135659/download

[26]https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-new-policy-help-expedite-availability-diagnostics: On Feb. 4, 2020, the Secretary of HHS determined that there is a public health emergency and that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the COVID-19 outbreak. Rapid detection of COVID-19 cases in the U.S. requires wide availability of diagnostic testing to control the emergence of a rapidly spreading, severe illness. The FDA has authorized one EUA for COVID-19 that is in use by the U.S. Centers for Disease Control and Prevention (CDC) and some public health labs across the country. The guidance issued today (2/29) describes a policy enabling laboratories to immediately use tests they developed and validated in order to achieve more rapid testing capacity in the U.S.

[27] See “red tape” and NYT reporting

[28]https://www.fda.gov/medical-devices/emergency-situations-medical-devices/faqs-diagnostic-testing-sars-cov-2

[29] https://www.labcorp.com/information-labcorp-about-coronavirus-disease-2019-covid-19 March 14 Media Statement: “LabCorp Rapidly Expanding Its COVID-19 Testing Capacity, Expects Ability to Perform 10,000 Tests Per Day by the End of Next Week and 20,000 Tests Per Day by the End of the Month”

[30] https://www.questdiagnostics.com/home/Covid-19/

[31] As of July 15, 2003, a total of 418 SARS cases were reported in the United States

[32] By December 31, 2014, the Ebola epidemic in West Africa had resulted in treatment of 10 Ebola case-patients in the United States; a maximum of 4 patients received treatment at any one time (1). Four of these 10 persons became clinically ill in the United States (2 infected outside the United States and 2 infected in the United States), and 6 were clinically ill persons medically evacuated from West Africa

[33]On March 12 “the U.S. Food and Drug Administration took two significant actions in the agency’s ongoing and aggressive commitment to address the coronavirus outbreak (COVID19).First, the agency issued enforcement discretion and is not objecting to the New York State Department of Health (NYSDOH) authorizing certain laboratories in New York to begin patient testing after validating their tests and notifying the NYSDOH. Under NYSDOH’s approach, laboratories will provide validation data to NYSDOH within 15 days in lieu of pursuing an Emergency Use Authorization (EUA) with FDA.Second, the FDA authorized the Roche cobas SARS-CoV-2 Test, the third Emergency Use Authorization (EUA) granted for a diagnostic test during the COVID-19 outbreak.

[34] https://twitter.com/NYGovCuomo/status/1238515024072671233?s=20 

[35] White House Press Briefing 3/15  https://www.youtube.com/watch?v=PQvbp6bDjoA&feature=emb_title 

Rev Transcript:  2,000 Labs (Admiral Giroir 21:09 “labs up to 2000)  Testing Centers (Admiral Giroir 23:14 “pod based units”  )  Tens of Thousands or Hundreds/week (Admiral Giroir 21:09 “tens of thousands to hundreds of thousands of individuals per week and maybe even more” ) Priority testing (VP Pence 16:04 “A priority will bplaced … health care workers and first responders … and then americans 65 or over with … symptoms” )

[36] "...pharyngeal swabs are the most common sampling method, however, they may occasionally cause missed diagnoses for smaller levels of SARS‐CoV‐2 residing in the pharynx."

[37] https://pubs.rsna.org/doi/10.1148/radiol.2020200823 RT-PCR testing has low sensitivity early on in the disease course.

[38] paper includes a case of a man who was very sick and had negative swabs for coronavirus; assumed to have flu; later on ventilator tested positive for coronavirus  - Patient 12 https://onlinelibrary.wiley.com/doi/10.1002/jmv.25749 

[39] This case highlights that a single negative result of the test, particularly if it is based on an upper respiratory tract specimen, in highly suspected cases, does not exclude COVID-19.

[40] People with COVID-19 generally develop signs and symptoms, including mild respiratory symptoms and fever, on an average of 5-6 days after infection (mean incubation period 5-6 days, range 1-14 days).

[41] Sars-cov2: Our review found the average R0 to be 3.28 and median to be 2.79, which exceed WHO estimates of 1.4 to 2.5...In more recent studies, R0 seems to have stabilized at around 2-3.

[42]  C.f R0 Measles: roughly 12-18;

[43] The Centers for Disease Control and Prevention recommended that no gatherings of 50 people or more be held in the U.S. for the next two months, one of the federal government’s most sweeping efforts to slow the spread of the coronavirus pandemic." - NYT

Guidance as of 3/15/20 https://www.cdc.gov/coronavirus/2019-ncov/community/large-events/mass-

[44] https://microbiology.columbia.edu/faculty-vincent-racaniello

[45] http://www.microbe.tv/twiv/

[46] Sars-cov2: Our review found the average R0 to be 3.28 and median to be 2.79, which exceed WHO estimates of 1.4 to 2.5...In more recent studies, R0 seems to have stabilized at around 2-3.

[47] https://www.pnas.org/content/pnas/104/18/7582.full.pdf Figure 1

[48] Study on 43 US cities: cities that implemented NPIs earlier (and had a layered response) experienced delays in reaching peak mortality, lower peak mortality rates, lower total mortality. School closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%)

[49] https://www.pnas.org/content/pnas/104/18/7582.full.pdf cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates 50% lower than those that did not

and had less-steep epidemic curves

[50] . San Francisco, St. Louis, Milwaukee, and Kansas City had the most effective interventions, reducing transmission rates by up to 30–50%....  Cities that introduced measures early in their epidemics achieved moderate but significant reductions in overall mortality

[51] https://sci-hub.tw/10.1098/rsif.2007.1197  Australia/1918 flu: During this period, extensive infection control measures were imposed, including: closing theatres and public places of entertainment; compulsory wearing of masks on all public transport and in public places; closure of schools… We estimate that, on average across the city, people reduced their infectious contact rate by as much as 38%... . This reduction in the clinical attack rate translates to an estimated 260 per 100 000 lives having been saved, and suggests that social distancing interventions could play a major role in mitigating the public health impact of future influenza pandemics.

[52]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5507503/pdf/pone.0180545.pdf  1918 modeling paper based on data from British cities on “reactive social distancing”- “a form of behavioral responses where individuals avoid potentially infectious contacts in response to available information on an ongoing epidemic or pandemic. Such behavioral responses could include avoiding mass gathering, putting on protective masks, actively maintaining personal hygiene and getting vaccinated… we showed that reactive social distancing could lead to reduction in final epidemic size.”

[53] No church services were held, some businesses were closed, and a statewide ban went into effect. Funerals were private.” (11) .. . Public gatherings of 20 or more people were all prohibited, including dances, parties, weddings, or funerals. Crowding in stores was banned. Streetcars were forbidden to carry more than 20 standing passengers. Elevators were sterilized once a day. Telephone booths were sterilized twice.” https://www.pnas.org/content/pnas/suppl/2007/04/09/0611071104.DC1/11071SIAppendix.pdf

[54] Sports and entertainment events were canceled in Japan for two weeks from 26

February to 11 March according to a government advisory.  An earlier study [9] estimated R0 for COVID-19 as 2.24–3.58 in Wuhan. Our R0 obtained before VEC was similar. However, Rv after VEC introduced was 35% reduction from R0.

[55] https://www.pnas.org/content/pnas/104/18/7588.full.pdf The impact of controls on the shape of the epidemics seen was much more major than the effect on overall mortality. For most cities, a single large epidemic peak would have been expected had controls not been imposed (Fig. 3).

[56] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757092/  local public health authorities should plan for the early and sustained institution of such measures in the event of such a severe pandemic. By doing this, local communities may decrease their patient burdens and thus mitigate surge demands on their local healthcare systems.

[57] https://www.biorxiv.org/content/10.1101/2020.01.27.922443v2.full modeling paper based on Wuhan data: If a 70% efficacy rate of public health intervention could be achieved, the number of cases being admitted to isolation ward and ICU would drop to a large extent throughout the course of outbreak. Similarly, greater benefits for healthcare system are expected to obtain if higher efficacy can be achieved (e.g., 80% or 90%). Total number of deaths would also be greatly reduced (Figure 6).”

[58] 1918 flu paper: https://sci-hub.tw/10.1001/jama.298.6.644  Optimally, appropriate implementation of nonpharmaceutical interventions would decrease the burden on health care services and critical infrastructure.

[59] https://www.medrxiv.org/content/10.1101/2020.03.06.20032177v1 when the city conducts different levels (strict, mild, or weak) of travel restrictions or regulation measures, the estimation results show that transmission dynamics will change and the peek number of cases shows the changing proportion is between 56%~159%. We concluded that public health interventions would reduce the risks of COVID-19 spreading and more rigorous control and prevention measures will effectively contain its further spread,

[60] China’s ICUs were also over capacity: “the volume of critically ill patients with SARSCoV-2 infection has surpassed the intensive care supply for quite a long period of time, meaning that only a small proportion of critically ill patients could get access to intensive care services”

[61] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30627-9/fulltext#fig1 Italy: Intensive care specialists are already considering denying life-saving care to the sickest and giving priority to those patients most likely to survive when deciding who to provide ventilation to…  the reality is that intensive care wards are overflowing with patients …  Considering that the number of available beds in intensive care units in Italy is close to 5200, and assuming that half of these beds can be used for patients with COVID-19, the system will be at maximum capacity, according to this prediction, by March 14, 2020.

[62]  https://jamanetwork.com/journals/jama/fullarticle/2763188 Despite prompt response of the local and regional ICU network, health authorities, and the government to try to contain the initial cluster, the surge in patients requiring ICU admission has been overwhelming.

[63] It may be necessary to place an age limit on entry into TI. It is not a question of making choices merely of value, but to reserve resources that could be very scarce for those who are primarily more likely to survival and secondarily to those who can have more years of life saved, with a view to maximizing of benefits for most people.”

[64] Italian Original

[65] WHO feb 23 sit rep report 2 deaths in italy (table 2)

[66] 3 deaths in Italy by Feb 23

[67] Feb 23 Quarantine of Lombardy and Veneto: “Ten towns in the Lombardy region and one in Veneto were placed on lockdown, with schools, businesses and train stations closed and scheduled public events canceled.”

[68] “In recent days, Italy has scrambled to close off a cluster of small towns south of Milan, some of the primary hot spots. Police have set up checkpoints outside those areas, and only people with special permission can enter or exit.

[69] https://abcnews.go.com/Health/wireStory/italy-cancels-venice-carnival-bid-halt-spread-virus-69160543:  2/23 Italy scrambled Sunday to check the spread of Europe's first major outbreak of the new viral disease amid rapidly rising numbers of infections and a third death, calling off the popular Venice Carnival, scrapping major league soccer matches in the stricken area and shuttering theaters, including Milan's legendary La Scala.

[70] March 8 Northern Italy quarantine (nyt)  Italy’s government early Sunday took the extraordinary step of locking down much of the country’s north, restricting movement for about a quarter of the Italian population in regions that serve as the country’s economic engine.

[71] March 8 Northern Italy quarantine (bloomberg, source for deaths) Italy reported 7,375 coronavirus cases and 366 deaths.

[72] WHO march 8 sit rep (table 2): 234 deaths in italy

[73] https://docs.google.com/spreadsheets/u/2/d/e/2PACX-1vRwAqp96T9sYYq2-i7Tj0pvTf6XVHjDSMIKBdZHXiCGGdNC0ypEU9NbngS8mxea55JuCFuua1MUeOj5/pubhtml#  as of March 16 at 5:45 PM, 71 deaths (see US Current tab)

[74] March 15 Cuomo press conference Cuomo said New York has 3,000 ICU beds, and they are already 80% occupied, leaving about 600 beds free today.

[75] Cuomo Press conference March 16th: 14:03 “I don’t believe we’re going to flatten the curve enough to meet the capacity of the healthcare system”

[76] Hong Kong’s first case on January 23: WHO sit rep (table 1)

[77] Announced Jan 27th Schools closed: all schools will extend their holidays to Feb 17

[78] January 29 Encouraged to telework: “The HKSAR Government appeals to employers to make flexible work arrangements for employees. Except for staff providing emergency and essential public services, all other employees of the Government are not required to return to their offices but to work at home after the holidays.”

[79] Jan 29: public facilities closed (sports centers, museums, libraries): A number of public facilities will be temporarily closed from January 29 until further notice

[80]https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200315-sitrep-55-covid-19.pdf?sfvrsn=33daa5cb_6

[81] As of March 5, 2020, there has been sustained local transmission of coronavirus disease 2019 (COVID-19) in Hong Kong, Singapore, and Japan. Singapore: restrict entry from mainland China, northern Italy, Iran, and South Korea. Hong Kong: mandatory 14-day quarantine for everyone who enters from the mainland, and denies entry to non-local visitors from South Korea, Iran, Italy. Japan: travel restrictions on citizens from Hubei and Zhejiang provinces, and cruise ships with cases of COVID-19 were quarantined.

[82] Taiwan Ministry of Health: Onboard quarantine of all direct flights arriving from Wuhan has been implemented since December 31, 2019

[83] Taiwan integrated travel and health information on January 27 and those identified as high risk (under home quarantine) were monitored electronically through their mobile phones

[84]  The median age of the patients was 59 years, with higher morbidity and mortality among the elderly and among those with coexisting conditions (similar to the situation with influenza)

[85] [23] The bulk of death cases had comorbidity (76.8%), including hypertension (56.1%), heart disease (20.7%), diabetes (18.3%), cerebrovascular disease (12.2%), and cancer (7.3%).

[86] https://www.gps-can.com.au/covid19-basics/a-guide

[87] https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/

[88] Between people who are in close contact with one another (within about 6 feet). https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Fprevention.html

[89] https://link.springer.com/content/pdf/10.1007/s12098-020-03263-6.pdf "These infected droplets can spread 1–2 m and deposit on surfaces"

[90] https://sci-hub.tw/10.1111/j.1600-0668.2007.00469.x  Expelled large droplets were carried more than 6 m away by exhaled air at a velocity of 50 m/s (sneezing), more than 2 m away at a velocity of 10 m/s (coughing), and less than 1 m away at a velocity of 1 m/s (breathing).

[91] https://aem.asm.org/content/73/6/1687Respiratory viruses cause sneezing and coughing, which expel an estimated 107 infectious virions per ml of nasal fluid (18). Nasal secretions can travel at a velocity of over 20 m per second and a distance greater than 3 m (about 10 feet) to contaminate surrounding fomites (42, 57, 78).

[92] https://www.mailman.columbia.edu/people/our-faculty/er2743

[93] The analysis of 22 studies reveals that human coronaviruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus or endemic human coronaviruses (HCoV) can persist on inanimate surfaces like metal, glass or plastic for up to 9 days, but can be efficiently inactivated by surface disinfection procedures with 62–71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute.

[94] HCoV-19 was most stable on plastic and stainless steel and viable virus could be detected up to

72 hours post application (Figure 1A), though the virus titer was greatly reduced https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v2.full.pdf   

[95] https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext 

[96] Coronaviruses and influenza both have the capacity to survive on a wide range of porous and non-porous materials, including metals, plastics (such as light switches, telephones, perspex, latex, rubber, and polystyrene), woven and non-woven fabrics (including cotton, polyester, handkerchiefs, and disposable tissues), paper (including magazine pages), wood, glass, stethoscopes, tissue, Formica®, bank notes, tiles, eggs, feathers, and soft toys.

[97] P80 In the absence of any border or travel restrictions, cases of pandemic influenza would likely arrive in the United States within 1 to 2 months after the virus first emergence elsewhere in the world. Current models suggest that highly restrictive border measures might delay the peak of pandemic by a few weeks.

[98] From the information available now, a substantial part of subjects diagnosed with infection from Covid-19 requires ventilatory support due to interstitial pneumonia characterized by severe hypoxemia. Interstitial disease is potentially reversible, but the acute phase can last many days [Google Translate]

[99] https://jamanetwork.com/journals/jama/fullarticle/2762692