dredmorbius@joindiaspora.com
Doc Morbius (moved to Glasswings)

A Laycat's COVID-19 / Coronavirus Updates -- February 28, 2020

With events of the past several days, I'm revising my views considerably. As the U.S. Centers for Disease Control (US CDC) says, "the Global Novel Coronavirus situation is rapidly evolving and expanding". The World Health Organisation (WHO): "No country will be spared, warn experts, as fight against coronavirus ramps up" (Reuters).

Global cases now exceed 83,000, deaths 2,800, still principally in China, though with outbreaks elsewhere this is likely to change.

Putting it mildly, all hell broke loose on February 24. I'm no longer able to keep up with developments, this piece has been in process for 4 days.

As usual: I'm a space alien cat on the Internets. I claim no expertise in public health, infectious disease, or epidemiology. I read widely and think too much. I synthesize information from numerous sources. This update is offered in that light. Sources are provided (I may have missed a few), and where information is uncertain I note this. I strongly recommend you verify this information and vet my sources. Questions welcomed, answers possible.

A terminology note: For the outbreak I'll be referring to the now-accepted name "COVID-19" rather than "2019-nCoV" or "coronavirus" largely going forward, and using the hashtags #covid19 and #sarscov2 rather than #ncov2019 in general going forward. The virus is now being referred to as SARS-CoV-2. Experts are describing the naming practice as "chaotic".

The term "community transmission" is also used, see below for definition and implications.

The hero images here show case and mortality, principally by age, and the latest global spread chart from Wikipedia.

General Advice

COVID-19 is now at community outbreak status in numerous countries and regions: China, South Korea, Japan, Hong Kong, Iran, Italy, Singapore, Taiwan, Thailand, Germany, the United States, Holland. There are occurrences in other countries though largely of known origin. This does not necessarily mean the disease is widespread, but it means sources aren't specifically known.

  • Stay informed on outbreak status. See "Sources" section.

  • There are few medical treatments or preventives: no vaccine, no medications.

  • Avoidance is the best practice. Practice basic hygiene: Wash your hands, cover your cough, stay home.

  • Prepare for several weeks of limited external contact, as well as closures of schools, businesses, and public event cancellations.

  • Secondary impacts will likely be widespread. You may have noticed financial markets declining. Expect more, as well as other effects.

Sources

I've tried to rely on medical journals or mainstream centrist news sources where possible. In cases, late-breaking news or developments are principally available from social media and informal sources. Where these seem reasonably credible and plausible, I've included several.

Overview

  • The situation in China is largely improving, though remains quite serious.
  • Outbreaks outside China are the biggest new development, and the most concerning. New cases outside China now represent the majority of new cases. Global spread to all countries is now a near certainty.
  • US CDC's clinicians expect a community outbreak within the U.S., "a matter of when, not if". OK, it's now "when".
  • Detection, surveillance, and monitoring capabilities and protocols are limited and strongly affect perceptions and responses to the outbreak.
  • As yet, there is no vaccine and there are no medications approved to treat COVID-19.
  • Mortality data are becoming clearer, especially by age, based on Chinese experience. This increases from age 50+, markedly at 60+, 70+, and 80+. Infants and children do not appear at significant risk. Men are more susceptible than women.
  • Viability in warm and humid climates is ... unclear, but seems low.
  • Genetic variations may affect susceptibility, highest for native Japanese, lowest in the Gulf / Middle East region, moderate for most people of European ancestry, based on ACE-2 receptor prevalence.
  • Public-health and "non-pharmaceutical interventions" (US CDC's language) are standard. Wash your hands, cover your cough, stay home.
  • Public health institutions: national, WHO, US CDC, and others.
  • Second-order effects, initially principally to financial markets and the economy, are likely the largest immediate impacts. More may follow.
  • There are several documents giving public advice and policy guidance. Breaking transmission chains is key through hygiene, sanitation, and avoidance measures.

More notably: My previous estimates of total case counts and mortality now appear to be low. I'd suggested ~100k cases and ~1,000 deaths. With broader spread these are likely to be much higher, possibly by 10x - 100x, perhaps more.

I'll discuss each of these at more length below.

China Containment

Reporting 78,824 cases, 2,788 deaths, and community transmission.

U.S. State Deparment travel advisory level 1 "Avoid non-essential travel".

Starting with the good news: It appears that China's efforts at containment are largely succeeding. Both cases and deaths are trending sharply downwards --- that is, there are fewer new cases and deaths with additional days. Whilst the disease has spread throughout the country the overwhelming majority of cases have been in Wuhan city and Hubei province.

China's intervention, largely widespread travel restrictions, had visible and pronounced effects by late January, virtually halting spread outside Hubei province, based on available data. This should be the model elsewhere.

Though there've been persistent questions about the accuracy and completeness of China's disclosures of data. Even without misreporting, there are strong clinical reasons to believe the total case-count understates total infections, but for the most part this does not matter as it is trends rather than absolute numbers which are most revealing, and data on deaths is more reliable and confirms, with a ~2 week lag, incidence data. That is: infected dead bodies are hard to hide, and trends in mortality data very strongly confirm a net reduction in new infections over recent weeks.

The shadow over Chinese response is possible outbreaks in prison and other institutional populations, which are large within China. This may lead to re-emergences, transmissions to the general population, and/or stubborn reservoirs of outbreak. As with many countries, services, and in particular medical and health care, to prison populations is not prioritised. This is reflected in other regions outside China as well.

My assessment is that China COVID-19 data are generally credible presently. The case counts themselves are likely low, deaths are a more reliable, though lagging indicator, but behaviour and correspondence seem generally sensible. Information outside China, particularly from neighbouring regions such as South Korea and Japan can also verify Chinese experience.

Outbreaks outside of China

As of 25 February 2020 there are more new daily reported cases outside of China than inside China.

This has been the most notable change in the past week, with known cases growing rapidly in Iran, Italy, South Korea, and Japan. There are further outbreaks, though fairly contained, in Hong Kong, Singapore, Korea, Taiwan, and Thailand.

By the US CDC's estimate, 2 of the 3 requirements for declaring a global pandemic have been met. The third is community transmission in multiple countries.

The specific histories and dynamics of various country's experiences, transmission, and responses to COVID-19 are also instructive. In particular, information access, trust, institutional competence, and infrastructure are all extremely significant in effective responses.

Given current trends, cases outside of China will top 10,000 within a few days, and could exceed 100,000 within a week or two. Limiting growth beyond those levels depends on containment efforts implemented immediately.

Iran

Reporting 388 cases, 34 deaths, and community transmission.

U.S. State Deparment travel advisory level 2: "Practice Enhanced Precautions".

Though not the largest outbreak, quite possibly the most troubling known one in that government competence, credibility, capability, and trust are all low. Iran's deputy health minister, after mocking concerns of an outbreak and declaring that "quarantines belong to the Stone Age", is infected with the virus, and self-quarantining at home. "Iran says official who played down virus fears is infected" (AP).

In particular, the high death rate (10% of cases) suggests a substantial undercount of actual infections, as this is well above the ~3% rate which seems typical elsewhere. Note that other middle-eastern countries with lower ACE-2 genetic markers might suggest Iran's overall susceptibility is lower than populations further east. The high spread and deaths are concerning.

Twitter stream to follow: Farnaz Fahishi: https://twitter.com/farnazfassihi "Journalist nytimes Former WSJ | War Correspondent | Mideast & Iran Expert Author book on Iraq war Ellis Island Medal of Honor Columbia & Harvard Alum"

South Korea

Reporting 2,377 cases, 16 deaths, and community transmission.

U.S. State Deparment travel advisory level 2: "Avoid non-essential travel".

The largest outbreak outside China. There's been a major increase in cases, most notably emerging from a conservative Christian church: Secretive Church Sect At The Center Of South Korea's Coronavirus Outbreak (NPR) 2020-02-24

Critics say the disease may have spread within the church quickly because of the way that it worships. "Shincheonji followers hold services sitting on the floor, without any chairs," packed together "like bean sprouts," says Shin Hyun-uk, director of the Guri Cult Counseling Center, an organization in Gyeonggi province that works to extract members from the church.... A petition on the presidential website, which has garnered more than half a million signatures, calls on the government to forcibly disband the group.

Italy

Reporting 655 cases, 17 deaths, and community transmission.

U.S. State Deparment travel advisory level 2: "Practice Enhanced Precautions".

The largest community outbreak in Europe. Two Chinese tourists tested positive in Rome on 31 January. An outbreak was detected in Lombardy (northern Italy, bordering Switzerland) on 21 February, now numbering over 400 cases, and confirmed or suspected cases throughout the country.

Japan

Reporting 228 cases, 5 deaths, and community transmission.

U.S. State Deparment travel advisory level 2: "Practice Enhanced Precautions".

PM Abe asks all of Japan schools to close over coronavirus (Reuters) 2020-02-27

Japan’s entire school system, from elementary to high schools, will be asked to close from Monday until spring break late in March to help contain the coronavirus outbreak, Prime Minister Shinzo Abe said on Thursday.

Philippines

Reporting 3 cases, 1 death. Possibly community transmission.

No travel advisory.

After initial cases, no further spread that I've noted.

On February 7, WHO-Philippines suggested that COVID-19 could spread in warm, humid climates. Since then it has not, which is reassuring.

As with other regions, testing and detection capabilities may be limited, so reassuringly low case counts may be misleading. So far, the information is encouraging.

North Korea

Reporting 0 cases, 0 deaths. Data generally considered implausible.

Though the country reports no cases officially, this is increasingly implausible given experiences in China and other neighbouring countries. As China's initial response showed, efforts to conceal potentially embarrassing or negative information from both international and domestic view can sharply limit initial awareness and communications. North Korea's extreme totalitarian dictatorship is not amenable to free-flowing information, most especially of bad news. The country's institutions and means for effective epidemic response are quite limited, based on past experiences.

There are unofficial reports of outbreaks, though these also may reflect politically motivated messengers or audiences. The unfortunate truth is that the state of information is simply unreliable. Though I find the likelihood of at least some and possibly serious outbreak high.

Among news items questioning the PRK situation:

  • "Could North Korea handle a Covid-19 outbreak?" (BBC) 2020-02-26. "North Korea is seen as highly vulnerable to infectious diseases, and its healthcare system ill-equipped to deal with them. So far, the country claims to have no cases of Covid-19 - but some observers are questioning whether that can be true. Experts say an outbreak in North Korea would be devastating for a population already suffering from malnourishment and poor health...."

  • "North Korea reportedly quarantines 380 foreigners in bid to prevent coronavirus outbreak" (CNBC) 2020-02-24. "North Korea has reportedly quarantined 380 foreigners as part of efforts to prevent the coronavirus outbreak. The majority of those quarantined are thought to be diplomats stationed in the capital city of Pyongyang, Yonhap news agency reported Monday, citing state media in North Korea.... The isolated regime has repeatedly denied any confirmed cases of the coronavirus. That's despite concerns North Korea would be vulnerable to an outbreak given it shares a long and porous border with China and lacks vital medical supplies and infrastructure to cope with a fast-spreading virus...."

  • "Coronavirus: North Korea quarantines foreigners" (BBC) 2020-02-24. "...North Korea has not confirmed any cases but the country shares a long and often porous border with China. There are concerns that North Korea, which is subject to international sanctions, lacks the health infrastructure to test and treat those infected and that any outbreak could quickly spread unchecked...."

  • "North Korea: Kim Jong-un makes first public appearance in 22 days amid coronavirus outbreak (SCMP) 2020-02-16. "...North Korea has not confirmed any cases of the new coronavirus, but state media said the government was extending to 30 days the quarantine period for people showing symptoms, and all government institutions and foreigners living in the country were expected to comply 'unconditionally'...."

  • "All of its neighbors have it, so why hasn't North Korea reported any coronavirus cases?" (CNN) 2020-02-07. "...One of the world's poorest countries has, according to its public statements, managed to avoid the virus despite the fact that in neighboring mainland China, it has killed more than 600 people and infected more than 31,000. More than 300 people have tested positive for the virus in over 25 places around the world -- including the other two countries that share a land border with North Korea, Russia and South Korea. In fact, every country and territory within a 1,500-mile radius of North Korea, except for sparsely populated Mongolia, has confirmed a case...."

Other Europe

Numerous cases in various countries. No additional travel advisories at this time.

Community transmission is generally probable, if not extant.

United States

Reporting 60 cases, 0 deaths, 6 recoveries. One case of community transmission detected.

Most U.S. coronavirus cases remain associated with the Diamond Princess cruise ship outbreak, with 54 of the 634 confirmed cases aboard the ship being Americans, now repatriated and quarantined in the U.S. Another 14 cases are travel related (2 by person-to-person transmission), and one community-transmitted case, in Northern California, involving a Solono County resident now treated at UC Davis Medical Center in Sacramento, CA.

There have been concerns voiced over politicisation of the outbreak in the U.S., of political rather than clinical leadership of the outbreak, and of attempts to limit or contain both announcements and testing of suspected COVID-19 cases. All of these are errors which were widely criticised in China's early response. I'm very much hoping the U.S. does not repeat these mistakes for long.

The long erosion in the U.S. of political and institutional trust, as well as governmental competence, is worrying.

US CDC Update,

On Tuesday 25 February 2020 the CDC held a press conference with an Update on COVID-19 (audio). This was the original inspiration for this post, as noted, events are overtaking me me.

Summarising:

  • The Global Novel Coronavirus situation is rapidly evolving and expanding
  • Community spread is defined as cases without any known source of exposure
  • Hong Kong, Iran, Italy, Japan, Singapore, South Korea, Taiwan, and Thailand are affected.
  • 2 of 3 definitions of pandemic have been met. The third is worldwide spread.
  • U.S. control especially at points of entry.
  • Monitoring and travel advisories are being issued by the U.S. State Department.
  • Quarantines, cooperation with HHS / DHS to repatriate individuals
  • Very few cases in U.S., no spread in community as of 25 February. (NOTE: This is no longer true.)
  • Ultimately we expect we will see community spread in this country. It's not so much a question of if this will happen any more, but rather more a question of exactly when this will happen, and how many people in this country will have severe illness.
  • At this time there is no vaccine to protect against this new virus, and no medications approved to treat it.
  • Non-pharmaceutical interventions (NPIs) will be the most important tool in our response to this virus. The specific interventions will vary by community and conditions.
  • Specific recommendations made in document mentioned last Friday
  • "Community mitigation guidelines to prevent pandemic influenza", United States, 2017, drawing on ~200 journal articles written 1990 - 2016. Provides a framework on response strategy.
  • 14 cases picked up through the public health system.
  • 42 cases repatriated from the Princess cruise liner.

Medical Characteristics

There's more information about the specific medical behaviour and characteristics of SARS-nCoV-2, the virus and disease behind COVID-19. Some of this is reassuring, some less so.

  • The long incubation period, infectiousness before symptoms present, and possible reinfection of "recovered" cases, all lead to an increased likelihood of spread. We don't know where this is until well after it's already there.
  • Availability of test kits, testing protocols, and healthcare insurance coverage and costs may all exacerbate spread of the disease.
  • Transmission continues to appear to be via droplets. This is not "airborne transmission", as such droplets fall rapidly to the ground, but can result in transmission especially via coughing or sneezing.
  • Hand-to-face transmission from surfaces is also common.
  • Both infectiona and mortality increase sharply with age, most espeically at ages 60+. Infants and childre appear at very low risk.
  • Co-morbidities of being a present or past smoker, and having cardiovascular disease, asthma, or diabetes, seem to greatly increase risk, especially of death.
  • There is a possible genetic component varying widely by region.
  • No drugs are currently approved for use, though several are being studied.

Case mortality by age

This is one of the two images I've attached to this post.

As noted above: there is a very low risk for infants and children, and modest risk through about age 50, increasing by about 2-3x for each 10 year span above that age, based on Chinese data. Experiences elsewhere may differ from this.

Pre-existing conditions show a strong influence, particularly smoking or previous smoking history.

From: "The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020" (China CDC).

Partially reproduced as a table:

Age Cases Deaths CFR% Mort/10 PD
0-9 416 0 -- --
10-19 549 1 0.2 0.002
20-29 3,619 7 0.2 0.001
30-39 7,600 18 0.2 0.002
40-49 8,571 38 0.4 0.003
50-59 10,008 130 1.3 0.009
60-69 8,583 309 3.6 0.024
70-79 3,918 312 8.0 0.056
80+ 1,408 208 14.8 0.111
  • "CFR" is case fatality rate
  • "PD" is patient-days

Mortality for men has been ~2x for women, possibly reflecting smoking rates.

Detection, monitoring, surveillance, and reporting

This all but certainly will have the biggest impact on containment efforts. COVID-19 is undetectable for a considerable period after infection, during which patients are infectious.

  • COVID-19 is asymptomatic well after contracting the disease and without symptoms being present. Latent cases within a community are highly likely. Detection lags infection by days or weeks.
  • Suspected and known cases lag actual infections.
  • Test kits are not widely available. Use is targeted to most likely cases, based on screening protocols. Testing has been specifically denied of suspected cases (e.g., California UC Davis Medical Center) on the basis of not meeting established protocols.
  • Protocols may themselves lag ground truth, particularly where screening by suspect countries of origin is concerned.
  • Testing may be prioritised toward medical personnel and first responders.
  • Regional and national variations in detection and disclosure are high.
  • "No reported cases" may not be good news --- this might be because of no cases, of no testing, or of barriers to reporting.
  • See especially: North Korea. At risk: any country with limited medical and/or public-health infrastructure, or a strongly privatised healthcare system.

Expanding "suspected case" clinical diagnosis criteria, increasing availability of test kits, allowing use of locally-sourced or locally-produced test-kits, and expanding testing protocol criteria, are all critical.

Most troubling has been the U.S. response after similar issues were widely criticised in China, of denying testing of a suspected patient over the objections of local doctors:

Diagnosis Of Coronavirus Patient In California Was Delayed For Days (NPR) 2020-02-27

The first suspected U.S. case of a patient getting the new coronavirus through "community spread" — with no history of travel to affected areas or exposure to someone known to have the COVID-19 illness — was left undiagnosed for days because a request for testing wasn't initially granted, according to officials at UC Davis Medical Center in Sacramento, Calif.... UC Davis included more details about the case in its own statement, drawing on an email sent to staff at its medical center. It said the CDC initially ruled out a test for the coronavirus because the patient's case didn't match its criteria....

"Upon admission, our team asked public health officials if this case could be COVID-19," the hospital said. "We requested COVID-19 testing by the CDC, since neither Sacramento County nor CDPH [California Department of Public Health] is doing testing for coronavirus at this time. Since the patient did not fit the existing CDC criteria for COVID-19, a test was not immediately administered. UC Davis Health does not control the testing process."

(Emphasis added.)

UC Davis Medical Center went to the unusual step of issuing its own letter on the incident.

Testing also requires individuals not face large financial costs or other penalties for coming forward. From Miami, FL: "Novel coronavirus test for Miami man leads to $3,275 bill:

Osmel Martinez Azcue ... went to Jackson Memorial Hospital ... [and was told] he’d need a CT scan to screen for coronavirus, but asked for a flu test first. “This will be out of my pocket"... [T]wo weeks later, [He got an insurance] claim for $3,270.

Healthcare is not a private concern. It is a concern of the common weal.

Remember, in the U.S., 40% of households cannot cover an unexpected $400 expense. Inequality is a public health issue.

Viability in warm and/or humid climates and seasonality

An early speculation was that SARS-CoV-2 would not survive well outside of cool and dry environments, typical of higher-latitude winters. Whilst the US CDC's 24 Feb press conference reiterated this, WHO-Philippine in a February 7, 2020 tweet s have suggested this may not be the case. Actual case count (3), mortality (1), and recovery (2) data for the Philippines, from Wikipedia, don't seem to indicate this.

"Warm and humid" also applies to spring and summer seasonal conditions in most places. There are hopes (again mentioned by US CDC).

Stay tuned.

Known-source vs. Community Transmission

"Community transmission" as defined in the US CDC's 24 February press conference means cases with no known source --- a disease is circulating within a community.

Epidemiologically, this means that efforts to trace contacts and restrict further exposures are limited, and instead general preventive measures must be implemented. My understanding is that community transmission does not necessarily mean cases are widespread, though it may. It does mean that specifically-targeted isolation and vector-disruption methods cannot be applied, and that general, community-wide measures must be relied on: hygiene, sanitation, reduced contacts, travel limitations, limiting large gatherings, quarantine.

Potential for Re-infection After Release

There've been Chinese reports of re-emergence of COVID-19 in individuals post-release (SCMP). This is now confirmed in Japan:

"Japanes Woman Confirmed as Coronavirus Case for Second Time Weeks After Initial Recovery":

A woman working as a tour bus guide was reinfected with the coronavirus, testing positive after having recovered from an earlier infection, Osaka’s prefectural government said. Her case, the first known of in Japan, highlighted how much is still unknown about the virus even as concerns grow about its global spread.

ACE-2 as infection route and genotypic variances

This is prelimiary information and may not be confirmed.

SARS-COV-2 may infect through a receptor known as ACE-2, principally through the lungs. Research suggests the genetic marker for that receptor is highly prevalent in Japan, much less so in the Middle East, and moderately prevalent in Western and Northern Europe.

https://www.researchgate.net/figure/ACE-II-genotype-frequency-in-different-populations-countries_tbl2_5642354

Personal and Community Responses

Again: there is no medical treatment. Breaking (or avoiding) transmission chains is most critical. At the personal level, this means basic hygiene and avoidance. At community and government levels, this means quarantines, travel restrictions, detection, monitoring, and effective response. These are decidely low-tech but effective.

Trust and competence by public health institutions and leaders are critical.

Adapted from: https://www.ready.gov/pandemic:

Before a Pandemic

  • Store a two week supply of water and food.
  • Periodically check your regular prescription drugs to ensure a continuous supply in your home.
  • Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, anti-diarrhoeal medication, fluids with electrolytes, and vitamins.
  • Get copies and maintain electronic versions of health records from doctors, hospitals, pharmacies and other sources and store them, for personal reference.
  • Talk with family members, loved ones, neighbours, co-workers, and other frequent contacts, about how they would be cared for if they got sick, or what will be needed to care for them in your home.

During a Pandemic

Limit the Spread of Germs and Prevent Infection.

  • Avoid close contact with people who are sick.
  • When you are sick, keep your distance from others to protect them from getting sick too.
  • Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
  • Wash your hands frequently to help protect you from germs.
  • Avoid touching your eyes, nose or mouth.
  • Practice other good health habits. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Zynep Tufekci's Scientific American article makes the case for "Preparing for Coronavirus to Strike the U.S.":

We should prepare, not because we may feel personally at risk, but so that we can help lessen the risk for everyone. We should prepare not because we are facing a doomsday scenario out of our control, but because we can alter every aspect of this risk we face as a society.

That’s right, you should prepare because your neighbors need you to prepare—especially your elderly neighbors, your neighbors who work at hospitals, your neighbors with chronic illnesses, and your neighbors who may not have the means or the time to prepare because of lack of resources or time.

Public Health Institutions

There are numerous institutions involved in the COVID-19 outbreak response, ranging from international and large-national centres to smaller national governments, as well as regional (state / province / prefecture) and local (city / county / metropolitan region). Names may be similar, and capabilities and authority, as well as independence and trust, vary widely.

Among these:

  • The World Health Organisation (WHO): "WHO works worldwide to promote health, keep the world safe, and serve the vulnerable." Roles are limited to advising and information sharing, with no policy and very limited operational capabilities within countries.
  • European Commission Public Health: " The EU's role is to complement national policies by helping them achieve shared objectives, generating economies of scale, pooling resources, and helping countries tackle common challenges such as antimicrobial resistance, pandemics, chronic diseases or the impact of increased life expectancies on healthcare systems."
  • The United States Centers for Disease Control and Prevention (US CDC): "CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats." Serves policy, informational, and operational roles within the U.S., often engages in international crises. May be called "the CDC", a practice I'll strive to avoid as this creates confusion with similarly-named agencies, many modelled on it, in other countries.
  • Other national CDCs: Notably China. Where referenced I'll note national affiliation, e.g., "China CDC" or "Japan CDC".

Second-order Effects

For all the concerns raised, the largest impacts of COVID-19 have not been to biological health but economic, financial, social, and commerce effects. In some places longer-term institutional and political impacts may result. For the most part, these are the consequence of preventive measures, most especially on travel, transport, and social aggregation, including schools, work, and other group activities.

Travel and association restrictions are effective at halting epidemics, but are disruptive to human economic and social activity. If your area becomes impacted, consider that these are issues you'll have to deal with, including loss of income, children out of school, and workplace disruptions. Those exposed to financial markets can also be affected.

Cultural and sport events may also be affected. "Olympic official: Tokyo is 'looking at a cancellation' if coronavirus not contained by late May" (Axios). "In light of global precautions being announced to combat the coronavirus outbreak, we’ve decided to postpone DEF CON China 2.0." (defcon) The UAE cycling tour has been cancelled (Reuters). Numerous others have now been reported.

Information, Misinformation, and Disinformation

Epidemics of rumour, misinformation, and disinformation follow epidemics of disease, and for virtually the same reasons. Both are information (one, words, ideas, and fears, the other DNA and lifeforms) spreading through a suceptible population via vectors and amplification mechanisms to create dysfunctional effects. Adam Kucharski's new book [The Rules of Contagion: Why things spread and how they stop](200~https://www.theguardian.com/commentisfree/2020/feb/08/misinformation-coronavirus-contagious-infections?CMP=fb_cif) is preternaturally timed with this current epidemic.

It's been noted that the aproaches of China and Russia (source eludes me) are both harmful to effective response in their own ways. China's early attempts to halt information or discussion delayed an early effective response. In Russia, apparent intentional sowing of disinformation is blunting containment efforts and spreading panic.

Authoritative information is concerning enough. I've pointedly avoided mentioning or linking rumours, few of which have any relevance to addressing the epidemic. Practice good information hygiene as well as epidemiological hygiene, and for the same reasons.

Epidemics attack trust: we're uncertain who is or isn't safe or a risk. Trust in institutions, tests, providers, responses, and response protocols all matter. Trust in supply chains, advice on what and what not to stockpile, as well.

"Coronavirus "infodemic" threatens world's health institutions":

Why it matters: The tide of bad information is undermining trust in governments, global health organizations, nonprofits and scientists — the very institutions that many believe are needed to organize a global response to what may be turning into a pandemic.

Informational Resources

Again, major public health organisations:

Specific guidance on response, both individual and organisational / community:

Be safe.

Wash your hands.

#covid19 #ncov2019 #coronavirus #epidemic #publicHealth #HealthcareForAll

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