28 February 2020

Narrative Fail: We're Missing Some Coronavirus Cases.

One of the most important questions the serious analyst can ever ask is the simple "Does this make sense?" In my career as a Voice and Data Engineer it is a crucial step in any diagnostic process--if the data and reported symptoms do not fit together into a coherent description of a situation, it is absolutely certain that something is missing.

Above all else, data must make sense. Hypotheses must fit the data to become theories--and they must fit all the data. When something does not fit, that incongruity is where our attention is properly focused.

In assembling and digesting the media reports about the COVID-19 coronavirus pandemic (yes, it is a pandemic even though the WHO still dithers and dickers about using the "p-word"), a glaring incongruity stands out: we are missing cases. More precisely, we are missing large numbers of severe cases and pneumonias. Based on the "official" data, there should be far more severe cases reported than there are.


As China is the country of origin, the case data from China must serve as our baseline for assessing how the disease is propagating in other countries.  Fortunately, we have research data assessing how COVID-19 cases present and the rough course of the disease, courtesy of Doctors Zunyou Wu and Jennifer M. McGoogan, in their study published in the Journal of The American Medical Asssociation (JAMA). Their evaluation of 44,415 confirmed cases provides the following breakdown:

Spectrum of disease (N = 44 415)
  • Mild: 81% (36 160 cases)
  • Severe: 14% (6168 cases)
  • Critical: 5% (2087 cases)
The criteria for "severe" and "critical" cases are described as follows:
However, 14% were severe (ie, dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300 and="" infiltrates="" lung="" or="">50% within 24 to 48 hours), and 5% were critical (ie, respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
A blood oxygen saturation below 95% is a condition known as hypoxemia and requires at least monitoring if not medical interventions and possibly supportive oxygen.

It was these "severe" and "critical" cases that first alerted doctors to the existence of the COVID-19 coronavirus, initially described in the January 8 CDC Health Advisory on what was then termed a "Pneumonia of Unknown Etiology".

According to a report from the Wuhan Municipal Health Commission, as of January 5, 2020, the national authorities in China have reported 59 patients with PUE to WHO. The patients had symptom onset dates from December 12 through December 29, 2019. Patients involved in the cluster reportedly have had fever, dyspnea, and bilateral lung infiltrates on chest radiograph. Of the 59 cases, seven are critically ill, and the remaining patients are in stable condition. No deaths have been reported and no health care providers have been reported to be ill. The Wuhan Municipal Health Commission has not reported human-to-human transmission.
Using the percentages computed in the Wu-McGoogan study, those 59 pneumonia cases presumably would be the severe/critical bloc of all cases at the time, which would be approximately 310 cases (59 being 19% of 310).

However, we already begin to run into a problem with the data. When we look at the total number of COVID-19 cases reported by China (which we must take with a grain of salt, as China has been almost blatantly manipulating the data they report publicly), we have the following totals:

78,824 total confirmed cases
2,788 deaths
7,952 severe cases
36,117 recovered
7,952 is only slightly more than 10% of 78,824. 19 percent of the total case number would be 14,976--almost double what we are told.

Did the disease become less severe as it moved through the Chinese population?

Missing Even More Cases Internationally

When we look at the totals for cases outside of China, we find an even greater deviation from the Wu-McGoogan totals:

5,320 confirmed cases
88 deaths
142 severe/critical cases
142 severe cases is only 2.6% of the total. 19% of 5,320 would be 1,010 cases.

Where are the other 868 cases? Should we be expecting 19% of COVID-19 cases to be severe?

According to medical "experts", yes. 20% is the estimated number of cases that will become severe according to Dr. Shawn Vasoo, acting clinical director at Singapore's National Centre for Infectious Diseases.

An estimated 20 per cent of the people infected with the Wuhan virus will become very ill, such as with more severe pneumonia, says a Singapore infectious diseases expert. That is the current estimate and this may change when more is known about the Wuhan coronavirus, also known as the novel coronavirus (2019-nCoV), says Dr Shawn Vasoo, the acting clinical director at the National Centre for Infectious Diseases (NCID). 
Nor is Dr. Vasoo alone in this assessment. The 20% estimate was also given by the World Health Organization at the end of January.
The source of the new virus and the full extent of its spread are still unknown. However, the World Health Organization said most cases reported to date "have been milder, with around 20% of those infected experiencing severe illness." 
The WHO was using the 20% total as late as mid-Feburary in its media releases and statements.
Covid-19, the new coronavirus that has killed nearly 1,800 people in China, causes only mild disease in four out of five people who get it, the World Health Organization has said.
At that time, there were not 20% of COVID-19 cases that were critical. On February 16, BNO News' coronavirus tracking page showed 68,509 cases in China, with 11,272 of those rated "severe", or 16% of cases. Internationally, there were 693 cases, of which a grand total of 19 were severe--2.7% of cases.

Where did the WHO get its 20% figure, since it clearly could not have gotten it from the reported cases totals?

Without citing it directly, it would appear the WHO is using the Wu-McGoogan study findings as their "official" estimate.

The conclusion comes from analysis of data from Chinese authorities relating to 44,000 cases of Covid-19 in Hubei province, where the coronavirus was first recorded.
Further, in the "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)", the WHO repeats the Wu-McGoogan synopsis almost verbatim--without citation or reference, it should be noted, as is customary and proper in any research or presentation format (which is why I always provide links to the materials I use here).
Most people infected with COVID-19 virus have mild disease and recover. Approximately 80% of laboratory confirmed patients have had mild to moderate disease, which includes non-pneumonia and pneumonia cases, 13.8% have severe disease (dyspnea, respiratory frequency ≥30/minute, blood oxygen saturation ≤93%, PaO2/FiO2 ratio <300 and="" lung="" nbsp="" or="" span="">infiltrates >50% of the lung field within 24-48 hours) and 6.1% are critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). 
But the study comes with some important caveats not divulged by the WHO. Most importantly, the data in the study was last refreshed on February 11, 2020, even though the article was published in JAMA on the 24th.
The Chinese Center for Disease Control and Prevention recently published the largest case series to date of coronavirus disease 2019 (COVID-19) in mainland China (72 314 cases, updated through February 11, 2020). This Viewpoint summarizes key findings from this report and discusses emerging understanding of and lessons from the COVID-19 epidemic.
The WHO is using an estimated formed during the early days of the pandemic based on data that has been considered suspect for some time. Moreover, at no time is the WHO giving any indication of revisiting their estimates in light of new case data coming in daily.

No, This Does Not Make Sense

Curiously, the WHO refuses to declare COVID-19 a pandemic, despite presenting such figures as a 20% hospitalization rate and a Case Fatality Rate of 3.8%, and despite the wide spread of the disease (cases in at least 57 countries at this time). This seems quite at odds with the criteria and layered approach used by the WHO in the last declared pandemic, the 2009-2010 Swine Flu Pandemic, which was based on a six-level alert system, the two highest levels were for pandemic conditions:

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short. 
Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.
With epidemic "community spread" levels of coronavirus in at least South Korea, Italy, Japan, and Iran, exactly how COVID-19 does not meet the criteria for Phases 5 and 6 of the scale used for the 2009 Swine Flu Pandemic seems uncertain.

As a comparison to the current COVID-19 not-a-pandemic, during the 2009 Swine Flu Pandemic, the CDC cited the following statistics:
From April 12, 2009 to April 10, 2010, CDC estimated there were 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (range: 195,086-402,719), and 12,469 deaths (range: 8868-18,306) in the United States due to the (H1N1)pdm09 virus.
That pandemic had a 0.4% hospitalization rate in the United States, and a 0.2% Case Fatality Rate--and the WHO unequivocally called that disease a pandemic on June 11, 2009.

In other words, the WHO is asserting COVID-19 has a higher hospitalization rate and a higher Case Fatality Rate than swine flu, yet it is not a pandemic, even though the organization seems oblivious to the apparent departure of their cited hospitlization rate from recorded reality.

To answer the question posed at the beginning, no, this does not make sense, it does not make even a little sense.

Once Again, The Media Fails To Get To The Facts

No legacy media outlet has paused to review the WHO statistics and compare them to recorded reality. Instead, they either accept uncritically the statements by the WHO or make reference to the underlying Wu-McGoogan study. Indeed, the Wu-McGoogan study (or its underlying data sets from China) appears to be the sole source of the estimate that 20% of COVID-19 cases will be severe and require hospitalization.

Nor should this be seen as an effort to cast doubt on the integrity of Doctors Wu and McGoogan. They gathered a subset of case histories from fairly early in the pandemic for study. There should be no surprise to find the rates and spectra of the disease shift over time, as different populations are exposed to the disease, and as more nuanced and sophisticated care pathways are developed. They researched the data they had at the time. We have data since that time, and our understanding of the disease should shift and evolve as the data sets shift and evolve.

While a study is limited to its data set, the raison d'etre of all media is to report on the constantly changing facts of any event. We should not analyze today with yesterday's data, and we should not analyze tomorrow with today's data. Rather, we should strive to use the best and most current data every day.

In reporting and discussing COVID-19, the WHO, the CDC, and the legacy media all appear to be stuck on yesterday's data.

We're Not Missing Cases, We're Missing Competence

The world is awash in information sources about COVID-19. BNO News provides near-realtime updates on case reports, as does Johns Hopkins University. Financial research firm Capital Economics provides daily updates of high-frequency indicators of economic activity in China in the wake of their extraordinary quarantines. The world wants--indeed, demands--timely and accurate information, as it should, given its availability.

There is neither reason nor justification for either the WHO or the legacy media to be stuck on outdated information, or to present as authoritative those estimates which have been superseded by reality. Keeping current with the data is the most basic level of competence for any journalist, and an absolute necessity for any public official engaged in any form of crisis response.

Instead of competence, all we are getting from the legacy media is yet another narrative fail. Having been two steps behind the COVID-19 pandemic from the beginning, they have chosen to remain in that dismal position, leaving you to search out the facts without them.

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