Corona virus epidemic in the US March 9 2020 covid-2019

The following are my opinions and analysis. This is NOT medical advice or medical recommendations.

I wrote this draft to provide a different view for opinion-makers, government, politicians.

I am an MD, PhD. I read dozens of articles in professional journals and websites. I have subscriptions to SCIENCE, NEJM, and many newsletters that summarize health articles across the world. On areas that interest me, I am usually better informed that health departments. In some areas like nutrition and some disorders, I believe I am years ahead of current state of the art.

Covid-2019 is caused by a virus similar to the Flu, but different. The infection rate is perhaps similar to the Flu. The severe disease rate and death is about 10x to 50x worse than seasonal influenza, but it affects different population groups, mostly the elderly or with suboptimal immunity. The elderly may be at risk of severe adverse effects 2x to 10x more than young or healthy. Perhaps about 20% of elderly, develop substantial health complications, later in the timeline of the disease. This may not be obvious for weeks. If the available evidence from other countries applies to the US (may not because the weather and technology are different), the US epidemic is barely starting.

The virus seems likely to survive up to 10 days on surfaces, but declines substantially in numbers over time, and in air (distance from origin, like mouth). It may survive better during cold weather, so it could be seasonal, but don’t know. It may expand to Southern hemisphere during the Summer in the North, and return next year. In the US, it could infect many people in one year, causing many deaths. But we do not know. It could be very susceptible to environmental factors like temperature and “die” mostly by May. Or survive. Or return.

Effective treatments are unlikely in the near future. We had the flu and many viruses for years without effective treatment.

Effective vaccines are unlikely in the near future. Contrary to some views, new research suggests that the flu vaccine does not provide appropriate protection to targeted groups such as the elderly. A vaccine for covid-2019 may be highly profitable for some, may or may not provide substantial protection to many people. Without government funding, the research for non-patentable prevention and treatment may not get done; the analysis on vaccines is incomplete (it is not profitable to prove that a vaccine is not adequate).

My analogy is cardiovascular disease and diabetes Type 2. We can spend billions on heart and blood tests, drugs to lower cholesterol, blood pressure, etc. Or we can eat healthier foods and lose weight (as I recommended for 30+ years). We need more research on optimal diets, but we know some foods are healthy and achieving ideal weight is healthy (no adverse effects). Yet most people place their hopes on drugs instead of weight loss. Healthy eating likely reduces risk of covid-2019.

We need drastic shifts in resources towards prevention, system changes. Proper prevention measures are effective, but are difficult to implement. Instead of vague “rules”, we need specific solutions. Not touching face is easier said than done. Instead, we should focus on creating a barrier to prevent touching the face (such as a substantial face mask). Face masks reduce excretions and prevent touching, so they likely reduce infection. We do not have enough face masks (have deficits of tens to hundreds of millions, not thousands). We need to redesign masks, manufacturing, etc. We need to redesign protective clothing. We need better, and huge numbers, of temperature detectors. We need to change lifestyles, organization. Shift to video and online conferences and meetings, etc. Different flows in stores and public transportation.

Governments are not ready and not competent to prevent infection. The flaw is worldwide, in countries, states, local government, and entities with many elderly customers such as large apartment buildings, HOAs (home owners associations), senior groups, retirement and nursing homes, etc. Instead of focusing on infection prevention and what matters, entities focus on other issues. HOAs may focus on the shade of paint and aesthetics of the outside of houses thinking they help sales and lawyers or brokers make more money. Retirement homes focus on social parties and making it easier for visitors and residents to interact and have fun. Strong infection prevention is not the first priority. Marketing focus on good life, not on infection prevention. By the time a severe epidemic with high mortality strikes the US (which is likely), it will be too late to change.

The US needs one person in charge with expertise in operations research, logistics, medicine, high GRE scores. Not politicians. It needs laws to provide more immunity to those who implement undesirable restrictions. It needs laws, like workman’s compensation, to provide compensation without litigation to those who are harmed. It needs comprehensive health insurance, paid by government, to cover infections, infection prevention, and accidents (this is different from comprehensive health insurance). It also needs to restructure the economy, train for different jobs, reduce the disruptions of an epidemic.

The most important data for prevention is often concealed by governments until it is too late. We need the location of individuals likely infected and their contacts, to determine the extent of prevention. We have a wide range of prevention, from drastic reductions in travel and contacts, frequent cleaning, etc. It cannot be done all the time everywhere, so we need a probability of risk by location.

For the Months of March and April, 2020, we need substantial restrictions in movement, particularly for the elderly and sick. Use data from local areas to calculate probability of infection and optimize extent of prevention (not all areas need equal restrictions). Use FHA regulations that mandate persons help those with health problems (e.g., 24 CFR s100.7). Create an infrastructure to assist the elderly and sick. Implement stronger prevention at schools, factories, stores, transportation (see what China is doing, and Italy, too late). Build isolation and quarantine units for thousands. Restructure work to minimize travel. Restructure tourism. Travel to foreign countries may be too risky in the future. Expand train travel with better prevention. Etc.

The focus on vaccines may be misplaced. These viruses are different from the polio, and may be difficult to create an effective vaccine. Effective drug treatment is probably years away, and is substantially driven by profits. Genetic maps and 3-D structures are great science, but not enough. We need comprehensive composition analysis of viruses (e.g., amounts of lipids, proteins, etc. using Mass Spec, NMR, etc.), the nutrients they need to reproduce, the shape of external proteins and how to distort them to reduce toxicity, factors affecting survival on surfaces, air, clothing, etc. We need federal and non-profit support of R&D into inexpensive prevention and treatment (rarely profitable enough for venture capital). Better face masks, temperature measurements, using building temperature and humidity to reduce virus life expectancy, healthier eating and weight loss to improve immune system (eating less costs less and prevents many diseases!), improved manufacturing, logistics, long term plans, storage of resources (e.g., masks, alcohol), etc. Draconian changes. There will be a more severe epidemic that will kill millions and crash economies and countries unless we plan ahead. The time for wishful thinking and press conferences is gone.

Politicians and opinion-makers should avoid writing or telling people not to panic. Instead, have ONE website for Federal, State, County. Only ONE source of information. Not dozens of emails and articles by each school, politician, etc.

I know how HHS works in the US, about infectious diseases, infectious control and logistics. I worked with infectious disease groups in hospitals. I worked with HSS and periodically speak with staff. I believe they are not adequately prepared. Nor are local or state governments. We need more transparency, better data, different R&D, better logistics, better training and instructions, better management and supervision.

I am an MD, PhD. I trained in laboratory medicine, including rotations in microbiology. I worked or attended hospitals in Miami, Boston, Washington, DC. I am familiar with infectious disease and medical and hospital practices. I read regularly over 100 scientific articles per month, including articles from the journals Science, NEJM.org, BMJ.com, and many more.

I frequently attend biotechnology meetings which discussed investment in biotech, vaccines, infectious diseases, profits. I read CDC, got the flu perhaps more than once.

I know enough to know that the information available to me from public education and medical websites is inadequate, incomplete.

For covid-2019, I read CDC websites, notices to physicians from medical societies and state health departments, journal articles and health professional websites, and news media. I found inconsistencies and suboptimal research. I write this article to bring issues to the attention of opinion-makers, scientists, politicians, so they can consider my analysis and improve health care.

I rely primarily on professional journals that present original, basic research. I read the articles, check references, statistical analysis. I consider the data if it makes sense, it is consistent with sound scientific knowledge and the analysis is valid. This effort takes considerable time, both to find the appropriate articles and study them (there are thousands on any topic). Then I consider secondary sources, such as review articles and government opinion. In my experience, they rely on research in professional journals like I do, but they may not interpret the data properly or have too many people involved and compromise (meaning they cut corners or have average opinions, such that 4 vote the Earth is Flat, 5 the Earth is a sphere, so they compromise the Earth is a squeezed sphere). Next are articles in news media. A few, written by experts, have high quality. The majority, written by non-experts, I rarely consider.

By reading this article, you agree with the terms, conditions, caveats, limitations stated at essentialfats.com, optimalpolicies.com. Errors, omissions, misrepresentations, exist. I do not have the time, money, resources to check all references and information.

I regret that I cannot answer personal questions nor provide medical care. I receive a huge number of requests, far beyond my capacity to respond. My policy is to communicate mostly with health professionals and professional journals, or post issues on my blogs/websites.

Please, do not ask me questions, do not write back to me. I do not have the time and resources to research topics or answer questions. I cannot provide medical nor legal advice. If you do not find my opinions useful, ignore them. If you do not like what I wrote, please ignore me and live a happy life. And, please, no death threats, no garbage on my property, no spam email, no cutting my car tires. Just ignore what I say. Either way, get help from experts and professionals. Do not rely on what I write or say. Just in case, I ate more chocolate today. Although unlikely to improve health, perhaps we should eat dessert first in case aliens invade or an epidemic forces quarantine without dessert.

Satire

Covid-2019 will harm many people, probably thousands in the US. Either due to action or inaction. Whatever is done, thousands will be harmed. Lawyers will figure out a way to sue somebody. I don’t’ want to be sued. I read that writing satire prevents lawsuits.

These notes, ideas, opinion, article, are tongue in cheek, satire. Every satire has some elements of truth; otherwise it would be too dumb. So, to help fake news websites and others, here are ideas, many dumb, fake, fictitious, nonsense. Just don’t blame me if you die from too much laugh. Many of my jokes are very bad, to prevent laughing too much. There are errors, intentional or otherwise, because this is satire and you, readers, should not rely on what I say. Instead, there are professional, competent information and websites from CDC, HHS, government health agencies, news media, friends, parents, grandparents, politicians, fearless leaders, cats, dogs, astrology, wishful thinking, religion, music, TV, etc. Not me. Read for fun, entertainment, spend time, practice eyes.

Risk factors, probability of infection

There is human-to-human transmission of the infection. Severe disease affects more people over 65 or people with diseases (morbidity) or reduced immune system. Some data are published, but may be misleading because the number of people infected and sick depends on the nature of the population available.[1]

Higher risk for older adults and people who have severe chronic medical conditions like heart, lung or kidney disease. "If you are an elderly person with an underlying condition, if you get infected, the risk of getting into trouble is considerable. So, it's our responsibility to protect the vulnerable"  [2]

Read https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

At high risk if I have an immune disorder, or take medications that alter immune system. In general, many systemic disorders alter immune system. Patients who take immune suppressants, such as patients with IBD or other inflammatory conditions, must be EXTRA careful. They may have a very high risk of infection from covid-2019.

There is no definitive test that proves that a person does not have an impaired immune system. The immune system is very complex with many different biomarkers. Although some abnormalities can be measured with biomarkers, it is impossible to prove the immune system works well. Instead, we rely on general biological concepts. For example, it is impractical to prove that a person falling onto a sidewalk concrete from a window above the 5^th floor will get hurt. There are too many variations, and volunteers are difficult to find. We rely on general principles of biology and physics.

The probability is high that a person has immune abnormalities if it has an immune related disorder, an inflammatory disorder that affects large parts of the body (systemic, in contrast to a minor scratch that creates a localized immune response). Individuals with chronic, systemic conditions such as cardiovascular disease (CVD) or diabetes (includingT2D, type 2 diabetes) are likely to have suboptimal immune system. Those with likely immune disorders should take extra steps to prevent infection.

Overweight is associated with reduced respiratory ability, a major contributing factor to COVID-19. Respiratory decline associated with BMI, weight gain in adulthood. Peralta G, et al. Thorax. 2020; doi:10.1136/thoraxjnl-2019-213880

Unfortunately, most people prefer a vaccine to losing weight. Politicians, concerned about their own overweight or loss of voters, would rather spend billions on a vaccine than massive overweight reduction. A vaccine is simple to use (one shot) without changes in lifestyle. Weight reduction is very complex and requires drastic lifestyle changes which most people don’t want to do. Contrary to some views, everybody loses weight if they eat far fewer calories (a fact proved in WW2). The difficult challenge is to persuade people (their minds or body) to eat less (far fewer calories), by decreasing appetite, reducing interest in foods, increasing body metabolism (and thus temperature), etc. Several effective treatments, putting people in a coma for one month, or hanging them in comfortable dungeons with unlimited TV, internet and water, or camps in isolated areas (e.g., islands) without food, are difficult to implement. Nevertheless, fasting is undisputable effective and perhaps the best prevention for COVID-19 and future flu-like infections. Needs expert medical supervision.

I approach infection prevention to mean reducing the probability that a substantial number of infecting particles (e.g., viruses, bacteria) enter my body. The actions I take to prevent infection depend on this probability.

There are a wide range of actions I can take (wearing masks, wearing protective clothing, not talking to people face to face, etc.). It is impossible to wash hands constantly or stop breathing. I must prioritize my defenses. I take stronger precautions when the probability is high. It means when I am likely to touch surfaces with infectious agents or have air or fluids touch me with infectious agents. If the virus is in my area, I take stronger precautions. Thus, to decide what to do I need to have an idea of the probabilities.

A person’s ability to transmit an infective agent depends on many factors. There is no certainty for or against, only probabilities. Whether or not the person has clinical indications of infection (signs, symptoms, etc.) depends on the person’s immune system, the stage of the condition (early, late, etc.). A person can transmit an infection before clinical indications appear, while they are there, or after they appear to be gone. The time it takes for clinical indications to appear depend on the person and the infections agent. Usually, they appear early for people with a good immune system, and late for people with poor immune system. A person may test positive or negative for a viral infection. The result is not decisive, because tests have false positives and negatives, samples are not easy to obtain correctly, etc.

Very young children, people with systemic diseases (such as cardiovascular disease =CVD, in contrast to a broken finger), those taking some drugs, people with immune disorders (e.g., IBD, particularly if taking immune suppressants) usually have impaired immune system. It means that people overweight (who usually have CVD, high lipids, high BP, diabetes) are at high risk (the risk probably increases with weight).

As an approximation, the probability of infection depends on the number of infectious agents. The cough from a person with a huge number of viruses is more infectious and for longer periods of time because more viruses will be alive after a long period of time. How long the virus is alive depends on many factors and how many viruses (most unknown because of lack of research) such as the type of surface, temperature, etc. Roughly, a person may shed more viruses when has clinical indications. The probability of infection increases with the number of infectious agents that touch us.

Thus, reducing infection involves several actions. Prevent an infectious person from spreading infection. Ex: facemasks for a likely infected person. Kill as many infectious agents as possible. Ex: clean surfaces, wash clothes. Prevent infectious agent from entering body. Ex: don’t touch probably infective surfaces, don’t touch face, wash hands, cover face, etc. Some surfaces protect infectious agents more than others (but we don’t have enough research).

One can get infected from a few infectious agents from a person without clinical indications or air or surfaces. And tests have errors.

We do not have valid, accurate models (algorithms) to calculate probabilities. So, guidelines are broad. But I use rough probabilities to decide how to prevent an infection myself, and err on the side of caution. I saw many people die from infections (or get very sick with organ damage).

Suppose we have 100 passengers on an airplane, P1, P2, . . . , P100. Passengers P1 to P50 are between 20 and 40 years old in excellent health. Passengers P51 to P100 are over 65 yo, each has cardiovascular disease, high BP, high cholesterol, mild T2D, is overweight. Incubation is 4 days for P1-P50, 7 days for P51-P100.

When the Airplane arrives to Atlanta, GA, Day 1 (D1), P20 has a fever and signs of Flu or covid-2019. A sample taken for analysis find SARS-CoV-2. All other passengers look healthy. They are taken to a hotel for quarantine. They cannot leave the hotel, but can walk around the hotel to a game room or restaurant to eat. Many get bored and talk with each other and people who help (cooks, cleaning people, administrators, etc.).

On D5, P15, P25, P30 become sick. They test positive for SARS-CoV-2 and are placed on a special isolation area. They shed virus and were coughing. On D4, they infect P40, P60, P70, P80, but nobody knows yet. On D8 P40 becomes sick, tests positive, is isolated. On D7, P40 infects P55, P65, P75. On D 11, P60, P70, P80 are sick, test positive, are isolated. On D 10, they infected P61, P71, P81, P91, P92. On D13, P55, P65, P75 become sick, test positive, are isolated. On D12, they infected P56, P66, P76, P86. The chain continues. The last infection occurs on D20. It becomes evident on the older passengers 7 days later on D27. They are placed in isolation. All remaining passengers must wait 21 days after D20 to be sure they are not infected. The 21 days means the probability of infection after that is low, but not zero. Waiting only 14 days is too short. Old patients with diseases may take longer to show signs of infection or death. Under this scenario, quarantine must last more than 30 days.

Is this example realistic, unlikely? We do not know, but it is likely to occur with thousands of people infected in many different environments. It means countries need stronger isolation measures, but are unlikely to have the space and resources. Something else must be done, such as strict restrictions on cooking and recreation areas, talking to other people, cleaning surfaces, cover entire face, perhaps gowns, etc.

What to do if you are at higher risk

New CDC guidance says older adults should 'stay at home as much as possible' due to coronavirus. https://www.cnn.com/2020/03/06/health/coronavirus-older-people-social-distancing/index.html;

Stay at home as much as possible.

Make sure you have access to several weeks of medications and supplies in case you need to stay home for prolonged periods of time.

When you go out in public, keep away from others who are likely to be sick (difficult to tell, they should stay home!), limit close contact and wash your hands often. How far? Perhaps 3-6 feet, enough so that if they sneeze or cough, you don’t catch it. This may be impractical in a store or public transportation. That is why I suggest face masks for the entire face and change clothing (indoor v. outdoor).

If a COVID-19 outbreak happens in your community, it could last for an unknown amount of time. I would be careful for at least 30 days.

I keep two sets of clothing: indoor and outdoor. Keep shoes outside my house. Change to indoor clothing when I come in. Wash my hands.

Keep my house clean so I can wonder around without having to wash my hands frequently.

If I get a package or mail, I clean the outside. Clean the front door handles. NOT bring garbage cans inside my house.

Wear a whole face mask or surgical mask going out to public places.

Wear disposable gloves. DO not touch face. Discard gloves before entering house.

If COVID-19 is spreading in a community, take extra measures to put distance between yourself and other people.

Stay home as much as possible. Consider ways of getting food brought to your house through family, social, or commercial networks. BUT be careful what you bring in.

Avoid crowds, especially in poorly ventilated spaces. The risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.

Dangers of excessive diagnosis or treatment

Unnecessary testing for COVID-19 could spread the disease and cause havoc in the US. Every test has false positives and false negatives. Tests for COVID-19 may be unreliable. The patient may not have enough virus or the disease is too early; the samples may not be adequate. When I was in medical school, we had a sick patient. Every student had to take a swab of the patient and it was sent for lab evaluation. The majority of the samples came back negative (mine came back positive) because they were bad samples. It is difficult to get a good sample in a setting with plenty of time and no pressure.

With high false negatives and high false positives, if we test 1,000 people in every location, we are likely to find some “positive” evidence of COVID-19. The result would require quarantine. If we tested every student and staff in every school, perhaps at least one person would be positive, requiring the closure of the school. Same for transportation, offices, etc. Mandatory and frequent testing could close the country! Further, many negative results would allow infected people to remain in the community.

Instead, testing may be used to confirm a disease, perhaps to assign individuals to different levels of quarantine. Even if free, not everybody should try to test for COVID-19, because it may either lead to unnecessary quarantine or mislead to safety. Instead, must use Bayes’ method and consider different factors for prevention, diagnosis and treatment.

The very difficult challenge is to decide who is infected, who to send to quarantine, isolation, who to allow back in the community or their home.  Excellent article on diagnosis, testing for COVID-19 and implications. Mandatory reading for all physicians and managers of epidemics.[3]

Need research on practical, effective, inexpensive prevention measures

Today, infection prevention measures are primitive, not optimal. Because there is no profit in it, there is little research on inexpensive ways to prevent infection

The likely mode of entry for respiratory viruses seems to be the face, eye, nose, mouth. Instead of spending billions on vaccines, that take years to develop and may not provide adequate protection to the most vulnerable populations, we should manufacture a “face” mask, similar to skiing masks, that makes it very difficult to touch one’s face, eye, nose, mouth. These masks could be made cheap, either disposable or washable. Perhaps they could cut infection enough to either dies or makes it feasible to quarantine the likely infected and a few others, not millions of people.

As an alternative, now that masks are very difficult to buy, perhaps we could make plastic and cloth transparent bags to protect our faces from touching or air, and protect others from our saliva.

I spent many years working in hospitals as a medical student, resident and staff, including a rotation in the microbiology department, evaluating samples for infectious disease, and attending autopsies of infected patients. My work required multiple contacts with many patients with infectious diseases. I touched them. I drew blood. I conducted extensive conversations (for medical history, follow up). Many classmates, physicians, nurses did similar activities. I do not recall one case of infection. Although I was not necessarily informed, I would know if my team members or people I saw almost every day got infected. Our precautions were simple. To enter the room of severely infected patients, we put on clothing (gowns that were discarded when we left the room or washed). There were no hazmat suits. We had conventional surgical face masks (poorly worn, nobody told me to make a seal around my face, and few did). Gloves. Lots of washing. No touching ourselves (or surfaces or handles) before washing. Staff was more careful during surgery. It worked. It may work with the flu.

When my child gets the flu, we implement these precautions (seem to work, have no research to support them). The child sleeps and stays in a separate room. The room has air cleaner with UV. The child wears a mask at all times (except when sleeping). The child washes at appropriate times. The child is not allowed to move around, touch things. Any surface touched by the child is promptly cleaned. All dishes are carefully handled, put in dishwasher, and washed at very high temperature. Same for clothing, washed frequently. I keep separate towels for the sick child. I change them at least daily.

Indoor v. outdoor clothing. No shoes inside house. We do not allow people in the house who are suspected of carrying infective agents.

Every person carries several paper towels in quickly accessible pockets. Tissue is too weak. Whenever they feel like sneezing or coughing, must use towel to cover mouth, and discard carefully (e.g., not touching surfaces or others, or put in pocket until find appropriate garbage can). We have multiple garbage containers throughout the house to easily discard the paper towels. At schools or business, I would have piles of small squares of paper towels (and nearby garbage bags).

I would instruct all school children, staff, business employees, transportation public places, etc. to be careful. Because it is impractical to distinguish flu from covid-2019 (or future similar disorders), EVERYONE must learn to carry towels appropriate to their needs. Those with frequent coughing or sneezing should wear masks that prevent droplets going into the air. If a towel is not available, cover with own’s clothing.

Individuals in jobs that interact or communicate physically with many people, such as police, fire, health care, stores, building managers, school staff etc., must be particularly careful. They should wear protective masks in areas at substantial risk of infection (for prevention; additional measures may be needed if they may be near infected individuals).

Example. If a person infected is found in a community, everyone connected to the infected person must immediately start preventive measures, wear masks, avoid unnecessary contacts, etc. until the risk of infection is gone (at least 21 days, probably 30 days).

Is Government prevention focused on TV speeches, moderation, and telling people to buy masks from another galaxy?

We hear and read it everywhere. Wash frequently, sanitize surfaces, wear mask if you have a cough (or wear a mask to prevent touching face, reducing impact of other people’s coughs). GREAT ideas! We should also buy stocks low and sell them high, carry an umbrella when it will rain (in my area, weather forecast makes inaccurate predictions 8 hours into the future!), don’t stay in the way of bullets, etc. Reality is different. By March, 2020, stores and online sellers were out of masks and rubbing alcohol (or available at exorbitant prices). In some parts of the US, they run out of paper towels and toilet paper.

It is not a mystery that the flu comes every year and millions get sick. It is a mystery why people do not stock supplies ahead of the flu season, and why governments, large business, schools, HOAs do not stock supplies in regional centers, particularly when they are not perishable, inexpensive, and easy to keep. People should be as careful with the flu or food infections as they now try to be with covid-2019. In my experience, people are careless about food infections or the flu. They touch things in ways that transmit infections. They fail to follow basic protections. The adverse consequences are millions of infected people every year.  A large proportion of deaths from the flu are preventable.

We are aware but careless about infections. We are not aware and we are extremely reckless about toxic chemicals. It is toxic chemicals that will mutate or damage DNA and bring the end of human civilization. Infections may kill millions, but toxic chemicals will kill billions and end reproduction.

What can be done to stop the epidemic, now and in the future

An approach to end the epidemic is to substantially reduce the probability that a potentially infected person transmits the virus. This is done by isolating people with potential infection, and teaching everybody else to prevent infections in schools, public transportation, etc. Every school child and teachers must learn to prevent infection, wear masks. Every day schools must clean surfaces (if virus can live more than 12 hours). Suspend or reduce all non-essential school activities (e.g., after hours clubs, sports, etc.). This helps prevent the spread of flu and other viruses.

Rotate public transportation (such as buses or trains) to allow time for the viruses to die. This will be difficult.

Notice that unnecessary cleaning pollutes the environment and likely causes mutations, cell death in brain and other organs. Guidelines for cleaning should be precise, not just wash and clean frequently. Too many chemicals may irritate the respiratory system making it easier for the virus to enter the body.

I agree with the CDC decision that infected individuals or those with high probability of infection should NOT share an airplane with healthy people. They should not share public transportation or stores. It is best to keep them where they are (country, home, etc.). Although the probability of death from SARS-CoV-2 seems about 2%, any death is unnecessary. The risks of infection are far more important than the inconvenience to travelers. IF one of the travelers is involved in matters critical to the US, such as preventing hurricanes or nuclear warfare, one could make an exception. But my view is that individuals so critical should not risk infections or have a replacement available.

I empathize with POTUS Trump when he got upset that likely infected individuals were allowed to travel in the same airplane with healthy individuals, and travel to the US. Trump is often criticized for his actions, but we should give him credit when he uses common sense.

No matter what is done, it is impossible to keep perfect isolation in an airplane. They are not designed for that purpose. Eventually somebody will touch somebody else with the virus. Except for very limited infections, infected individuals should not travel via airplane. In the near future the probability is high that the US will face an unpredictable, highly infectious and pathogenic agent (cause death or severe disability). The policies must be in place to prevent epidemics. Airplanes should redesign to aspirate air and pas it through filters that kill microorganisms.

Some actions local governments can do NOW

Require each person at a school who has symptoms (or signs) of flu to wear a face mask, even if there is no fever and the symptoms could be misleading. At last, it reduces exposure to air droplets.

Measure temperatures in every healthy person to establish a baseline. Normal, healthy temperatures are below established criteria (reference ranges are obsolete, and every person should compare with itself). Define a substantial increase, such as 1F. A person with a substantial increase must stay home.

Teach all persons at schools how to wash hands, how to minimize touching surfaces, faucets, how to put on and remove a face mask.

Keep a supply of face masks adequate for all the persons who need them.

Cut paper towels into small squares and have them ready everywhere to use. Students to keep some in pockets. When sneezing, cover with paper towel and discard. Have garbage containers in nearby locations, multiple locations for quick disposal of paper towels (conventional tissue paper breaks too easily).

Federal Government should determine if there is an expiration date for face masks, evaluate designs, and provide recommendations for different types of infections. Resolve conflicting advice comparing surgical v. N95 v N99 masks. Change design to make them more effective, easy to put on and off (like eating) by people who wear them all day (which is different from a surgeon wearing them for surgery, or a physician entering the room of a sick patient, which discard the mask after using). The straps can be designed for easy on and off, for hanging while eating, etc.

Coordinate manufacturing of face masks in US, ASAP. China will require billions of masks, supplies cannot match current demand, the US does not have enough.

Are counties ready with school systems?[4] Do parents have alternative child care or job leave if children stay at home? Have counties identified all critical workers to manage fire, police, utilities, transportation, cleaning, food delivery, etc.?

If a person is infected, all physically close family members, contacts, friends, etc. should be in quarantine for probably 4 weeks. Most people do not have enough food supplies. Are delivery services ready? Workers protected? (I doubt it).

Who keeps the master list of tasks to do, individuals assigned (for each city, county, state, federal)?

Are we relying on wishful thinking and meaningless advice such as “eat in moderation”, “wash hands carefully” (sure, it prevents many deaths from people who wash their hands recklessly, get them mixed up, and strangle themselves by error); clean surfaces (the government does not say how often, but somewhere between once per minute and once per week is good enough; preferably every 2 minutes to kill virus and lose weight). And, don’t forget the masks (hahaha, you need one every day but they don’t sell them anymore, however, for $250 each, I have a supply).

Am I the only one who thinks the Emperor has no clothes, or do others see the nonsense and lack of practical preparation and task management? Put me in charge and I will fix it.

“Wash your hands regularly. Cover your nose and mouth when you sneeze. And when you’re sick, stay home from work or school and drink lots of fluids.”  https://www.washingtonpost.com/health/2020/02/26/how-to-prepare-for-coronavirus/?arc404=true

I disagree with some of the Wash Post recommendations. As a physician, I worked in many hospitals and in a lab that measured infectious diseases. I saw many patients with infectious diseases, live and dead (e.g., autopsies by pathologists). “Wash your hands regularly” is non-sense. What is regularly? Every hour? Once/day? After touching a surface? Covering mouth and nose is useful, but impractical. I see many people sneezing, it comes suddenly, and there is no time to search for a paper towel (most tissues are too fragile). Spitting on clothes or hands and then touching surfaces spreads the virus.

Instead, preventive masks are critical (but many people don’t know how to wear a mask, or masks are not available). Staying home when sick makes sense. But few do it, and, if sick, family members and others close to that person could be infected and contagious, so they should also stay home . . . in a secluded place, to prevent infecting other family members. How many people do that? I would guess less than 5%. Among the people I know, it is less than 1%. How many have air filters ON in their homes? Is UV light protective in air filters? It may be difficult to determine who is sick.

When the infective agent arrives and many people have it, it will be too late to implement prevention.

What I can do to prevent infection

The government’s guidelines are too vague, inadequate. This is what I do. Summary of my suggestions (as a starting point, validate with experts, read references)

There is no 100% vaccine to prevent infection. Even when a vaccine is created for a new virus, the virus mutates and vaccines may not be effective to prevent severe disease or death in susceptible individuals, supposedly their main purpose.

Reduce unnecessary travel in public transportation. If I go to a meeting with people, particularly people over 60 or substantially overweight, I take a face mask. These individuals are at high risk of a viral infection. If I know they were in contact with likely infected people, then I wear gloves, take extra precautions (likely infected individuals should not go outside their homes, and wear substantial protection). I do it when I go shopping, use public transportation, etc. If I believe governments are concealing the locations where infected individuals may have spread the disease, then I assume it is everywhere and I substantially restrict my social activities and implement stronger prevention. If government is transparent, accurate, then I can better assess probabilities and may not need to severely restrict social activities, shopping, etc. There is the danger that family members of people at risk, who work on critical jobs (e.g., police) will NOT stay home and ignore signs of family infection. Also, people without adequate sick leave will go to work.

I wear a face mask when I go shopping or to public places.  I went to a food store on Fr. I had a face mask (only one). Nobody wanted to stand in line behind me! Ironically, I was the best protected. Other people were sneezing, while I protected others.

All staff, employees, with substantial public contacts must wear face masks, replaced at least daily. They include clerks at check outs, school staff (primarily teachers), security guards, police, etc.

Postpone substantial gatherings, particularly if they involve individuals at substantial risk.

I would continue these prevention measures until we have at least 14 days without evidence of infection, or the infection is very localized (all cases are quarantined in some way, like staying home and everybody at their home stays home or takes substantial precautions).

Avoid touching your eyes, nose and mouth with unwashed hands. Eyeglasses and masks help prevent touching. BE very careful with surfaces (e.g., handles) in common public places such as bathrooms, seats and doors in public transportation. Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom, before eating and after blowing your nose, coughing or sneezing, or after touching suspected surfaces. Be careful touching handles of faucets (use paper towel or clean faucets after opening them), door handles after washing hands (surfaces may be contaminated). If you don’t have access to soap and water, use an alcohol-based hand sanitizer with at least 60 percent alcohol. However, too much alcohol or washing can create cracks in the skin that allow the virus through.

Stay home when you are sick. Cover your cough or sneeze with a tissue and throw the tissue in the trash.

Clean at home, after coming in, the few surfaces you commonly touch: faucets, toilet, door handles (e.g., entrance door). Remove shoes. Change clothes from outside to inside. Use different clothes inside the house. Wash hands after coming in, BEFORE touching surfaces.

If wear a facemask outside, fit it well and do not touch it. If it has virus on its surface, touching it brings the virus to your hand and elsewhere. CAREFUL when removing the mask. If plan to reuse, have a place (like a paper towel) to put it on overnight. If plan to discard, grab it from string outside nose or mouth and throw away without touching it.

“We touch our face with our hands, including our nose, eyes, and mouth -- areas with mucous membranes, an average of 15 to 23 times an hour. . . We also touch door handles, subway poles, handrails, saltshakers, other people's hands and grocery carts. We inhale tiny droplets that come from someone sneezing or coughing nearby.”  “In a study we conducted on hand hygiene, the most common areas missed by hand washers were thumbs, wrists, and in between fingers.” [5]

Public bathrooms, like schools. At night clean surfaces: toilet handles, faucets, sink surface, door handles or area where people push door to open.

The risk of infection is low in the US, but may increase until May (if virus needs low temperature to survive). The probability of death is low, but may be higher than for flu and common situations that we consider risky, like driving a car or flying. No matter how low, nobody likes to die of an infection. Much better to die slowly from eating cheese cake or chocolate ice cream and pizza. My point is that everybody takes risks in life, but some risks are perceived as much higher and we can reduce the risk (probability of harm).

I do not know what to do because the government, even though corona viruses and flu are known for years, has not supported appropriate research.

The fundamental question is simple. The risk of severe disease, probably killing a few organ and brain cells, or death, is probably greater for covid-2019 than Flu. It may be around 2%, higher for elderly people and people with morbidities (e.g., CVD, diabetes, overweight). It means only a small percent of people will get very sick or die. Should I worry about it? Only a small percent of people suffers the adverse consequences of DUI (drunk driving), or high-speed accidents (why bother with speed limits) or drug overdose or nuclear warfare or terrorism. It does not mean I do not worry. I am not the type of person who likes to climb extremely cold mountains in the winter, or drive motorcycles at high speed without a helmet. I rather NOT be the 2% who gets very sick or dies.

The extent of implementation depends on the expected risk. Very healthy individuals may have very low risk of severe disease and perhaps do not need to take extraordinary measures. Ex: healthy teachers and administrators at schools. However, they could get the disease and become carriers and transmitters without getting very sick.

Individuals with reduced immune system may want to take extraordinary precautions (e.g., elderly, overweight, cardiovascular disease, diabetes, etc.)

Which precautions to implement depend on lifestyle, resources, etc. Read government recommendations, doctor’s advice, common sense. Will increasing alcohol levels in blood help? I do not know.

Clean surfaces AFTER use, such as doorknobs and parts of front door (clean every time I use them from going out).

Wash hands when I come inside my house from going out.

Keep backpack or brief case or whatever I took outside the house in a separate corner and do not touch it (or do it very carefully if I need to remove papers, etc.). THESE issues are critical with children!

When going out, put outside clothes separate from inside clothes. Wear whole face mask or surgical mask (tight), gloves.

If at substantial risk (due to health, age, or infections in the area), DO NOT eat (or drink) in public places. It is very difficult to eat or drink without touching surfaces and the face. Utensils, food, etc. all have been touched. Workers with gloves do not prevent transmission. I have not seen data proving that virus survival on gloves is only a minute; I suspect is much longer and can be transmitted by gloves. Have breakfast at home. Skip lunch. Eat dinner. For many people, skipping a meal a day is healthy anyway.

Minimize visits home from other people. Postpone house maintenance/ repairs unless essential. If other people must come to my house, such as a plumber for an emergency, have them remove shoes (or wear new protection over shoes, such as plastic bags), put on a clean new mask (disposable) and a gown (to be washed later). Workers may not like this and charge more for their time.

Minimize visits to other places with many people, particularly people at risk of disease. Postpone non-essential medical and dental visits.

These are questions for which answers are feasible, yet I do not find them in government recommendations:

What is the optimal indoor temperature of my house? Like many people in the East Coast, I have a HVAC. I can easily keep indoor temperature at a specific number between 60 F (using sweaters) and 75 F. Which one should I use? It seems the virus has shorter survival on surfaces and air at higher temperatures. Is that true? Will it make a difference the temperature of my house?

The house temperature changes the surface temperature of my body. Will higher temperatures reduce infection? Help the body fight infection? There must be a reason why the flu is more active in winter than summer.

In March, with indoor heat, the humidity inside my house can be between 25% and 45% (I can regulate it with humidifiers or dehumidifiers). How does indoor temperature affect virus survival on surfaces and air? What humidity should I use?

Who do I listen?

Instead of meaningless guidelines, government must create reasonably accurate math models that estimate the probability that a person is infected, and calculate probabilities of alternative strategies to contain the epidemic. This is feasible, it can be done quickly. For the future, we need better data and better models.

Decisions and guidelines should be made by experts in medicine, probability theory, operations research with 99% scores in math GRE. Politicians, volunteers, well-intended people, very nice people, good people, opinion-makers, aliens from other galaxies, and many others should pay taxes to provide enough income to the experts; not give opinions.

Bill Gates. Responding to Covid-19 — A Once-in-a-Century Pandemic? [6]

Gates asks for billions to “accelerate work on treatments and vaccines for Covid-19”. He proposes more of the same, but we may get more of the same results. Covid-19 is a virus similar to the flu. It likely mutates frequently. Vaccines for one form may not be effective for other forms. This is the case with the flu vaccine. Contrary to previous hypothesis, the flu vaccine does not help the population most susceptible to the virus, elderly people. It seems unlikely to help people with depressed immune system (because a vaccine works with the immune system).

The treatments proposed, basically a drug to kill the virus, are far in the future. We had viruses for years, like the flu. We do not have effective treatments. We do have profitable treatments.

We need a different approach to prevention and treatment, one based on a system approach that identifies the weakest links in epidemics (transmission) and in virus survival. We already have enough evidence to support the research. Unfortunately, the likely prevention and treatment derived from a system approach may involve methods difficult to patent and profit from them.

Examples. We write an algorithm that uses bio data on a person (e.g., morbidities, age, biomarkers of immune system, geography, environment, temperature, etc.) to calculate an a priori probability that Person X is infected, P(X) infected. We create far more effective biomarkers of the state of the body. We have technology now that can measure RNA, proteins and thousands of molecules in the body. The pattern of these biomarkers is likely to distinguish an infected from a healthy person, and also the phase or stage of infection (starting, peak, decline, etc.).We change the probability of infection, using Bayes’ theorem, according to further tests, additional data (e.g., fever value, not just yes or no, rates of change of body temperature, extent of cough, etc.). We use that probability to optimize the decision about who to quarantine and for how long. This approach transforms an impractical problem to manage (e.g., closing transportation and sealing a city with 100,000+ people) into a manageable one.

We identify the biophysics/ biochemistry of the virus, what keeps it alive, what reduces its life expectancy. We know the Flu, and probably Covid-19, are susceptible to temperature, with less survival at high temperatures. We can reduce infection perhaps by increasing the temperature of places where people may be infected.

Because the virus is mostly localized to respiratory areas, we can have patients eat hot foods and breath hot air (studies are needed to identify optimal conditions). We can raise body temperatures in many ways. Although many patients do not develop a high fever, it may be desirable to encourage it (drugs and treatments exist for these purposes).

The virus requires nutrients. We need to identify them and see if the virus can be deprived of them, so the immune system can kill them better.

We should shift focus from preventing infection to preventing severe disease and death. From a community perspective, weight loss is one of the most effective means to reduce deaths. Suboptimal nutrition is likely a major factor in suboptimal immune system, disease and death. A massive campaign to reduce excessive weight (e.g., starvation or very low-calorie diets) supplemented with specialty foods may reduce severe disease and deaths far better than a vaccine. These treatments are inexpensive and technically easy to implement. If we provide the means for people to avoid severe disease or death, then infection can be less of a problem than the flu.

If I do not care about risks or risk management, and believe I know what is best for me because I want to enjoy life no matter what

Do what I want to do. Please, try not to hurt others. Get good liability insurance in case I hurt others.

Play Russian roulette. It is fun for those who make it. Just in case, stand far from other people trying. The blood scatter is difficult to clean and you may not like the taste of other people’s blood.

What I would do if I had tickets to travel outside the US? Probably stay

There are conflicting analyses. The airlines have lost money and need to reduce loses. They are unlikely to cancel flights. If the flight is cancelled, they may have to return the fares (not only they lose the money, but incur costs in refunds). If the flight takes place, they may keep the money. Any adverse consequences, such as infection or delays or quarantines, are paid by others.

The government is managed by politicians. They want to reduce political impact. If things go bad, they want to prevent infections. But they do not want to reduce mobility too much because people want to travel, etc. Decisions are made depending on random factors.

For consumers, it is a trade between a ticket paid, desired travel, and the inconvenience of adverse consequences.

Testing for the virus is unreliable. It is impossible to tell who is infected, the probability of transmission, etc. Apparently healthy people may be infected, apparently sick people do not transmit the virus. We know little about risks of infection, far less than the probability of who wins presidential elections or football games. And you know how easy they are to predict accurately.

Depending on the country, one has a low or medium or high probability of meeting someone who is infected (low, medium, high depends on political winds, profits, etc.). If the probability is high, it is likely it will happen. It means every person around that area will probably go into quarantine either in the original country or in the US. In March, the probability is high in many countries. In April, the probability may be low (due to warmer weather and more prevention), or could be high in selected countries. In May, the probability may be low in many Northern countries. By June, the probability increases in Southern countries (they are getting cold, so they are more likely to get the Flu). However, because of extensive world travel, it is now possible for people from Southern countries to travel to Europe or US and infect others. Even if they do not infect anybody, they may get sick and compel quarantine for all around them. Because it is extremely difficult to predict who really has the virus (due to substantial false positive and false negative results), whether the person is sick or recovering, can or cannot transmit the virus, governments may be scared and compel quarantine. It is not fun to be in another country inside a hotel or a restriction camp, full of people who may get sick and transmit the virus. May be more fun to stay home and watch it all on TV! But airline prices may decline, encouraging some to take the risk.

Life is about decision making under uncertainty. Evaluate the rough probabilities, the pros, cons, risks, benefits. If you like to jump from airplanes or climb freezing mountains in the winter (so your bones are preserved for future archeologists), or frequently cross the Oceans on a canoe, the risk of infection is tiny and you may find fun staying in quarantine and meeting people. If you have children or need to work for a living, you may find local travel or staying home less risky than travelling abroad. Watch travel videos, get good books, eat healthy foods, and enjoy freedom in your home.

What I would do if I was in charge

I will not rely primarily on tests. The tests likely have false positives and false negatives. I would rely on the entire clinical condition and probability of infection.

All first responders (police, etc.), government employees that interact frequently with the public, must wear face masks and take preventive measures. The range depends on the probability of infection in the community (# cases, location, etc.). We must look not just at one person, but the entire household.

Get enough thermometers to measure temperatures at public schools, large stores, transportation centers (e.g., subway stations). If the relevant entities did not anticipate this problem and bought them, plan for the future. Flu and epidemics are a way of life and appropriate entities should have enough supplies. Each police should carry a thermometer.

All individuals with substantial public contact must wear masks. If not enough available, create a rotation system. At my house, I calculate that viral survival is very small after 4 days (it is a speculation, I do not have accurate data). I wear a mask for one day, then I put it on a paper towel to dry for 4 days and reuse it. This includes checkout employees, school staff like teachers, bus drivers, security, etc.

Reporting system to identify people with high probability of infection. Request or order quarantine, isolation, etc.

Teach people how to conduct a quarantine in their homes. Provide training materials, supplies. This is not easy and many people do not know how to do it (and get infected).

Create a system to support individuals in quarantine at their homes. Deliver food, supplies needed, check periodically (probably daily), ask them to keep a diary of temperature, clinical condition. Teach how to keep a diary. Deliver notebooks and pens to keep a diary. Pick up clothing for washing at high temperatures and return them.

The US probably has millions of people infected with flu, hundreds of thousands very ill, thousands dead. It is the same every year (some years worse). The odds are high that one year the virus will evolve and kill far more people. What are governments waiting for? Are they trying to purge the population and eliminate the immune deficient? Because people over 65 are at much higher risk of death (perhaps 2x+) than other adults, the flu is a means to reduce social security and Medicare payments (and let families inherit from elderly who perhaps spend their money on medications or travel for themselves). Or what?

I do not see students wearing masks at school, passengers with mask in public transportation or stores. Why not? Prevention could reduce infection and death substantially. They do it in China. They aren’t dumb. Should government or housing entities distribute face masks to everyone over 65?  If we cover 100M people for 60 days, we need 6B masks. With appropriate manufacturing, 10c per mask, $600M, perhaps we can help 100K people not be ill. Less than $6,000 per person, far less than the cost of health care, etc. A tiny fraction of the money spent on tanks or a wide range of things. Why? Elderly don’t matter?

The US seems to rely on past recommendations such as “eat in moderation”, exercise with moderation, live healthier lives, buy stocks cheap, sell them high, avoid getting infected (as if sick people carried a sign or a virus was like a speeding car!), avoid bullets (hint: move faster out of the way), wash often, but not too often because it harms skin, avoid contact with infected persons (hint: if they had a fever and died, and weird things come out of their mouths, better don’t touch them; because infection is not obvious, get throat samples, send them to the lab, and wait; meanwhile, wrap the person in sealed plastic).

Am I the only one who thinks recommendations for being reasonable or moderation are non-sense (too vague, ambiguous)? Why not pass a law mandating that infecting virus get a license before they spread? (think the virus will care or obey?) Is the Emperor naked?

People sneeze or cough and spread the virus. It is impossible to stop these actions. People touch their faces. The solution is to wear protection. There are not enough surgical masks for the people who need them. It will take months or years for supply to catch up with demand worldwide. Prices used to be around 10c to 20c per mask. Governments should conduct research on alternatives. Thin ski masks. Scarfs. Handkerchiefs. Paper towels (held with tape or something else). Plastic bags with holes. Anything that reduces transmission.

If I was in charge, I would deal with these issues

When to wash hands and how. Extensive, detailed guidelines.

When to wear facemasks, what facemasks are adequate, what substitutes exist (paper towels, handkerchief, scarfs, etc.), how to put a facemask on (many people wear them improperly), etc.

Substantially increase awareness at schools, public places of signs and symptoms. Strongly urge people with signs or symptoms to wear facemasks, etc. Otherwise NOT admit to public places, schools, etc. Those with fever compelled to seek medical care, perhaps be quarantine, for the protection of their families, children, etc.

Publish locations visited by people likely to be infected, and let anyone close to infection self-quarantine ASAP. In those locations, clean them well and measure temperatures of involved people every day for at least 14 days. Take all necessary steps to prevent expansion.

Create a vast infrastructure to help people with evidence of infection so they can stay in isolation (not just home, but in isolation)

Recommendation for sick people to stay home is NOT good enough. They may stay home and infect family members, children, others, who then go out and infect other people. This is not a hypothetical, but it is likely happening with the flu and virus.

Advice is confusing and contradictory. See “How to prepare for coronavirus in the U.S. (Spoiler: Not sick? No need to wear a mask.)”.  https://www.washingtonpost.com/health/2020/02/26/how-to-prepare-for-coronavirus/?arc404=true.  I disagree. The experts at WashPost who wrote this article probably studied at a different medical school than mine, or worked in a different infectious disease department or hospital. I worked with many infectious patients (probably dozens). Every time I was not sick (my coworkers were not sick). We used masks. When a child in my house is coughing or has signs of the flu, I wear a face mask to reduce the probability an infectious agent will touch my face or enter my nose.

Preventing an infection is a matter of probabilities and good sense applying them. Most decisions we make while driving a car involve probabilities. How often do I look 4 ways before changing lanes or turning? It is impossible to reduce the probability of infection to 0 (zero). But I can reduce it from 0.8 (80%) to 0.01 (1%) by washing hands which touched a suspected surface, not touching face, nose, eyes, wearing face mask if facing potential infected people, cleaning surfaces if they are likely to be contaminated. If a child is coughing with an infection and washes his hands in the bathroom, I clean the faucet handles and anything he touched (I ask him to avoid touching things). I give him his own towel. I change towels and pillow cases every day and wash them in hot water and let them dry overnight (extra pillowcases and towels are inexpensive).

My approach is substantially different from WashPost

I agree with “washing with soap and water for at least 20 seconds after using the bathroom, before eating and after blowing your nose or sneezing.” I agree not to touch your eyes, nose and mouth. However, it is too vague and impractical “to clean objects and surfaces you touch often.” I touch things probably 1,000 times per day. Should I clean my keyboard 10 times per day? My bathroom door handle and faucets 20 times per day? The challenge is where and how to decide. We all know the way to get rich is buy stocks low and sell them high. But when, how?

Instead, I keep a separate environment outside and inside my house. We reduce the risk of bringing infectious agents, allergens, toxic chemicals, food infections, etc. We have two separate sets of clothes: inside and outside house. We remove shoes at the entrance (and clean foyer appropriately). We limit visitors as much as possible, and insist on shoe removal. For more infection control, if needed, we require visitors (like a plumber) to wear a mask. All deliveries are received outside the door. If planning a social event, the house must be properly organized to limit access and infection control. If a family member is sick, we create a quarantine area and implement more stringent infection controls.

We wash hands after coming inside the house (from school, work, public transportation, etc.). I clean surfaces frequently used. Faucet handles are cleaned after almost every use (either with a towel or with water). Refrigerator and doors handle frequently used are cleaned a few times per day. Every night I clean foods used to prepare food and surfaces we touched (tables, counters, refrigerator doors, etc.). The goal is to keep “clean” house, clean body and clothes so we don’t have to clean often.

“CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory diseases.”  https://www.washingtonpost.com/health/2020/02/26/how-to-prepare-for-coronavirus/?arc404=true.  Really? So, all the physicians and nurses, who are well, and wear masks are dumb? They are not infected, so they should not wear a mask?  Nonsense. How about the caveat: “except when you may be exposed to a person with a respiratory disease; then wear a mask to reduce the probability a virus in the air will touch your face and enter your body”. How about saying: “If you go to a public place where some people have a respiratory disease (probably almost everywhere), a face mask may reduce probability of infection. If you spend your life in a secluded mountain hole with the nearest human 20 miles away, and never interact with humans, you probably do not need to wear a mask.” Did I miss the best idea “carry a large thick plastic garbage bag”? When you see a person coughing or looking infected or looking the wrong way or wearing clothes you don’t like, cover them with the plastic bag.” This method is likely to reduce infection (although it may have some undesirable side effects for the bag carrier).

There is photo of military hospital in 1918, showing a huge number of soldiers together, sharing the same air, without adequate protection to prevent spread of influenza.[7]  This is an example of what NOT TO DO. In photos I see of people wearing masks, the mask is not properly used. There are many gaps around the edges where air will likely flow (less resistance) carrying virus. Mask must be tight against face.

Stop the spread of misleading or incorrect information. An epidemic is NOT the time for a thousand different opinions to bloom. Every politician SHOULD NOT send emails telling people not to worry or be careful out there.

“As the pandemic raged through October of that year, Americans could see with their own eyes that the “absurd reassurances” coming from local and national officials weren’t true. This crisis of credibility led to wild rumors about bogus cures and unnecessary precautions.” [8]

The scientific (biochemical) and epidemiologic (surveys) data are inadequate to make reasonably valid predictions. The spread of the virus could die in the US by April, when the weather is warm. Or it could spread everywhere. We do not know if the virus in the US is highly infectious or has low survival time outside the body.

Should the US do nothing but talk (current recommendations), take active, substantial preventive measures (e.g., massive training and education, prepare isolation facilities), prepare for draconian measure if needed (e.g., close schools, public events, transportation) or get high on marijuana, beer and watch sports and sexy movies? Difficult choices.

Do we pester people NOT to drink, before they drive, or do we catch DUI and give them tickets? The death rate from COVID-19 is likely under 2% of infected people. For those not dying, the hassle of strong prevention is not worth the benefits. For the dead, it does not matter. For the surviving families or with only severe adverse consequences (e.g., reduced lung function and brain damage), substantial prevention comes too late.

I recommend active, substantial preventive measures and prepare for draconian measure if needed. If not now, severe epidemic, natural or bioterror, is likely to hit the US. The US is not prepared. The consequences are like nothing people has seen, almost collapse of the US.

Comparison with other flu-like epidemics

While news media focus is on covid-2019, the flu virus is now far more dangerous. Based on historical trends, and the fact that his year’s virus is likely to be more harmful than previous viruses, “in the 2019-2020 season so far, 15 million people in the US have gotten the flu and 8,200 people have died from it, including at least 54 children. [9]

The virus mutates (changes) frequently. It is feasible for a person to be infected twice. Vaccines provide limited immunity because they are based on versions of the virus from months before it arrives to the US. The best protection is prevention. But prevention is poorly taught in schools, it is rarely implemented, and the country may not have enough masks for all school children and people over 65 (populations at high risk).

The signs and symptoms of covid-2019 are similar to the Flu; the Flu this year is hyperactive and likely millions will get it. Not only it is difficult for individuals to tell them apart, but with draconian actions across the world, people will likely conceal it to avoid quarantine and undesirable government actions.

“Get a grippe, America. The flu is a much bigger threat than coronavirus, for now.” “it has infected as many as 26 million people in the United States in just four months, killing up to 25,000 so far;” 310,000 have been hospitalized. (Feb 1, 2020) [10]  [11]  CDC estimates that up to 43M people got sick during the 2018-2019 flu season, 650,000 people were hospitalized and 60K died. The CDC's 2017-2018 estimates of 49M illnesses, 960K hospitalizations and 80K deaths. [12]

Flu “has already killed thousands across all ages, and is infecting kids at unusually high rates.” [13]  More children than coronavirus. The FLU remains far more dangerous (more people infected, more people sick, more people die) than covid-2019. Yet little is done to prevent infection at schools, work, public transportation. Substantial education and preventive measures are feasible and should be implemented. A major danger of the flu is the continuing mutations that could create a super virus that kills thousands of children and elderly. Eventually the US will face a virus that will kill millions.

“McCaughey estimates 380,000 nursing homes residents die each year of infections, about half of them preventable.” [14]  Could the US prevent 30,000 deaths? Why isn’t the US better prepared to prevent disease and death? We should cut deaths by 50%!

I see the problem is too many nice, well intended people are in charge instead of health professionals who implement strict prevention measures even if not polite or pleasant. I do not put aesthetics ahead of life expectancy; whenever somebody tells me they do something for aesthetics in homes or retirement communities, I wonder if they do enough to prevent illness and death.

About epidemics and viruses

“An infection is the successful colonization of a host by a microorganism. Infections can lead to disease, which causes signs and symptoms resulting in a deviation from the normal structure or functioning of the host.” [15]

“Infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to the infectious agents and the toxins they produce.” [16]

There are many things we don’t know about infections, but we should know.

How many viruses does a person send into the air or environment around the person (per unit of time, per sneeze, etc.)?

How long those viruses survive in a location where they can be transferred to another person?

How many viruses that touch a person or enter the person’s body reproduce before they are killed by the body (or environmental factors)?

Why does a virus die outside a cell within a few hours?

If 1M in China received the virus, most will not have evidence of infection. For practically purposes, they are not deemed “infected”, even though they are. The outcome depends on age, immune system, and likely country (e.g., environment, etc.). In China, where the virus originated, we can expect people to be more prepared for it (those with low resistance to corona viruses probably died long ago). The outcome would be different in the US with widely different types of people, most rarely exposed to those viruses. It could be that the environment is less favorable to the virus or the animals are different, or the genetic mixture of humans are different.

The infection rate is only measured among those with evidence of infection. Most people will either not show evidence, or the evidence is mild, do not receive health care, and do not count as “infected”. Thus, the mortality rate is low if we considered everyone who received the virus.

Among people who received the virus, most will not have enough quantities to infect other people. However, it is possible to be a carrier without evidence of infection. A person may appear healthy, yet have enough viruses to infect others.  Further, the time to show symptoms from the date of exposure to the virus could be up to about 20 days, not 14 (most people show symptoms within 14 days, but some take much longer).

It is impossible or impractical to measure the virus in every person who could be exposed. Further, it requires a minimum quantity of virus to measure it. Thus, a person may be infected, but not have enough viruses to detect the infection. The alternative is to take tissue samples every day on every person, but that is impractical or impossible on a large scale.

Thus, the safe approach is to consider that anyone likely exposed to the virus is infected and should be in quarantine (or restricted to their home and monitored).

Data about the virus

Disease = coronavirus disease = COVID-19; Virus = severe acute respiratory syndrome coronavirus 2 = SARS-CoV-2 (abbreviated CoV-2). “Viruses, and the diseases they cause, often have different names”. [17] Use the appropriate name for the virus or the disease.

CDC believes at this time that symptoms of COVID-19 may appear in as few as 2 days or as long as 14 after exposure. [18]

A “50-year-old man who traveled to Wuhan on January 8 and started to have a fever a week later upon returning to Beijing” died about Jan 26, 2020. [19]  Time from infection to death about 18 days. About 1 week to develop a fever. But there is likely substantial variability. About 5M people left Wuhan since the infection started. The food market where the virus probably originated is a few blocks from the main train station and center for railroad. The odds are high that thousands of people got exposed to the virus and travelled in crowded transportation to crowded cities. The probability is substantial that thousands to millions of people were exposed (impossible to know). With exposures late in January, infections late in January, and likely thousands more exposed later, there will be many infected people in February, and March, 2020. It may or may not decline afterwards in China.

Although quarantines are reported to require 14 days, data published in NEJM.org indicates that a person’s infection may be measurable only after 14 days, and quarantines should last between 14 and 21 days (pending more research).

SARS-CoV-2 may now consist of two types, the L (more dangerous, more prevalent earlier, and the S (less dangerous, perhaps more prevalent now). Substantial research to measure different types of SARS-CoV-2 and their associated clinical features helps select optimal treatment and quarantine. This is more important than vaccines; we should put at least $2B into research of the evolution, gene differences, clinical effects, survival rates in different media (air, surfaces, etc.), simple treatments (e.g., heat, humidity, etc.). [20]

“independent self-sustaining human-to-human spread is already present in multiple major Chinese cities, many of which are global transport hubs with huge numbers of both inbound and outbound passengers (e.g., Beijing, Shanghai, Guangzhou, and Shenzhen).” “Large cities overseas with close transport links to China could also become outbreak epicenters, unless substantial public health interventions at both the population and personal levels are implemented immediately. Preparedness plans and mitigation interventions should be readied for quick deployment globally.” [21]

“human coronaviruses, such as SARS and MERS, have been found to persist on inanimate surfaces -- including metal, glass or plastic surfaces -- for as long as nine days if that surface had not been disinfected.”  [22]

SARS-CoV-2, described with incubation times between 2-10 days, facilitating its spread via droplets, contaminated hands or surfaces.  Efficiently inactivated by surface disinfection procedures with 62–71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. [23]

The virus may survive for less time when the temperature is higher. It may be worthwhile to raise temperatures in buildings at risk of infection.

With influenza A virus, a contact of 5 sec can transfer 30% of the viral load to the hands; perhaps less transmission with other viruses.  Or perhaps more. Depends on the material of the surface, the type of contact, etc. The point is that transmission by surface contact can be very good (for the virus). [24]

Scientists do not know why there are substantial differences in infection rates. “Fewer than 1% of people who encounter poliovirus for the first time get the disease, compared to greater than 99% who become ill after infection by measles virus.” [25]

Adverse economic consequences of epidemics. Inadequate preparation.

The economy v. covid-2019. A fight to the death . . . of both? [26]  In January, 2020, stock prices went down because one patient with covid-2019 showed up in the US. The US was not prepared, even though they knew about the virus for some time. The person came into an airport and left. Unknown people were close to that person. As more people became infected and died, the stock market went down more.

The US is not prepared to adequately and quickly respond to a sudden infection. A more severe and contagious virus could infect millions. When it happens, millions or tens of millions could die. The US is not willing, able, capable of imposing severe restrictions, killing and burning infected individuals, etc. Thus, the US may crash.

The US, government officials at local and national levels are NOT taking adequate preparations for a substantial viral infection. There are no meaningful plans to close in and out from cities, close major transportation, open hospitals to manage over 1,000 patients, create large quarantine areas where people can live for 30 days, etc.

In the event of a major infection epidemic, each susceptible or potentially infected individual should be in quarantine at least for the time it takes for the disease to become evident (usually around 14 days). However, because of poor management, that person may have infected others. If many people are kept together, then the virus can spread back and forth for almost unlimited time (certainly many weeks).

There are no adequate plans to feed, clothe and house thousands of people.  Around Washington, DC, in major counties such as Fairfax and Montgomery County, with easy access to international airports and many travelers, there are no adequate plans to contain an epidemic.

Washington, DC is highly susceptible to an epidemic, particularly Montgomery County and Rockville. There is a huge number of entities involved in international travel and health care, and contacts with Asia and China. These areas are very close to 3 large international airports, Reagan, Dulles, Baltimore.

The next infection may start in China. It could start in the US or be a mutated virus in the US. Infections can spread VERY quickly, in days, not months. By the time governments take steps to prevent spread, it is too late. The solution is a DETAILED plan now, with adequate preparations. The plan is the same everywhere, with minor modifications. It must be prepared by the federal government. This is NOT the time for letting 1,000 communities develop their own emergency response. We need $200M+ for NIST, to evaluate and create the best, uniform, standard measurement devices for the US, including thermometers for individuals and population measures, heat sensors, virus collection systems, etc. We need $200M+ to measure physical variables in the virus, chemical composition, survival, etc.

$5M to each state government to implement state-wide plans following specific guidelines from the federal government. The plans include detailed spreadsheets with the number of supplies needed (e.g., how many face masks, assuming face masks can be used for 1 week), heat sensors, hospital beds, isolation units, plans to close schools, highways, transportation, etc.

$50M to HHS to create prototype, uniform, emergency plans with detailed spreadsheets for calculation of supplies, logistics for distribution of items, contracts to manufacturers, etc. Award contracts to 3 manufacturers to prepare plants to start making temperature and other devices.

Award contracts to each state to build or expand or adapt a building to use as additional hospital beds and isolation facility in the event of a major epidemic. Each state should have one facility, surrounded by superior security (to prevent entrance or exit) with periodic inspections to maintain in good condition.

Each state, county and major city must identify one person for emergency response and coordination (could be the same for climate change, storms). Each must have the emails and phone number of the person above at the state level. Create means of communications for routine purposes (while Internet and cell phone work) and in the event of disruption of cell phone and internet.

HHS must create algorithms for cities and counties to decide when to close schools, roads, public and private transportation, prohibit people going outside their homes, minimum quantities of food and water everyone should keep and how. Ex: how good is a water bottle? When are plastic residues too high? Can we get water in glass stored for years? Can we get food cans stored for 10 to 20 years (probably yes)? How to manufacture them. How to recirculate the food and water. Have schedules to avoid overwhelming supply and demand.

Issue special stickers to emergency personnel (police, fire, physicians, nurses, etc.). Identify drivers and buses or cars for special public transportation (as they did in China) if private or public transportation is closed. Identify hospitals or locations to transport sick patients, etc.

Washington, DC preparations are inadequate

When a politician or opinion-writer tells me not to panic, wash my hands often, eat and drink in moderation, avoid infections, move out of bullet’s way, drive safely, stay out of the way of nuclear bombs (e.g., cover your head with a paper bag or lie under a desk), and all manner of silly, vague and obvious nonsense, I PANIC! It means somebody is not competent enough to tell the difference between useful and meaningless advice. They feel they have to talk to support their voters or customers. Please limit most comments about infections to physicians or experts. Unnecessary comments cause information overload.

In January, 2020, a major, substantial infectious viral disease developed in China. In a few weeks there were over 10,000 cases and more than 100 deaths.[27] It then spread to other countries.[28] The viral infection spreads very quickly. In the Washington, DC area, we could go from zero cases to 50 cases in less than two weeks. What are the plans to reduce travel? To ask people to remain in their homes? To close schools? To provide food and water? Provide adequate training?

How many homes have enough water and food for 15 days? For 30 days? Are governments ready to publish and enforce a ban on travel except for emergency vehicles, health care staff? Do they have a means to deliver food and water? Are there enough hospital beds in isolated areas? Enough clothing, face masks for everybody?

When, how, is a decision made to mandate face masks for everyone? Which ones? Where do we get them? Are there enough?

Do schools, colleges have a plan for online education (e.g., subscriptions to video services, tested delivery, etc.)?

Should we require children at schools to wear facemasks most of the time (reduce probability of infection) or do we wait until someone is infected and then burn them if they die? Are large HOAs, apartment buildings, retirement homes, prepared to reduce entrances, mandate face masks?

What is the life expectancy of the virus in air, surfaces, clothing, food? This is critical to determine transmission routes. Who is conducting the experiments to measure life expectancy?

Is there a temperature and time to cook food or wash clothing that kills the virus? With a microwave?

NOW is the time to PLAN. If this virus is not a HUGE killer, the next one may be. It is not IF, but WHEN. Either by natural mutation or by artificial mutation, the probability is high that a substantial infection will occur. Already many infectious agents like bacteria do not respond to existing antibiotics.

“U.S. Hospitals Aren’t Ready for the Coronavirus”. [29]  This is an understatement; many hospitals in US are in chaos. They follow practices of the 1980s which I found inadequate or incorrect or suboptimal. Health IT, instead of helping, make chaos more prevalent (faster computers implement errors faster!).

The China government built a 1,000-hospital bed in about 10 days, to take care of sick patients. The US, a far more advanced technology with brilliant minds, hard workers, democratic and highly competent governments could do the same. Or better. Quiz: the US could build a similar hospital near DC in: a) 7 days; b) 5 days; c) 2 days; d) 7 hours; e) 20 years, if they get prompt approval from government agencies, SCOTUS quickly resolves the likely litigation for and against, weather is constant, perfect, for at least 10 years, Congress appropriates $3B for construction, $2B for rewards, $4B for overtime; $3B for consultants; $6B for safeguards, night guards, etc.; $25B for new transportation to get there; my mother agrees.

“The five patients who've been confirmed had all recently returned from Wuhan, the CDC said.”  [30] We know since December, 2019, that there is an infection epidemic brewing in Wuhan, coming to the US. Why didn’t the US put in quarantine EVERYBODY who came from Wuhan? And everyone with a known contact with a person from Wuhan? At least for 2 weeks.

The US should build enough facilities, like hotels, for quarantine of hundreds to thousands of people. Infection epidemics are likely to get much worse. Either the US takes appropriate measures, or could face thousands (or perhaps millions) of deaths. The US system facilitates infection. Currently it is impossible to have quarantines of many people or restrict travel for weeks. But countries may need to do it for months!

In the Washington, DC area, news media criticize POTUS Trump for his actions to prevent CoV-2, even though he acted reasonably and followed the conflicting advice of experts. Montgomery County (MoCo), is a wealthy suburb of Wash, DC, the site of the largest medical, research and pharma centers to study infectious diseases and vaccines, with likely the top experts in the US. Its population is highly educated, with HUGE numbers of MDs, PhDs, JDs, politicians and opinion-writers.

I receive frequent misleading or inaccurate information from well-intended politicians and opinion-writers. News media and Washington Post have too many articles which confuse instead of help. The Homeowner’s Association (HOA) where I live spends huge amounts of money to inspect houses to find that the shade of gray of siding may not be good enough, or plants are not neat or in shape, or whatever. Its landscapers walk around breathing everywhere. It holds meetings to discuss how to comply with HOA rules about the appearance of a house with many elderly individuals at high risk of infection. Statistically, I think that some of the individuals spreading their breathing are likely to have the Flu and perhaps CoV-2, there is no way to tell until people get very sick and is then too late. Like the 2018 Spanish Flu epidemic, people care about trivial matters until they get sick or die, too late for prevention. About 5,000 people live in my HOA, many over 65, with morbidities and high risk of infection. Little is done about it. Too busy checking the shape of plants and shade of paint.

The government, schools, politicians, medical organizations, send me emails with conflicting information and frequently impractical information (e.g., be careful, be reasonable, moderation, wash often, avoid infection!). Surely, they would recommend that I don’t get infected. Mostly, I get it: I should avoid dying because it is bad for my health! Unless I die with moderation, nothing extreme. My advice = STAY OUT. If you are NOT an expert in infectious diseases, and have something unique, and practical information to offer (such as the indoor temperature for heating systems, or where to find the best masks at fair prices), close your mouth (it is safer for everybody). Don’t raise above your level of expertise (Peter’s Principle). Instead, figure out your expertise and how to use it (or do nothing, often the best to avoid information overload and misrepresentations). We do not need volunteers or politicians to add chaos to confusion.

The information available, the prevention measures, the education and emergency preparedness are inadequate.

There is a high probability that the coronavirus will become prevalent in the US. I cannot tell from the data whether it will be 10 or 100 or 10,000 cases. I know that human to human transmission occurs with high probability. The good news (perhaps, I speculate) is that tens of thousands (or millions?) of people were exposed worldwide to the virus, and perhaps less than 100,000 (?) were infected and about 2% died. But these numbers are rough approximations. The probability of getting clinically measurable disease after contact (e.g., what we usually call infection) is unknown, but probably very low. However, in medicine, probabilities are frequently misconstrued and inadequate. We prohibit drunk drivers, even though the probability of being severely harmed by a drunk driver is very small (compared with the number of miles driven in the US).

When a killer started shooting a few people in the Washington, DC area several years ago, people were afraid. I was afraid to get gas. When I did, I was behind my car. So did other people at the gas station.

I believe there would be widespread panic if many cases of COVID-19 appear in the DC area. As a minimum, they would cause severe disruption of life and transportation. Schools would close. Parents, unable to get child care (almost impossible), stay home. These are the people who drive public transportation, manage government agencies. Subways, buses, trains would be delayed. IRS would take even longer to answer phones (meaning impossible to get through). The Russians will NOT come (afraid to get infected!).

DC must plan ahead. Have designated drivers and workers for emergency purposes, individuals who can work even if schools are closed, gas pumps running out of fuel, etc.

I have seen many people die from infections. Probably thousands die every year from an infection that was either preventable or controlled early on, but not enough was done due to suboptimal logistics, fear of liability or inappropriate behavior, misunderstanding, etc. The US may criticize China because it allowed “a bureaucratic culture that prioritized political stability over all else probably allowed the virus to spread farther and faster.” [31]

But the US also prioritizes political purposes and economic growth over all else (the impeachment actions in Congress eliminate any remaining doubts). I believe it is impossible for the US to close public transportation, schools, jobs, prohibit travel, compel people to stay in their homes. The US lacks the expertise, logistics, power, will. Perhaps the US can handle 10,000 infected people. But I doubt 100,000.

Is there a plan with substantial virus infection? If so, what is done about the flu, which kills thousands of people, primarily children and elderly individuals? Is it part of a plan to reduce the elderly population, save on health care, and have more houses for sale?

Emergency preparedness for severe infectious disease is inadequate

“China’s errors, dating back to the very first patients, were compounded by political leaders who dragged their feet to inform the public of the risks and to take decisive control measures. The result is an epidemic that has gripped the global economy.”[32]

“It is uncertain at the current time whether it is possible to contain the continuing epidemic within China.” [33] The world is far from the peak in infections and reduction in risk of infection (and spread of epidemic). It seems the world is far from a reduction in risk. It means the US and Europe must get ready now (for 2020 and future, because infectious epidemics are likely to increase, not decrease, due to more mutations, more transmission).

Measuring temperatures at airports is insufficient to stop an epidemic. “China says virus can spread before symptoms show -- calling into question US strategy to contain virus.” [34] The US needs to implement a tracking system for every likely infective person. There is no need for $100M contract for data base. We can create in ONE day an adequate data system using off-the-shelf data base software. Enter data using existing technologies. Then implement a follow up system, ranked by priority, calling each person at substantial risk until the risk is almost zero (about 14 days). Make reporting of symptoms, like fever, mandatory or face isolation and/or deportation.

The US needs to restructure HHS to make responsibilities, assignments (tasks), chain of authority explicit and clear. Reorganize HHS by major sections. All health matters (other than billings from payors like Medicare) should report to the Assistant Secretary for Health. A person responsible for health/ medical emergencies at HHS, works for and reports to Deputy Assistant Secretary for Planning and Evaluation. This person heads a US wide coordinating task force. Each major entity (e.g., CDC, NIH, The White House, State Department) identifies a responsible coordinator. The entity grouping state health officers (already exists) identifies a responsible person in each state, and a representative to the US coordinating task force. If needed, Congressional or POTUS authority is used to exempt them from publication requirements, notice of public meetings, etc. The task force must work very quickly with delegated authority. Appropriate immunity from litigation is provided.

Emergency responders (e.g., fire, police, ambulance) and most people must know, in each state, the facility designated for infection evaluation. Create a massive education campaign, as soon as the logistics are completed. This is critical in Washington, DC area counties, and locations with substantial foreigners who travel frequently.

Dangers of future infections

In Episode S3:E9 (from Netflix) of “Designated survivor”, a terrorist creates a virus that damages reproductive DNA, inducing sterilization. The virus can be released in targeted populations, or could contain code to target genes more prevalent in some people than others. A similar virus could evolve naturally and would selectively target the area where it evolved, or, if it evolved slowly, would target a different population not prepared for it. Thus, perhaps blacks could target whites or whites could target blacks.

Or, likely, the virus would evolve (mutate) after release and target most people, an equal opportunity destroyer of humans. We know that viruses that evolve or appear in places like China or Asia, like the flu, mutate and target Europe and America. If it does not mutate rapidly enough by itself, the science identifying the nature, purpose or consequences of mutations is rapidly becoming public (published in journals) and someone can mutate it.

Research questions and issues the US (and the world) should address

“the measles virus, which can live for up to two hours in the air after an infected person coughs or sneezes”. [35] SARS-CoV-2 may last days on a surface, I do not know how long in the air.

The virus is known for over one month. How long does it take to do an experiment, expose the virus on different surfaces and air, and find out how long it lives? If it lives less than 2 hours, couldn’t we do the experiment in 2 days? What kills the virus? Alcohol? Chlorine? Waiting 2 hours? Flamethrower? A hammer? How (concentrations, duration exposure, etc.). Is somebody doing these experiments now?

Logistical and preparedness questions

What we need are master plans and massive logistics, a problem solved by operations research, industrial engineers, not politicians or opinion-writers on news media.

I read the CDC website, the NEJM.org Jan 30, 2020 articles about the new virus. They are well written, with useful analysis and explanations (from China and other countries). Yet they do not answer the questions or issues that bother me.

Are there enough masks in the US for 50% of the people? I doubt. In China and Hong Kong, with excellent manufacturing, distribution and decision-making process, they do not have enough. Even though we see millions wearing masks, millions cannot buy them, which means there are no replacements when the current ones need replacement (soon).

Has the US started making hundreds of millions of these masks long ago (and created a stockpile)? How many people have a box of 30 at home (I doubt many)? Who is in charge of counting masks, being certain there are enough for months of flu and other viruses?

Are schools teaching children how to wash hands, wear a mask (both not obvious, frequently done wrong), implement CDC guidelines. Consider the thousands (?) of patients taking immune suppressant drugs. Did their physicians warn them about infections? Are they wearing masks all day? Have they changed treatment to alternatives (often several exist) which would cut billions in profits for some entities? (answer is probably NO). At U MD, a student apparently taking immune suppressant drugs died from an infection (which led to extensive writing by news media, but not change in treatment or use of masks or other prevention measures).

If there are 10 cases in the DC area, and fear of hundreds more, and people rush to buy face masks, will they find them? Are schools ready to provide face masks to each student? Do they have enough supply? Do they know how to wear them?

“To possibly succeed, substantial, even draconian measures that limit population mobility should be seriously and immediately considered in affected areas, as should strategies to drastically reduce within-population contact rates through cancellation of mass gatherings, school closures, and instituting work-from-home arrangements.” [36]

The US already has multiple epidemics poorly prevented of salmonella, food infections, flu. There are hidden epidemics caused by toxic chemicals. The US is unprepared for an epidemic. I doubt government and stores have 500M masks available now, with hundreds of millions needed every week.

Most people do not know how to wash hands properly (don’t touch faucets with clean hands, wash between fingers, count to 20 seconds), what side of mask to wear touching face (white side), how to put on a mask, take it off and discard (don’t touch outside); replace face masks daily (?).[37]  If there are not enough face masks, how to reuse them? What to use instead?

Is US ready to build a 500-bed hospital or dorms to house 1,000 people in less than 15 days? 25? 40? Or, more likely at least 1 year? (China builds 2 1,000 bed hospital in less than 15 days). Does US have the logistics and all the parts needed? I watched a video of China constructing two huge hospitals in a few days. They have the thousands of parts needed. I doubt the US does. Where will they get them?

How long will it take in the US to make 10M masks per day (most people need a mask every day). Worldwide supplies are close to zero. China and other countries cannot meet their own needs. Where will the US get them? When will the US make it mandatory for children and people in public transportation to wear masks? (good enough for the Flu). The US population is unlikely to comply with government recommendations or mandates (already they refuse to comply). Should police, facing a person coughing moving towards them, shoot him? Will the thousands (or is it millions) of homeless, mentally ill, careless, ignorant and unwilling people be forced into quarantine areas? My prediction is that a major epidemic in the US could be out of control and kill thousands (or more) because the US is neither ready, nor willing, nor able to do what it takes to stop it.

The production of face masks is FAR below the needs of the US or the world. A US company makes about 600K masks per day (?). The US has over 10M people infected with the flu. More are coming. It means it needs at least 10M masks per day, probably about 30M (assuming each person with the flu interacts with 3 other people). In China, they probably need about 300M masks/ day.

Major entities, such as schools, government, HOAs, should have a supply of masks to cover all relevant individuals for at least two weeks (all children, all elderly with reduced immune function, people who interact a lot with customers; transportation drivers, etc.) if there are infected individuals in the area.

Schools should have several non-contact thermometers. Students should align every day by classroom and teachers measure their temperature. Perhaps it could be coordinated with attendance rolls. I have more than 5 thermometers. They cost between $10 and $20. They give me substantially different results. I could not figure out which one to buy. The reviews include pros and cons. The federal government can ask NIST (old national bureau of standards) to evaluate thermometers, select 3 reliable, valid. Order 10 or more for each school, a reasonable cost within the budget of schools. It should be good for 5 to 10 years. Perhaps it could be made in the US. In at risk areas, stores and public transportation could measure T in customers.

Create labs capable of quickly evaluating infective diseases that can become epidemic. Among other tasks, the labs should conduct experiments to find out the life expectancy (survival) of the agent outside the body (on typical surfaces likely to transmit the infection, such as air, door handles, etc.), the means to transmit infection (blood, urine, fecal matter, saliva, touching, breathing, eating, etc.); means to prevent or reduce transmission (e.g., types of facemasks needed, what else is needed); etc.

In the event of a substantial infection, comparable to the flu, the US needs 30M+ facemasks per day. It should measure the shelf life of a facemask (probably years) and keep a supply in regional centers of at least 500M.

Manufacturing facilities with capacity and supply chain ready to increase production as needed.

Procedures to close schools, transportation networks, etc.

Education of children at schools, and adults elsewhere. Start now, teaching tasks such as cleaning hands, infection prevention.

Means to distribute prevention, such as facemasks, at schools, large transportation centers (e.g., subways, trains, airports).

Mandatory Location of all international travelers for at least the duration of the epidemic, and all times for all non-US residents.

Quarantine centers capable of supervising 100,000 people (this is a small number; the flu exceeds this number). The goal should be 1,000,000 with alternative means. It probably involves setting up large sleeping areas, build hospitals, use existing large hotels, etc. The air systems may need updating, as well as installing other means to prevent infections. During several years I spent in hospitals, we had many patients with infectious diseases in special areas. We had to change clothes every time we entered and left, etc. I observed several health providers were not careful enough. During pathology autopsies, I observed sometimes the attending people (pathologists, residents, physicians, etc.) were not careful enough. I remember one patient with TB, the staff was not careful enough. When the chest was open, a huge mass of “stuff” came out and everybody run for the showers.

Create isolated residential areas for quarantine. If not in use for epidemics, use for rehabilitation, weight loss, fasting.

Plans to close cities and distribute food, water, etc.

How to maintain critical workers in critical facilities such as electricity, water pumps, police, fire, medical centers, etc.

Counties to create plans with HOAs and large apartment buildings. Example: each entity should identify one person in charge, and an alternate.

“Britain’s chief medical officer said Thursday that schools and offices could be closed in the country for two months and mass gatherings and sporting events banned if the coronavirus takes hold there.” [38]  The US is not prepared for logistics and is not taking adequate steps to prevent the need for draconian measures. Local counties, cities, schools, HOAs need far more prevention and preparation (e.g., stockpiles of masks, distribution of food, identification of critical workers, etc.).

We need to create and improve the manufacturing (in the US) and appropriate supply chains of pharmaceuticals, personal protective equipment, hospital supplies, etc. to make the US self-sufficient. With a global outbreak, we cannot rely on imports.

We must identify and prepare supply chains for all items essential to US (food, transportation repairs, utilities, etc.). Current logistics are inadequate for epidemics. Substantial disruptions mean that it may be impossible to obtain an essential part in a short time. There must be enough spare parts in the US, enough machine tools to build spare parts if needed, etc.

See 10 steps the government could take to maximize the effectiveness of the U.S. response to a pandemic, while also reassuring the public that the government is competent to address the threat. [39]  Very well written by an expert on these matters. address supply-chain ruptures and accelerate production and availability of critical medical supplies

Prevention of infections

Common surgical masks block the droplets coming out of a sick person from getting into the air, but they are not tight enough to prevent what’s already in the air from getting in. There are specialized masks — known as N95 masks because they filter out 95 percent of airborne particles

Explains different types of masks and their uses, surgical mask (OK for flu), N95 or N99 (for some viral diseases), gowns, etc.[40]

R&D for treatment of infections

Flaws in medical R&D: the search for treatment solutions or treatment profits. They are often incompatible. Treatment solutions that are inexpensive are ignored because there is no profit. Examples include substantial weight loss (fasting, intermittent fasting) for Diabetes Type 2, estrogen to treat prostate cancer, hot humid air to treat respiratory infections, soybean oil to treat high cholesterol or high triglycerides. Each of these concepts may work very well, with modifications. Research is needed to create the modifications. But the profits from effective treatment will likely be too small to justify venture capital or research time. Instead, the profits are much higher for finding a way to increase the life expectancy by 1 year in a child with rare disease. Thus, instead of focusing of simpler ways to prevent or treat the flu (affecting millions), a children’s hospital may focus on rare diseases affecting thousands. They follow the money.

Virus mutates. Different versions exist. Perhaps the most harmful (pathogenic) variation kills people faster or more frequently. If this is the case, isolate and control better those associated with patients who died. Then the more pathogenic variation will cease to exist.

Scientists do not know why people die. Current R&D is inadequate to kill the virus. It may be suboptimal immune or genes or nutrition. Apparently, the virus’s survival on air or surfaces decreases with increasing environmental temperature. Perhaps it also decreases with increased body temperature. If so, instead of treating fever with antipyretics, we should allow fever, perhaps up to 102 or 103 F. Personally, that is what I try when I have an infection (except at night, when I am afraid the temperature could go up too high while sleeping).

Perhaps breathing hot air reduces the number of viruses and thus reduces the probability of infection and the severity of the disease. We do not know because there is not enough research on these issues. Huge chunks of money go to vaccines. Think of selling over 100M doses at around $20, it is $2B per season in the US alone! It is probably highly profitable. In contrast, proving that breathing hot air kills the virus is unlikely to be so profitable.

If the virus kills many cells, the dead cells release chemicals in the blood. They may substantially increase their concentration in blood. Modern technology can measure thousands of chemicals and estimate if the virus is increasing in quantity, killing more cells, or it is killing fewer cells (meaning the body’s immune is destroying it). For people without symptoms, a blood or urine or breath test may indicate the presence and strength of the infection.

If temperature is a key factor, should be consider increasing the temperature of the environment (in hospitals, homes, transportation, offices)? Wear more clothes, like when we go skiing? Breath hot air? Rinse mouth with hot water?

Vaccines are not necessarily the best solution for a frequently changing virus. The search for a vaccine may mislead consumers, opinion makers, government. Putting billions into vaccine development and implementation may not improve desirable outcomes, and may worse desirable outcomes due to a shift in resources. One must carefully evaluate the data because some vaccines are not useful for their intended purposes. The disease COVID-19 harms substantially mostly elderly individuals and individuals with reduced immunity due to existing morbidity (CVD, diabetes, overweight, etc.). It usually has minor adverse consequences on most people. Thus, a vaccine, to be effective and useful for its intended purpose, must prevent death and hospitalizations in older adults.

Current guidelines recommend the flu vaccine for older adults. Unfortunately, recent research found previous analysis misleading. Better data analysis found that Flu vaccination does not reduce hospitalizations or death in older adults (the potential benefits of the flu vaccine were too small to be meaningful, not necessarily positive benefits). See Anderson ML, et al. Flu vaccination does not reduce hospitalizations, death in older adults. [41]

Instead of spending huge amounts of resources (time, money) on a vaccine highly profitable to its vendors, governments should allocate more money to less profitable but potentially far more effective prevention and treatment methods. We should target susceptible populations.

For prevention, we need to focus on weight reduction, which cuts substantially (probably more than ½) the risk of severe adverse events with COVID-19. Other prevention measures include better nutrition, environmental factors such as Temperature, perhaps inexpensive air cleaners at home (when one person is sick) or facilities such as nursing homes, hospitals, offices, etc.). For treatment, we need better research on inexpensive and almost risk-free alternatives such as breathing with heated air, and other means to reduce the effectiveness of viruses.

Government responses and counter-productive emails and news media

There should be ONE website with relevant information, either at the STATE level and/or COUNTY level (not city level). They should post general guidelines, and specific local instructions.

We should NOT get multiple emails from schools, HOAs, public officials, medical organizations, etc. This is called “information overload”. It is impossible to read all the emails and sort out what is new, what is old, what is correct, etc.

I get emails from medical organizations, county officers, school, HOA and many more. There are countless articles in news media. They are inconsistent or too vague. I find them counter-productive. They provide misleading or incomplete information to others (thus raising the threat level).

Instead, they should cite one or two websites, the STATE and the COUNTY. Just two links. Not more. I would prefer ONE link, with the STATE having a section for each COUNTY. It includes a MAP with rough probabilities or risk, so people can take precautions depending on the level of risk.

I find many recommendations counter-productive. “wash hands for 20 seconds, frequently”. For a family of 4, try washing hands for 20 seconds. How often? How many sinks do you need? What do you do with the towels? Who cleans the faucet handles, doors, etc.? If you are a store employee and touch things touched by others, what do you do? Wear gloves and dispose of them every hour? Every 15 minutes if there are crowds? Every day (may be too late!).

Some individuals tend to socialize with specific groups, such as religious or business. If one of their members is affected, then all members should take extra precautions. Ex: people who attended the same conference in Germany were at high risk of infection, and several likely became infected. NEJM.org. If a person attended a gathering of people with similar religious or political or whatever views, then I would at least wear a face mask to attend a meeting with these people, be extra careful when preparing food or drinks (touching glasses, utensils, etc.), wash everything more carefully, perhaps provide protecting gowns to everyone (and wash them afterwards) if risk is high, etc. (if the event cannot be cancelled).

If I was having a social event or party, I would provide surgical face masks for all attendees. This may be impractical because now I cannot buy them (normally they are inexpensive). In 2019 I bought 10 N95 masks for under $8. Similar ones sold for $3+ each in March, 2020.

I would be very careful with the distribution of glasses, plates, utensils. Be sure that nobody touches anybody’s else things. Same for clothing.

I see government officials together at public announcements. The governor or the county executive, surrounded by police chief or fire or health secretary and assistants, announce one more death or whatever, and assure us (the public, the viewers) that everything is under control, not to panic, and remember to wash hands and not get infected. I panic. It means they are not acting in my best interest. Some government officials are overweight, likely with morbidities such as T2D and CVD. They should STAY HOME, work via video. I like them. I do not want them to die or get sick. They lack the expertise to make optimal decisions. Instead, ONLY ONE person at the FEDERAL, STATE, perhaps the COUNTY level, should explain the plans, what is going on, what people can do. Surrounded by a nice background, not people. Everybody else should work at their level of competence (beware of Peter’s Principle) and implement best policies.

Infections and epidemics are NOT like the aftermath of a hurricane, where politicians rush to assure voters that they sympathize and will help them file insurance claims or get power back soon. Preventing epidemics means people DO NOT get close to each other unless they HAVE TO. I understand police or fire may need to go places. But politicians can manage most issues by phone or video.

“As long as people wash their hands thoroughly, stay home if sick, and limit contact with others who are sick, the risk to residents of contracting COVID-19 is low.”  Please, if you are a politician, don’t say that. Wash hands every 5 minutes at school, stores? It is impractical. Sick people have a sign on their eyes? Nonsense. Many people with active infection look healthy and feel well (please read professional medical journals about this). Stay home if sick is good but inadequate advice. It is important to know what to do at home to avoid infecting others. Better to say: “If you avoid the virus, the risk of COVID-19 is zero”. If you avoid bullets, guns cannot kill you. BE SAFE. Borrow clothes from Superman!

When I was in medical school, one day we have an amazingly beautiful woman with a severe infectious disease. Randomly, she was assigned to my team. I went to examine her. There was a huge crowd of males entering and leaving the room. There was no room inside. I stood there, not sure what to do. An infectious disease professor came in and gave us a “talk”. He said we were very dumb to be there, without protecting gowns and masks, etc. The odds were high one of us would die. The guys split out faster than the speed of light. He also told me to leave. The case was too complex for medical students and there was nothing I could do. If I wanted to learn, I should read the chart, IN ANOTHER ROOM, with Gloves and protective gear. Politicians, read websites about the virus, don’t talk to residents.

The stock markets crashed and people panic because they realize politicians and governments are in chaos. Government managers are unable by politics and lack of expertise in systems (e.g., operations research, logistics) to prevent the epidemic. There are too many people in “charge”, yet no one has the power to do what needs to be done. Fear of litigation and voter anger makes decisions. Every one seeks to defers to others decisions to share and transfer blame. The reason is simple: no matter what is done, thousands will be harmed and lawsuits and voter anger will follow. Severe restraints kill the economy and make people angry, particularly when the vast majority has mild disease. Loose restrictions expand the epidemic which lead to severe restraints.

Instead of providing specific solutions, such as enough masks or alternatives, a precise plan of what to clean and when, creating economic restrictions designed by math experts to minimize infections instead of closing huge areas, politicians plead for calm and claim everything is going well. And sometimes it is, because covid-2019 is a mild disease with low death rates (the flu has more deaths). It is the flawed logic of drunk drivers, most of the time nothing bad happens so they should continue to drive drunk.

Government and private industry policies to help elderly people

Anyone over 65 who must complete taxes for himself, family or small corporation should have a 60-day automatic delay. The deadlines in March and April are automatically extended to June 15 for all tax related purposes. No late filing penalties apply if tax returns filed by June 15. Other deadlines, such as 6-month extension to pay taxes, do not get extended. Payments of taxes are not changed.

The federal government strongly encourages all states to apply the same rules to all tax returns.

Anyone with covid-2019 gets the same extension. A letter signed by the taxpayer is sufficient evidence, though the taxpayer is not allowed to lie to the government. Laws exist to prevent lies and misrepresentations.

HOAs, large apartments, senior organizations, can coordinate food purchase and deliveries the same day to nearby addresses, which reduces infection risk, saves energy, could reduce delivery costs.

Running water is unlikely to be affected. Electrical power and gas will likely continue. In contrast to a hurricane, residents can stock perishable foods if they have room in their refrigerator/freezers. I store some foods in my cold garage when there is not enough room in refrigerator (such as some fruits, vegetables). NOT foods that must be kept a low temperature.

Implement massive logistics effort to identify needs, supplies to reduce outside travel.

Amazon prime and other providers of online videos reach agreements with owners and distributors to substantially increase the range of options available. For example, movies on Amazon or Netflix that expire at the end of March are kept until the end of April. Additional movies are added. Offer free trial subscriptions or heavily discounted subscriptions until the end of April, 2020.

Mail is reduced to 3 times per week. Other similar distributors (e.g., amazon prime) force deliveries together (to reduce transmission of virus).

Implement a massive production and distribution of restaurant food to prevent huge loses to restaurant industry via better deliveries with far better infection prevention. Reschedule for May or later all large-scale gatherings. Assist entities to reschedule vacations, etc.

There will be substantial economic loses, but we can create a system that reduces losses and keeps alive most of the US economy. Other countries can do the same. For example, replace foreign with local travel; shift the time for travel, etc.

Have massive retraining for future needs. Individuals unemployed (from hotels, airlines, etc.) get paid for retraining or doing other work.

All schools replace most education with online courses, online meetings, etc. (services exist, we may need to increase bandwidth, a good idea). Some entertainment, like theater, can also be replace via online transmissions.

Challenging questions for reporters and opinion-makers (satire, why some opinions are fun)

“In the wake of the coronavirus outbreak, should you cancel your trip to China?” [42]  This question now has an obvious answer, but too many people made the wrong decision to travel on cruises and elsewhere. The data available in news media, websites and professional journals pointed to a severe epidemic by early January, 2020. Yet few posed the critical questions or took the necessary actions. How many went on cruises in Jan, Feb, March, 2020? How many traveled to Europe, Asia? It is not just fun to be alive. Think the wonderful time in quarantine!

Allow me to pose more challenging questions for the Washington Post reporters to ponder for training purposes:

It is 1945. You are a reporter. You learn the US will drop the atomic bomb in Hiroshima. Should you wear a protective raincoat to be the first US reporter at the site where the bomb drops?

It is 1945. You know US and England plan to burn Dresden. You like to be the first to travel and learn about foreign countries. You want to be there when the city burns. Should you take ONE or TWO sweaters?

The Ebola virus is reported in Country AZ11. Ten people are dead, 55 infected. The number is growing. You volunteered many times to cook pizza for homeless, bake cookies for PTA meetings, etc. You want to go and help people there. Should you get infected as soon as you arrive, so they can tell if you are a survivor and not worry about it, or wait until it is dark?

The US Army is testing a new machine gun. Faster. More powerful. Bigger bullets. More per minute. They do not have experience with live people (apparently, they had difficulties finding volunteers). Should you volunteer to be in front of the machine gun for ONLY 15 minutes? If so, should you go fasting, eat ice cream before, or not? Should you stop drinking 2 hours before and then go pipi so you are relaxed? What kind of clothing you should wear? Are shoes necessary or could you use sandals. These are important questions and I feel certain the US army manuals ignored them. That is why we need enterprising reporters.

Or perhaps figure out how to ask the important questions and find answers.

Alternative policies to deal with epidemics have complex undesirable consequences, difficult to evaluate

What is the goal for prevention and government policies? What outcomes are optimized? Desirable outcomes are inconsistent. Individuals want to maximize life expectancy, minimize risk of disease or death, maximize income. Governments (society) want to maximize society’s function, economic growth, minimize death. If one allows everybody to continue life as usual, with minimal disruptions in work, transportation, etc., it means the virus will spread, probably have minor harm on most people, substantial harm 5% to 10% who may require hospitalization, and kill perhaps 1%. But the impact on the economy and lifestyles will be trivial. The economic benefits reduce stress and may improve life expectancy overall, perhaps surpassing the harm.

If one imposes severe restrictions on travel, quarantines for those at risk of being infected, the harm to the economy and lifestyle is huge. People will lose their job; companies will go bankrupt. In 2020 we expect entire industries severely disrupted or almost terminated. Cruise ships and airlines suffer huge loses, must change their business model (creating better screening for passengers, air cleaning, etc.). Schools, child care, education are severely disrupted with unknown consequences.

It is very difficult to predict the system consequences of alternative policies. Flattenthecurve.com proposes to postpone infections, instead of a huge peak over a narrow time interval, have a curve flatter, over a longer time period. This allows governments to better match resources (e.g., hospital beds, doctors) to demand, and hope for better treatments. However, it substantially extends the adverse economic consequences, it allows the virus more time to mutate and adapt to different environments and weather, so it could last all year instead of just winter. And may increase the number of infected people.

Perhaps the best strategy is to reduce unnecessary meetings and travel, replace some activities with video conferences (all good for the environment anyway), replace education with a different model (learn at home via internet, go to school as needed to solve problems, labs, etc.), strict prevention for social meetings (masks, cleaning, etc.), jobs with substantial human interaction (store cashiers, security, etc.). Create model of probability of infection and quarantine only those at substantial risk to infect others. Restructure the economy to adapt, needed anyway to protect the environment.

Should entities hold meetings? Most meetings will probably be safe. But some will spread infections. Because infected people may look and feel fine, it is impossible to predict with certainty which people and which meetings are safe and which ones spread infection. Ironically, a meeting “for senior managers at Boston-area biotech Biogen has emerged as a hotbed for novel coronavirus infections.” [43] Many meetings worldwide spread infection. In the US, meetings and activities attended by elderly people (e.g., temples, social events, political groups, etc.) spread the infection. Since these issues were known since December, and publicly since January, why were people going on cruises, scheduling and attending meetings in Feb, March? Why didn’t they implement strong prevention such as substantial face masks, gowns, cleaning, not touching, food and utensils restrictions, etc. if they wanted to have the meeting?

In March 9, 2020, the University of MD issued “COVID-19: new guidance on travel, events and preparation”. Well written, it is a model for government meetings, social events, etc. Among other things, recommends compliance with CDC and other guidelines for social distancing, means avoiding mass gatherings and maintaining distance (approximately 6 feet) from others when possible. This is difficult or impractical for events with more than 3 people, particularly events whose purpose is for people to talk or elderly individuals to meet (they would need to shout over the voices of others).

The technology exists; its use makes sense. Most higher education schools should offer, at least as an option, attendance online for most of its courses. Eventually, all courses should move online. The best teachers record the best presentations. There is no need to repeat the same concepts every year. It is best for everyone (and saves time and money).

About Mo Co and Rockville

One person was sick in a NY county. It infected many. By March 6, 2020, over 1,000 people are quarantine in a NY county.[44] Some schools are closed. More than 22 people have the virus. It could have been substantially prevented by early proper action. The majority of people will either not get infected or have a mild disease. It does not mean we should not worry about it. Almost every severe disease or death is preventable, avoidable, and we should at least reduce the risk by 50%.

If something similar happens in Mo Co, with 3 people sick, two separate “families”, we expect many cases. We can’t predict because we do not know who the people are, where they live, where they travelled in Mo Co. But the odds favor more people sick because Mo Co is more dense than New Rochelle, NY.

In Mo Co, a person who tested positive visited The Village at Rockville, Rockville, MD. [45]  [46]  This means the probability is high somebody at this place may be infected. And because of unrestricted travel and connections, several people in Rockville may be infected. It seems likely the original person got infected OUTSIDE Maryland. We must know all contacts since the person arrived to the US, all contacts within distance and time to be infected, surfaces likely to contain the virus. This information must be public, so individuals can determine their risk and start a quarantine ASAP. TRANSPARENCY is the key to prevention.

The most important mistake is not to disclose the location of those who tested positive, and the location of those in contact with them.

In Washington, DC, officials asked everyone attending a church to quarantine. They disclosed the church involved, so people knew they were at high risk of infection. In MD, officials knew a likely infected person attended meetings. They did not disclose the location of meetings, did not ask people to quarantine, even though evidence from other locations indicates the virus easily transmits via social meetings. Instead of a limited response, they caused mass buying and worries because anyone could be at substantial risk. The recommendations from CDC and the experience of other countries seems ignored. That may be good for the economy and most people who don’t get severely ill. It is bad for the elderly and myself, because, surprisingly, I do not like to get sick or die, even if it is good for the economy.[47]

I consider the Rockville area and associated public schools and business as a location with a substantial probability (risk) for infection. Until the government produces a detailed chart of at-risk areas, I would implement strong prevention measures. Concealing this information is similar to governments in Italy and China did to prevent “panic” and ended up closing most of the country.

The response in Mo Co is chaotic. I heard that at one Costco they were cleaning carts. But people did not have facemasks. I like M. Erlich. I voted for him for county executive because he seemed the candidate most likely to protect our lives and environment. Erlich is a good leader for MoCo. I spoke with him for a long time. He is intelligent, caring, nice. He does not meet my criteria for expert in epidemics. I probably saw far more people sick or dying from infections than he did. He should not speak publicly. When he speaks or I read his statements in the WashPost, I panic. I am afraid that people may pay attention to what he says because he is a senior government executive in the county. What he is saying makes me think that Mo Co has no reasonable clue about how to prevent, contain and treat an epidemic. It is time to panic and go into survival mode. Similarly, for other politicians. There are excellent websites. They should refer to them.

After I read politicians’ emails or speeches, I assume that government officials are not competent, we are going to get very lucky and have few infections, and I do not want to be infected. It is very simple. I do not want myself or my family infected and risk substantial disease with likely death of brain cells, or death. Call me naïve, think I get easily frustrated or stressed. But I do not like disease or death. It is my opinion, perhaps unique among many brilliant minds in MoCo. I know people like some football games or cheese cake. I don’t. I prefer chocolate cake. I prefer not to die.

I would implement actions very different from those implemented by County executives, Governors, federal officials. For reasons similar to why I would not let politicians do even simple appendectomies on people, or even remove a small infected mass (which I prefer be done by expert surgeons, not just any surgeon), I would not let politicians or opinion-makers treat cancer or heart disease or infections or epidemics. Sorry, nothing personal. Politicians may be great at kissing babies, giving hugs to people, approving money for more highway lanes or deciding what time schools open for different grades (but, to me, these are operations research/industrial engineering topics).

The choices were simple. Disclose the locations, travel and likely contacts of the persons sick, so those affected can take appropriate counter measures, or keep them secret. By keeping them secret, EVERYONE in Mo Co must take appropriate counter measures and there is chaos.

I read the news of 3 infected people in Mo Co on Thursday night, March 5, 2020. The next day, Friday, March 6, 2020, I found long lines at two local supermarkets. People were buying whole carts of food, cans, liquids, etc. Masks, alcohol are gone. I do not know the supply chains, but I read some stores are running out of paper towels, toilet paper, cleaning things. What would happen if we had a major epidemic like China or Spanish flu? Collapse of the US?

MD Governor, county executive, city manager decided (implicitly or explicitly) that some deaths are acceptable to maintain commerce, the economy, the lifestyles of those who do not die. We do it with many other decisions. The problem is that there is no objective analysis of a desirable death rate (politically, it is better to ignore it and not talk about it).

The government could impose strict requirements to prevent drunk driving and reduce accidents from drinking close to zero. It would be expensive, so the government proceeds with a chaotic approach based on “advice”, public pressure, special interests, whatever.

Every country, every political area prioritizes a goal over infection prevention and deaths. Even if we had a mortality of 50% that killed those in power, politicians would not make optimal decisions. Iran perhaps prioritized high voter turn-out in the Feb. 11 parliamentary elections than virus infections. “by downplaying the crisis, . . .  officials have actually managed to aggravate the public panic they wanted to avoid — and have undermined their own legitimacy in the process.” [48] (hint: does it apply to all governments?).

Whenever I hear a politician say “do not panic”, we have plans, everything is under control, I interpret it to mean that they have chaos, have few clues about what to do, they prioritize voters over deaths, and I should prepare for the worst.

I would feel better if instead of politicians speaking, I heard industrial engineers and experts in logistics who tell me they have excellent math models of product distribution. They predict enough paper towels and toilet paper in the stores, or a 20% reduction in supply (and ask us to use 20% less), face masks for all individuals at risk, or for only 20%, and others should take these precautions . . ., they have 800 kits to test for infections. People with the following SPECIFIC signs/symptoms (not just everyone with a cold or flu) should go to one of these locations (list them) to be tested. Etc. Facts, not fiction, wishful thinking, nonsense.

India advises people to maintain at least one 3 feet’s distance from anyone with a cough, fever or breathlessness (v. 6 ft in US?). [49] This is more practical that avoid sick people when it is impossible to tell (unless we conduct a medical exam, carry thermometers, etc.).

We do not have a good mathematical model that predicts infections and deaths from specific actions, and tells us if it is better to clean surfaces more often or take the temperature of every person entering a store or subway. These models are feasible and would help optimize resources, minimize unnecessary cleaning (which also has undesirable health effects), reduce fear, and make life better. It would require substantial knowledge of math and medicine, and putting in charge people with expertise.

Will Rockville, MD be lucky (warmer weather, more biotech companies, smarter people, great leaders, closer to The White House, etc.), be like Germany, or follow the path of King County, Rochelle, NY, Iran, Italy? How should government act: let what will be, will be? Close their eyes and pray? Or take extensive preventive measures?

Recent data indicates two types of virus, L and S. Has MD sent samples for identification of the type of virus? When will they know results? Why? Knowing the type if critical to decide between extensive or mild restrictions in travel, store openings, etc. Should we do like Costco in China, measuring temperature of every person entering the store, and substantial prevention/ protection inside the store? Or is it unnecessary? Or we have no clue, because America has freedom, the land of choice and equal opportunity for everyone to get infected, not like China where people are forced to measure their temperature and prevent infection. Forcing the elderly and sick to stay home may be disability discrimination. Or is it the opposite?

SARS-CoV-2 continues its rapid spread, confounding efforts by global leaders. [50] CDC recommends elderly people stay home, everywhere in US. Rockville, Mo Co, has at least one person with covid-2019. What should we do? For how long?

Consider the Timeline for Life Care Center of Kirkland, ground zero for the West Coast's covid-2019 outbreak. Feb 19, first tested positive. March 7. 13 deaths have tested positive. [51]  March 7. 70 Life Care Center employees show symptoms of coronavirus. [52]  [53]

Some patients went from having no symptoms to hospitalization and even death within a day. In about 17 days, from one positive patient to more than 70. Assuming it took 5 days for the first patient to test positive, in about 22 days went from one to more than 70.

Can we expect similar results in MD? From 3 person positive on March 6 [54] to 100+ by the end of March? It could take until March 16 before we see many additional patients with suspected covid-2019. Or are we going to be lucky?

In meantime, should people wait and not worry? Read MAD magazine (what me, worry?). Wait and take some precautions (with small probability of success)? Take substantial precautions to substantially increase probability of prevention? Implement substantial preventive measures throughout Rockville and nearby areas visited by the positive patients? Or cover most of Mo Co? Should people take random measures because they lack adequate data or should the county provide adequate data to make good assessments?

It is a risk/benefit analysis. The probability of severe disease or death is small, but it is very high for those affected!

Montgomery County Health Officer Travis Gayles said. “Officials declined to say where the three had been traveling but said they did not meet those testing guidelines.”  Uhh? Is it an excuse for not reporting data on probability of future infection?  Obviously, the testing guidelines used by Mo Co were inadequate, incorrect, wrong, not smart. Because of inappropriate guidelines, thousands of people are now at substantial risk of severe disease or death.[55]

King county did not plan properly. In March, it recommended about 2.2M people work at home; people over 60 stay indoors. [56]

Should Mo Co implement similar guidelines? When? After many deaths or before? After 3 infections, zero deaths or after 10 infections 2 deaths? Prevent or react? What is the plan? What is the decision-making algorithm? If Seatlle, WA, the home of Microsoft and high talent STEM could not make optimal decisions, can then be done in Mo Co, the home of NIH, biotech and statistics?

“The president and his aides frittered away weeks of opportunities to manage and prepare for an outbreak that has now killed thousands worldwide and is spreading in the United States” [57]  I disagree. Politicians everywhere are responsible. Mo Co leaders had far more time to prepare, more opportunities to be transparent and prevent disease. They are lucky that disease and deaths may be low, but it is not excuse. They put in danger my life. Knowing the location of infected individuals and their paths helps me determine the extent of prevention. The virus now can be in many places.

It is easy to say: wash hands, don’t touch your face, etc. It is mostly nonsense, VERY difficult to implement. If a family has children that go to school and parties, it may be difficult to stop. How often should I wash? How often clean surfaces? What places to avoid? How much protective gear to use (to avoid contact with virus in clothes or air or packages delivered or mail envelopes or etc.)?  If I know the probabilities of infection, I know better what to do.

Where is the response by the City of Rockville? Does the city have enough supply of protective equipment for all agents that contact the public frequently? To help seniors? Where is the senior advisory group? Do they have a plan to contain the flu (dangerous to seniors) and covid-2019? Why haven’t they inspected and trained retirement communities, nursing homes, etc. in Rockville?

I recently visited a retirement community for elderly people, many with substantial health problems. The staff was very friendly. They smiled. They touched things. I did not see most people wearing protective face masks or gowns. There were visitors and people walking everywhere, touching things. Some people were coughing into the open air. I did not see an appropriate plan to prevent infection. I also visited a senior center in Rockville, MD, before. People ate meals. They touch all kinds of areas: utensils, tables, chairs, etc. To me, it was a disaster of failure to prevent the flu, infectious diseases. These places should implement a radical new approach. Otherwise, if there is a serious epidemic, the death rates would be high.

Mo Co may be very lucky. The SARS-CoV-2 may be type S, milder. The weather may be warmer. The infected cases are milder. A major epidemic seems unlikely. We may have minor disease and no deaths. Or there could be another mutation, and the virus becomes more pathogenic. By the time the authorities implement better restriction models, tens of thousands of people would be infected, with over 100 severe disease or death.

I worked in hospitals and ER. I saw many drunk people who came for minor injuries or other issues. Their argument was that they could be drunk and drive without harming anyone. I disagree. The risk is too high and DUI must be prohibited. I believe in risk reduction; I do not want other people to make my life miserable or increase the risk of harm to me.

The US needs a radical change in its approach to epidemics. Change the direction of research, prevention, treatment. Focus less on vaccines. SARS-CoV-2 is not like the polio virus, where a vaccine substantially prevents it. We had the flu for years and made very limited progress to prevent or treat it, despite probably billions spent on research and vaccines.

There are many things cities like Rockville, MD, counties like Mo Co, MD, states like MD, and the Feds can do in the US.

See how Costco manages a shopping experience in China. Customers do not eat inside the store. They move quickly. They wear face masks, etc. Most of these precautions are easy and inexpensive to implement. There is no reason why they are not implemented in the US. [58]

MCPS must be prepared to close schools and conduct education via internet, such as Zoom.com (already used in other places like NY). Minimize all activities with elderly individuals or those with relevant morbidities for at least 2 weeks (if no one else is infected); longer if new cases appear.

There is a distinction between panic and incompetence, unnecessarily increasing the risk of substantial disease or death to many people. Instead of concealing essential information or telling people not to panic, provide the travel patterns of everyone infected and anyone in contact with them.

Have alternative plans. Subscribe to video services for students. Cancel gatherings of people over 60 yo. Help people over 60 yo to stay home. Plan to deliver food to the elderly for about 2 weeks.

Preventing infection, avoiding places where there are likely infected people is NOT panic. It is a reasonable, intelligent response. Ignoring reality and pretending that everything is fine is DUMB behavior.

Had I known that there were many people in Mo Co who were likely to be infected and were probably walking around, I would have implemented stronger measures. Use a mask when I went out, perhaps a whole face mask. Reduced the places I visited and go out only if necessary. Avoid going to places visited by the likely infected people.

These issues are well known. The errors in MD are the same types of errors of many other countries. They conceal information instead of taking steps to prevent infection.

Does Gov Hogan knows that he is a higher risk of death if infected? What about Erlich, who is also at higher risk of death if infected because of his age and existing conditions. Every person over 60 who is substantially overweight is likely at much higher risk of death or severe disease if infected. These facts are published in medical journals.

The Mo. County information is misleading and incomplete. To me, it reflects inadequate planning and management. We are lucky that the virus kills a small percent of the population. Otherwise, there would many deaths in MD.

The government should not allow people who are likely to be infective to mix around with the healthy population. The available tests have substantial false positive and false negatives (reported in professional articles). It means they are not decisive. People may have the disease with a negative test, and not have it with a positive test.

The people who came from OUTSIDE the US were likely to be infected (otherwise they would not be sick). Based on the location of their travel, days there, and clinical characteristics, SOMEBODY should have known they were likely to be infected. These are individuals who are at substantial risk of infection because of their age. Statistically, people of that age have morbidities, conditions that reduce the immune system and make them more likely to become infected. Further, the time from infection to clinical signs/symptoms or positive test is longer. It is possible that some of the people who tested negative may be positive later (I do not now, but a comprehensive exam would calculate the probability; there are now several published scientific articles that provide data for calculating probability of infection).

Every person who came in contact with the infected people is at risk of infection. “the three victims returned to Maryland from the same overseas trip on Feb. 20.” They have been in Mo Co for more than 10 days. Unless they took extraordinary precautions, they are likely to have been in contact with people at the airport, transportation, food, etc. These individuals may become sick soon, and may already have enough viral capacity to infect others.

The state of MD and Mo Co may be very lucky, but, based on reports from other countries, of people travelling with others while infected, the odds, the probability is substantial that they infected several other people (statistically, about 3, but it could be many more).

The authorities must take this matter more seriously. All individuals in contact with the sick individuals must be informed publicly, ASAP. The locations and travels of the infected individuals should be public. All those in contact must immediately take substantial precautions before the infection is transmitted to many others, children and the elderly. HOAs, apartment buildings, retirement homes, and places with a substantial elderly population must be informed and become more observant and ready to implement appropriate measures such as isolation, masks, cleaning of surfaces, etc.

If it is not done, MoCo and then MD and DC may face substantial expansion of the epidemic, which may then require closing schools, subways, etc. as done in other countries. Italy and Iran waited too long while telling the public not to panic.

Telling people not to panic while the government takes inappropriate and inadequate actions is not good. The appropriate response is to provide the evidence so individuals can prepare and contain the epidemic.

I disagree with the decisions and actions by the health department and the government. We should know the locations where these individuals were, and who is at substantial risk of having contracted the infection (even if it does not show yet). Those at substantial risk should quarantine or take appropriate measures NOW.

Things are bad worldwide and probably getting worse. Things are bad in the US and getting worse. Rockville has infections. Is it time to go out and mix with elderly people to reduce Medicare expenses? Tell people not to panic and continue doing what they do? Or is it time to cut risks, implement substantial infection prevention? I decided. And, judging by the long lines at Costco and elsewhere, many people decide like me, prevention is the key. Let others the opportunity to use test facilities, practice breathing on respirators, etc. Like Iran, perhaps politicians will get the opportunity they asked for.

I admit my bias. I do not like being sick. I do not like to die. I had the flu several times. I had pneumonia. I did not have fun. I did not like it. I prefer life instead of death. Why? Perhaps I like paying taxes, getting my social security payroll taxes back to me. I like smelling roses and eating my figs. I like chatting with my family. Although there are many bad movies and TV shows, there are many I like. I like eating. I like the smell of fresh, clean air. I do not like living 6 ft underground or turned into ashes. It is not my lifestyle or first choice. I do not believe that my purpose in life is to die so my soul can live forever in heaven. May be there is heaven. But they may not have a subscription to my favorite magazines. Or carry the type of dark chocolate I like. I do not know and cannot check. So, I prefer managers that fight for me to be alive, not to make my life miserable or impose unnecessary risks or restrictions in the use and enjoyment of my home and life.

References (politicians, others, refer to these websites; do not include your ideas or opinions)

https://www.cdc.gov/coronavirus/2019-ncov/index.html   Best overall. Still has ambiguities. Must read/study. Recent substantial rewrite.

https://www.flattenthecurve.com/  Good ideas, nice graphs. Supplements CDC

master link:  https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html

isolation:  https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf

hand hygiene:  https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

MUST READ for health professionals, politicians, opinion-makers. https://theconversation.com/how-big-will-the-coronavirus-epidemic-be-an-epidemiologist-updates-his-concerns-133133 .By an epidemiologist with eight years of field experience. “For an easily transmissible disease, a 2% or 3% fatality rate is extremely dangerous.”  “The infection fatality rate (IFR) gives the probability of dying for an infected person. The case fatality rate (CFR) gives the probability of dying for an infected person who is sick enough to report to a hospital or clinic. CFR is larger than IFR, because individuals who report to hospitals are typically more severely ill.” “COVID-19 is about 10 to 20 times as deadly as seasonal influenza” (about 0.5%-1%). “The virus appears to be about as contagious as influenza. But this comparison is difficult to make since we have no immunity to the new coronavirus.”.  Read the full article on The Conversation

https://health.maryland.gov/coronavirus/Pages/default.aspx\    Information about MD virus. Inadequate. Does not disclose locations.

https://theconversation.com/why-so-many-epidemics-originate-in-asia-and-africa-and-why-we-can-expect-more-131657

Why so many epidemics originate in Asia and Africa – and why we can expect more. By a virologist and associate director of the Animal Diagnostic Laboratory at Penn State University.

Useful, but I disagree with some recommendations; others are not precise enough. https://theconversation.com/what-really-works-to-keep-coronavirus-away-4-questions-answered-by-a-public-health-professional-132959. Read the full article on The Conversation.

Copyright © Edward Siguel 2020. All rights reserved.

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[1]  https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=TOC

[2]  https://www.msn.com/en-us/health/health-news/fauci-those-vulnerable-to-coronavirus-should-limit-travel-and-crowd-exposure/ar-BB10Utey?li=BBnb7Kz&ocid=mailsignout

[3]  https://towardsdatascience.com/statistics-and-unreliable-tests-coronavirus-is-difficult-to-contain-e113b5c0967c

[4]  Japan closes schools for more than 1 month. Many countries implement draconian measures. https://www.washingtonpost.com/world/2020/02/27/coronavirus-live-updates/ Feb 27, 2020.

[5]  https://www.cnn.com/2020/02/26/opinions/colleen-kraft-coronavirus-best-defense/index.html

[6]  Feb 2020 DOI: 10.1056/NEJMp2003762. https://www.nejm.org/doi/full/10.1056/NEJMp2003762?query=TOC

[7]  https://www.washingtonpost.com/history/2020/02/29/1918-flu-coronavirus-trump/

[8]  https://www.washingtonpost.com/history/2020/02/29/1918-flu-coronavirus-trump/

[9]  https://www.cnn.com/2020/01/30/health/flu-deadly-virus-15-million-infected-trnd/index.html

[10]  https://www.washingtonpost.com/health/time-for-a-reality-check-america-the-flu-is-a-much-bigger-threat-than-coronavirus-for-now/2020/01/31/46a15166-4444-11ea-b5fc-eefa848cde99_story.html

[11]  Weekly influenza report. https://www.cdc.gov/flu/weekly/index.htm#ILIActivityMap

[12]  https://time.com/5610878/2018-2019-flu-season/

[13]  https://www.wsj.com/articles/the-flu-is-hitting-children-especially-hard-this-season-11580750592?mod=hp_listc_pos3

[14]  https://abcnews.go.com/Technology/wireStory/germ-fest-party-preceded-deadly-nursing-home-outbreak-69442987

[15]  https://courses.lumenlearning.com/microbiology/chapter/characteristics-of-infectious-disease/

[16]  https://en.wikipedia.org/wiki/Infection

[17]  https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it.

[18]  https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

[19]  https://www.cnn.com/asia/live-news/coronavirus-outbreak-01-27-20-intl-hnk/index.html

[20]  https://academic.oup.com/nsr/advance-article/doi/10.1093/nsr/nwaa036/5775463?searchresult=1;  Xiaolu Tang, Changcheng Wu, Xiang Li, Yuhe Song, Xinmin Yao, Xinkai Wu, Yuange Duan, Hong Zhang, Yirong Wang, Zhaohui Qian, Jie Cui, Jian Lu, On the origin and continuing evolution of SARS-CoV-2, National Science Review, , nwaa036, https://doi.org/10.1093/nsr/nwaa036

[21]  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30260-9/fulltext; DOI:https://doi.org/10.1016/S0140-6736(20)30260-9.  Wu et al. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study

[22]  https://www.cnn.com/2020/02/17/health/novel-coronavirus-surfaces-study/?hpt=ob_blogfooterold

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

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

[25]  Principles of Viral Pathogenesis.  Michael B.A Oldstone, M. D. https://www.cell.com/fulltext/S0092-8674(00)81987-X. DOI:https://doi.org/10.1016/S0092-8674(00)81987-X

[26]  https://www.washingtonpost.com/opinions/trumps-luck-is-turning-against-him/2020/03/06/f365b982-5fdd-11ea-b29b-9db42f7803a7_story.html

[27]  https://www.washingtonpost.com/world/coronavirus-china-live-updates/2020/01/24/4e678f9c-3e03-11ea-afe2-090eb37b60b1_story.html

[28]  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30185-9/fulltext

A novel coronavirus outbreak of global health concern. Jan 24, 2020. In Dec 30, 2019, cases of rare pneumonia were reported. On Jan 11, 2020, first death. By Jan 20, 2020, cases in countries other than China. In about 30 days there was a huge increase in number of new cases, number of deaths, number of countries involved. Death rates seem below 5%. But they are enough to be a potentially HUGE problem in the US, Europe.

[29]  https://www.wsj.com/articles/u-s-hospitals-arent-ready-for-the-coronavirus-11579975968?mod=hp_opin_pos_1

[30]  https://www.cnn.com/2020/01/27/health/coronavirus-in-the-us-what-we-know-trnd/index.html

[31]  Read https://www.washingtonpost.com/world/2020/02/01/early-missteps-state-secrecy-china-likely-allowed-coronavirus-spread-farther-faster/.

[32]  https://www.wsj.com/articles/how-it-all-started-chinas-early-coronavirus-missteps-11583508932?mod=hp_lead_pos3

[33]  https://www.washingtonpost.com/health/chinese-leader-warns-of-accelerating-spread-of-deadly-coronavirus/2020/01/25/6409bc78-3f8c-11ea-baca-eb7ace0a3455_story.html

[34]  https://www.cnn.com/asia/live-news/coronavirus-outbreak-hnk-intl-01-26-20/index.html.

[35]  https://www.washingtonpost.com/health/how-the-new-coronavirus-differs-from-sars-measles-and-ebola/2020/01/23/aac6bb06-3e1b-11ea-b90d-5652806c3b3a_story.html. The coronavirus is presumed to last less.

[36]  https://www.washingtonpost.com/health/coronavirus-came-from-bats-or-possibly-pangolins-amid-acceleration-of-new-zoonotic-infections/2020/02/07/11eb7f3a-4379-11ea-b503-2b077c436617_story.html

[37]  See https://health.ny.gov/publications/7224/.

[38]  https://www.washingtonpost.com/world/2020/02/27/coronavirus-live-updates/#link-IBIYOIQVDJDRVB45PI4IFK5YSA

[39]  https://www.washingtonpost.com/opinions/2020/03/02/how-build-public-trust-face-coronavirus/

[40]  https://www.msn.com/en-us/health/medical/the-difference-between-a-surgical-mask-and-a-respirator-mask/ar-BB10KfFp?ocid=spartandhp

[41]  Ann Intern Med. 2020;doi:10.7326/M19-3075. March 3, 2020. https://www.healio.com/primary-care/vaccination/news/online/%7Bf4504ac0-609c-425b-8fab-ffbf8a3a03e4%7D/flu-vaccination-does-not-reduce-hospitalizations-death-in-older-adults?utm_source=selligent&utm_medium=email&utm_campaign=primary%20care%20news&m_bt=2786618677049

[42]  https://www.washingtonpost.com/lifestyle/travel/should-you-cancel-your-trip-to-china-heres-what-to-consider/2020/01/24/4fef6bbc-3d42-11ea-b90d-5652806c3b3a_story.html#comments-wrapper

[43]  https://www.wsj.com/articles/how-biogens-strategy-meeting-spread-coronavirus-in-massachusetts-and-beyond-11583815952?mod=hp_lead_pos3

[44]  https://www.wsj.com/articles/how-the-coronavirus-spread-from-one-patient-to-1-000-now-quarantined-in-new-york-11583423323; https://www.nytimes.com/2020/03/06/nyregion/coronavirus-new-york.html

[45]  https://www.washingtonpost.com/local/maryland-coronavirus-montgomery-county/2020/03/06/6975d6ae-5fb4-11ea-b29b-9db42f7803a7_story.html

[46]  https://health.maryland.gov/newsroom/Pages/Maryland-Department-of-Health-reports-potential-COVID-19-exposure-risk-at-The-Village-at-Rockville.aspx

[47]  Authorities in the Washington area took different approaches Monday as they scrambled to stop the spread of the novel coronavirus: D.C. officials asked hundreds of churchgoers to self-quarantine, while officials in Maryland and Virginia said cases within their borders did not require such measures. https://www.washingtonpost.com/local/dc-virus-christ-church-quarantine/2020/03/09/17567796-61fa-11ea-845d-e35b0234b136_story.html

[48]  See https://www.washingtonpost.com/opinions/2020/03/07/irans-response-coronavirus-is-just-making-everything-worse/

[49]  https://www.washingtonpost.com/world/2020/03/10/coronavirus-live-updates/#link-MJAX5O6Y5NA2FOTOAIW3ZROYLE

[50]  Wash Post headline March 8, 2020. https://www.washingtonpost.com/health/2020/03/07/coronavirus-continues-its-rapid-spread-confounding-efforts-by-global-leaders/

[51]  https://www.cnn.com/asia/live-news/coronavirus-outbreak-03-07-20-intl-hnk/h_8a27a2ac866a23a8dfdbc32dd032d404

[52]  https://www.cnn.com/asia/live-news/coronavirus-outbreak-03-07-20-intl-hnk/h_8a27a2ac866a23a8dfdbc32dd032d404

[53]  https://www.nbcnews.com/news/us-news/13-deaths-seattle-area-care-facility-connected-coronavirus-n1152306

[54]  3 cases of covid-2019 in Mo Co. https://www.washingtonpost.com/local/md-politics/maryland-confirms-three-cases-of-coronavirus/2020/03/05/687def10-5f3d-11ea-b014-4fafa866bb81_story.html

[55]  https://www.washingtonpost.com/local/maryland-coronavirus-montgomery-county/2020/03/06/6975d6ae-5fb4-11ea-b29b-9db42f7803a7_story.html

[56]  https://www.msn.com/en-us/health/medical/washington-coronavirus-39-cases-in-king-snohomish-10-deaths/ar-BB10KwTK

[57]  reports the W post. https://www.washingtonpost.com/politics/trump-coronavirus-response-squandered-time/2020/03/07/5c47d3d0-5fcb-11ea-9055-5fa12981bbbf_story.html

[58]  https://www.cnn.com/videos/business/2020/03/06/china-coronavirus-covid-19-shanghai-costco-shopping-culver-pkg-intl-hnk-vpx.cnn/video/playlists/stories-worth-watching/ https://www.cnn.com/videos/business/2020/03/06/china-coronavirus-covid-19-shanghai-costco-shopping-culver-pkg-intl-hnk-vpx.cnn/video/playlists/stories-worth-watching/