6 ms·

Co-morbidities certainly have an impact on outcomes and explains why the IFR is much worse in certain parts of the world but IMHO it doesn't fully explain the m

by lhl 6y ago

Co-morbidities certainly have an impact on outcomes and explains why the IFR is much worse in certain parts of the world but IMHO it doesn't fully explain the magnitude lower attack rate/spread (50-100X worse in the US). That's still a mystery for which there are many plausible contributors, but I don't think it's so easy to just say it's obesity. In the US, this n=5700 NYC study showed 41.7% were obese [1] (not so different from the current US adult obesity rate is currently of about 42% [2]). Note that age is actually the most reliable predictor for hospitalization and death with COVID-19 [3][4] although you can make more accurate estimates with some other factors as well [5]. Note, based on the age-stratified pyramids, Japan's expected IFR sits right at the top [6], so even if you discount the undercounting of hospitalizations and deaths, there's still a huge disparity to make up. BTW, your argument on flu outbreaks actually lends credence that the mask mitigations have been extremely effective. Here's a recent NHK report on the flu numbers this year [7]: - "The number of patients with seasonal flu in Japan was below 100 during the first seven days of February. That's far below the levels seen before. ... Usually, seasonal flu peaks at this time of year, with the number of flu patients per week ranging between 100,000 and 200,000 people." Flu cases are 1000-2000X less than normal. I'm in Tokyo myself and paying close attention to how people are behaving (and comparing it to the footage and media I'm seeing from the US and other countries) and there's a huge difference in behavior from what I've seen over this past year. If you're disappointed by how the general population behaves here, I suspect you'd be horrified/stupefied by what's going on in the rest of the world. My conclusion is that on a population/public health level, it actually doesn't take all that much effort to contain the spread of the virus (elimination is much harder, although several countries have shown that it can be done, and have reaped the economic & social benefits of doing so). [1] Richardson, Safiya, Jamie S. Hirsch, Mangala Narasimhan, James M. Crawford, Thomas McGinn, Karina W. Davidson, and the Northwell COVID-19 Research Consortium, et al. “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.” JAMA 323, no. 20 (May 26, 2020): 2052. https://doi.org/10.1001/jama.2020.6775 https://doi.org/10.1001/jama.2020.6775. [2] https://www.cdc.gov/obesity/data/adult.html https://www.cdc.gov/obesity/data/adult.html [3] O’Driscoll, Megan, Gabriel Ribeiro Dos Santos, Lin Wang, Derek A. T. Cummings, Andrew S. Azman, Juliette Paireau, Arnaud Fontanet, Simon Cauchemez, and Henrik Salje. “Age-Specific Mortality and Immunity Patterns of SARS-CoV-2.” Nature 590, no. 7844 (February 2021): 140–45. https://doi.org/10.1038/s41586-020-2918-0 https://doi.org/10.1038/s41586-020-2918-0. [4] Levin, Andrew T., William P. Hanage, Nana Owusu-Boaitey, Kensington B. Cochran, Seamus P. Walsh, and Gideon Meyerowitz-Katz. “Assessing the Age Specificity of Infection Fatality Rates for COVID-19: Systematic Review, Meta-Analysis, and Public Policy Implications.” European Journal of Epidemiology 35, no. 12 (December 1, 2020): 1123–38. https://doi.org/10.1007/s10654-020-00698-1 https://doi.org/10.1007/s10654-020-00698-1. [5] Ghisolfi, Selene, Ingvild Almås, Justin C Sandefur, Tillman von Carnap, Jesse Heitner, and Tessa Bold. “Predicted COVID-19 Fatality Rates Based on Age, Sex, Comorbidities and Health System Capacity.” BMJ Global Health 5, no. 9 (September 9, 2020). https://doi.org/10.1136/bmjgh-2020-003094 https://doi.org/10.1136/bmjgh-2020-003094. [6] https://github.com/mbevand/covid19-age-stratified-ifr#age-stratified-ifr-applied-to-countries-population-pyramids https://github.com/mbevand/covid19-age-stratified-ifr#age-st... [7] https://www3.nhk.or.jp/nhkworld/en/news/20210215_26/ https://www3.nhk.or.jp/nhkworld/en/news/20210215_26/

brigandish 6y ago
> If you're disappointed by how the general population behaves here, I suspect you'd be horrified/stupefied by what's going on in the rest of the world You definitely have a point there (and that's not to say you don't have a point in the rest of what you wrote, some very interesting stuff, before I get lost on a tangent…) as I've not left Japan during the pandemic, making a good comparison is that bit more difficult. I certainly wouldn't deny there are many factors at play, though if I were going to bet on the major factors and their order of importance (which is hugely simplistic but lists are fun): 1. age (obviously) 2. weight 3. vitamin D levels 4. hand hygiene 5. limiting contact / social distance I can't say that I'd be impressed at Japan's attack on (4) and (5) but (2) and (3) seem like very strong buffers for the virus and/or disease. I'll be interested to see what comes out in the wash but I'm expecting it to take years, at least, if only because of political considerations. > BTW, your argument on flu outbreaks actually lends credence that the mask mitigations have been extremely effective. I do wonder if it's more the case that people feeling sick are sent home or don't come to work at all? Certainly it's happening far more often than in the past (as an aside, my wife's friend had a stroke while at work, continued working, and the next morning still rang into work to excuse herself, while partly paralysed and increasingly losing motor function… and wasn't believed and told to come in!). That and all the temperature checking could improve matters from other years. Again, it needs research. The part of me that likes dark humour would muse that bringing real sick days to Japan and the end of the hanko might justify releasing the virus from the lab it was created in…
- lhl 6y ago
  I agree that it will take a while to get non "hot takes" but in the meantime, agree that speculation can be fun. I'd previously spent a lot of time in Japan visiting, but this past year has been my first really "living" here so it's been a bit eye-opening to see first-hand some of the extreme dichotomies of bureaucratic competence/incompetence during this period. I have a few theories of my own on Japan's low numbers: * There's probably consistently an undercount (in my head, I just multiply the daily numbers by 5-10X), but not much more than that as we saw in Dec-Jan that a true spike will be reflected by hospital overflows (https://www.stopcovid19.jp/ https://www.stopcovid19.jp/ has been my go-to for tracking hospitalization numbers). There's some finagling of the death toll as well (COVID-19 deaths reported as pneumonia) but I think we'll get a true accounting eventually with excess mortality modeling (offset by much lower flu) that won't be so far off to matter. [1][2] Overall, somehow, the numbers really have been pretty low. This is corroborated by most seroprevalence research. [3][4] * There seems to have been a lot more spread amongst young people in Tokyo/Osaka, especially over the summer but it seems to be fairly well contained - I think that metabolic health does play a big role there in why there wasn't a big spike in serious cases (obesity, and maybe more importantly, hypovitaminosis D is significantly lower in Japan). As to why it didn't spread beyond that group like most other places, I believe that the lower rate of shared housing is likely a big factor - single person households makes up an amazing (and still increasing) 35% of the population. Anecdotally, there seems to have been a conscious decision by many people to not see older family members to put them at risk, and there's been some interesting (but not conclusive) research on Japanese lockdown behaviors that seem to differ a bit from what I've seen in the West. [5][6] * While there are exceptions, again, totally anecdotally, I've seen a huge decrease in people publicly coughing, sneezing etc and when there have been people coughing in public, generally people were well, avoiding them like they had the plague. In any case, I think an early focus on ventilation and near universal masking was pretty successful in significantly lowering casual spread. * One thing that hasn't been reported much, but Bromhexine and Ambroxol are both very common OTC cold medicines in Japan. These are TMPRSS2 inhibitors, blocking the primary entry path for the SARS-CoV-2 virus (the secondary path, endosomal entry, can be blocked by Nitazoxanide or Niclosamide). It's quite possible that in Japan, people have been unknowingly taking medicine that has been effective in moderating COVID-19 severity (this to me, seems more likely than any proposed variolation effect).[7] To me, one of the frustrating things over the past few months is that there's been enough research pointing towards many low-risk prophylactics/treatments that are probably effective for preventing severe COVID that have been pretty largely ignored. [1] Yorifuji, Takashi, Naomi Matsumoto, and Soshi Takao. “Excess All-Cause Mortality During the COVID-19 Outbreak in Japan.” Journal of Epidemiology 31, no. 1 (January 5, 2021): 90–92. https://doi.org/10.2188/jea.JE20200492 https://doi.org/10.2188/jea.JE20200492. [2] Kurita, Junko, Tamie Sugawara, Yoshiyuki Sugishita, and Yasushi Ohkusa. “Excess Mortality Probably Due to COVID-19 in Tokyo, Japan in August and September, 2020.” MedRxiv, February 9, 2021, 2020.07.09.20143164. https://doi.org/10.1101/2020.07.09.20143164 https://doi.org/10.1101/2020.07.09.20143164. [3] Yoshiyama, Takashi, Yasuki Saito, Kunitsugu Masuda, Yoshiko Nakanishi, Yasutoshi Kido, Kazuhiro Uchimura, Satoshi Mitarai, et al. “Prevalence of SARS-CoV-2–Specific Antibodies, Japan, June 2020 - Volume 27, Number 2—February 2021 - Emerging Infectious Diseases Journal - CDC.” Accessed March 11, 2021. https://doi.org/10.3201/eid2702.204088 https://doi.org/10.3201/eid2702.204088. [4] Tanaka, Akihito, Shohei Yamamoto, Kengo Miyo, Tetsuya Mizoue, Kenji Maeda, Wataru Sugiura, Hiroaki Mitsuya, Haruhito Sugiyama, and Norio Ohmagari. “Seroprevalence of Antibodies against SARS-CoV-2 in a Large National Hospital and Affiliated Facility in Tokyo, Japan.” The Journal of Infection. Accessed March 11, 2021. https://doi.org/10.1016/j.jinf.2021.01.010 https://doi.org/10.1016/j.jinf.2021.01.010. [5] CARF:Center for Advanced Research in Finance. “Japan’s Voluntary Lockdown.” https://www.carf.e.u-tokyo.ac.jp/en/research/5603/ https://www.carf.e.u-tokyo.ac.jp/en/research/5603/. [6] Muto, Kaori, Isamu Yamamoto, Miwako Nagasu, Mikihito Tanaka, and Koji Wada. “Japanese Citizens’ Behavioral Changes and Preparedness against COVID-19: An Online Survey during the Early Phase of the Pandemic.” PLOS ONE 15, no. 6 (June 11, 2020): e0234292. https://doi.org/10.1371/journal.pone.0234292 https://doi.org/10.1371/journal.pone.0234292. [7] Gandhi, Monica, and George W. Rutherford. “Facial Masking for Covid-19 — Potential for ‘Variolation’ as We Await a Vaccine.” New England Journal of Medicine 383, no. 18 (October 29, 2020): e101. https://doi.org/10.1056/NEJMp2026913 https://doi.org/10.1056/NEJMp2026913.

by lhl 6y ago

brigandish 6y ago

> If you're disappointed by how the general population behaves here, I suspect you'd be horrified/stupefied by what's going on in the rest of the world You definitely have a point there (and that's not to say you don't have a point in the rest of what you wrote, some very interesting stuff, before I get lost on a tangent…) as I've not left Japan during the pandemic, making a good comparison is that bit more difficult. I certainly wouldn't deny there are many factors at play, though if I were going to bet on the major factors and their order of importance (which is hugely simplistic but lists are fun): 1. age (obviously) 2. weight 3. vitamin D levels 4. hand hygiene 5. limiting contact / social distance I can't say that I'd be impressed at Japan's attack on (4) and (5) but (2) and (3) seem like very strong buffers for the virus and/or disease. I'll be interested to see what comes out in the wash but I'm expecting it to take years, at least, if only because of political considerations. > BTW, your argument on flu outbreaks actually lends credence that the mask mitigations have been extremely effective. I do wonder if it's more the case that people feeling sick are sent home or don't come to work at all? Certainly it's happening far more often than in the past (as an aside, my wife's friend had a stroke while at work, continued working, and the next morning still rang into work to excuse herself, while partly paralysed and increasingly losing motor function… and wasn't believed and told to come in!). That and all the temperature checking could improve matters from other years. Again, it needs research. The part of me that likes dark humour would muse that bringing real sick days to Japan and the end of the hanko might justify releasing the virus from the lab it was created in…

lhl 6y ago
I agree that it will take a while to get non "hot takes" but in the meantime, agree that speculation can be fun. I'd previously spent a lot of time in Japan visiting, but this past year has been my first really "living" here so it's been a bit eye-opening to see first-hand some of the extreme dichotomies of bureaucratic competence/incompetence during this period. I have a few theories of my own on Japan's low numbers: * There's probably consistently an undercount (in my head, I just multiply the daily numbers by 5-10X), but not much more than that as we saw in Dec-Jan that a true spike will be reflected by hospital overflows (https://www.stopcovid19.jp/ https://www.stopcovid19.jp/ has been my go-to for tracking hospitalization numbers). There's some finagling of the death toll as well (COVID-19 deaths reported as pneumonia) but I think we'll get a true accounting eventually with excess mortality modeling (offset by much lower flu) that won't be so far off to matter. [1][2] Overall, somehow, the numbers really have been pretty low. This is corroborated by most seroprevalence research. [3][4] * There seems to have been a lot more spread amongst young people in Tokyo/Osaka, especially over the summer but it seems to be fairly well contained - I think that metabolic health does play a big role there in why there wasn't a big spike in serious cases (obesity, and maybe more importantly, hypovitaminosis D is significantly lower in Japan). As to why it didn't spread beyond that group like most other places, I believe that the lower rate of shared housing is likely a big factor - single person households makes up an amazing (and still increasing) 35% of the population. Anecdotally, there seems to have been a conscious decision by many people to not see older family members to put them at risk, and there's been some interesting (but not conclusive) research on Japanese lockdown behaviors that seem to differ a bit from what I've seen in the West. [5][6] * While there are exceptions, again, totally anecdotally, I've seen a huge decrease in people publicly coughing, sneezing etc and when there have been people coughing in public, generally people were well, avoiding them like they had the plague. In any case, I think an early focus on ventilation and near universal masking was pretty successful in significantly lowering casual spread. * One thing that hasn't been reported much, but Bromhexine and Ambroxol are both very common OTC cold medicines in Japan. These are TMPRSS2 inhibitors, blocking the primary entry path for the SARS-CoV-2 virus (the secondary path, endosomal entry, can be blocked by Nitazoxanide or Niclosamide). It's quite possible that in Japan, people have been unknowingly taking medicine that has been effective in moderating COVID-19 severity (this to me, seems more likely than any proposed variolation effect).[7] To me, one of the frustrating things over the past few months is that there's been enough research pointing towards many low-risk prophylactics/treatments that are probably effective for preventing severe COVID that have been pretty largely ignored. [1] Yorifuji, Takashi, Naomi Matsumoto, and Soshi Takao. “Excess All-Cause Mortality During the COVID-19 Outbreak in Japan.” Journal of Epidemiology 31, no. 1 (January 5, 2021): 90–92. https://doi.org/10.2188/jea.JE20200492 https://doi.org/10.2188/jea.JE20200492. [2] Kurita, Junko, Tamie Sugawara, Yoshiyuki Sugishita, and Yasushi Ohkusa. “Excess Mortality Probably Due to COVID-19 in Tokyo, Japan in August and September, 2020.” MedRxiv, February 9, 2021, 2020.07.09.20143164. https://doi.org/10.1101/2020.07.09.20143164 https://doi.org/10.1101/2020.07.09.20143164. [3] Yoshiyama, Takashi, Yasuki Saito, Kunitsugu Masuda, Yoshiko Nakanishi, Yasutoshi Kido, Kazuhiro Uchimura, Satoshi Mitarai, et al. “Prevalence of SARS-CoV-2–Specific Antibodies, Japan, June 2020 - Volume 27, Number 2—February 2021 - Emerging Infectious Diseases Journal - CDC.” Accessed March 11, 2021. https://doi.org/10.3201/eid2702.204088 https://doi.org/10.3201/eid2702.204088. [4] Tanaka, Akihito, Shohei Yamamoto, Kengo Miyo, Tetsuya Mizoue, Kenji Maeda, Wataru Sugiura, Hiroaki Mitsuya, Haruhito Sugiyama, and Norio Ohmagari. “Seroprevalence of Antibodies against SARS-CoV-2 in a Large National Hospital and Affiliated Facility in Tokyo, Japan.” The Journal of Infection. Accessed March 11, 2021. https://doi.org/10.1016/j.jinf.2021.01.010 https://doi.org/10.1016/j.jinf.2021.01.010. [5] CARF:Center for Advanced Research in Finance. “Japan’s Voluntary Lockdown.” https://www.carf.e.u-tokyo.ac.jp/en/research/5603/ https://www.carf.e.u-tokyo.ac.jp/en/research/5603/. [6] Muto, Kaori, Isamu Yamamoto, Miwako Nagasu, Mikihito Tanaka, and Koji Wada. “Japanese Citizens’ Behavioral Changes and Preparedness against COVID-19: An Online Survey during the Early Phase of the Pandemic.” PLOS ONE 15, no. 6 (June 11, 2020): e0234292. https://doi.org/10.1371/journal.pone.0234292 https://doi.org/10.1371/journal.pone.0234292. [7] Gandhi, Monica, and George W. Rutherford. “Facial Masking for Covid-19 — Potential for ‘Variolation’ as We Await a Vaccine.” New England Journal of Medicine 383, no. 18 (October 29, 2020): e101. https://doi.org/10.1056/NEJMp2026913 https://doi.org/10.1056/NEJMp2026913.