COVID-19 Update, 1246 GMT, 23 March 2020

The country-by-country report from the battleground of COVID-19.

In a previous blog on my website ( I described a proprietary toll I developed to provide a snapshot, a single moment in time, in the status of this battle. Based on how China and South Korea were able to declare victory (although pockets of fighting continue) the Days to a Ten-Fold Growth in case number (DTFG) is a predictive tool as to whom is winning. I have color coded the chart below and given the definition of each scoring possibility. Countries have four conditions: human victory, humans winning, a virus-human stalemate, and virus winning. I saw no reason to have a category of virus victory, at this time.

The scoreboard as of the time above:

Two countries have declared victory and two countries are winning.

There is a group of nine countries in which the virus and the humans are at a stalemate. Now, while it is always better to be winning, a stalemate is a good thing because, in almost all cases, the virus starts out on offensive, gets the ball first, and spends a week or two winning, moving the case number up quickly, marching down the field. So in American football terms, a stalemate is when the forward progress of the virus has been stopped and the virus has to kick on fourth down.

I welcome my international friends and colleagues to provide soccer or rugby analogies.


Also, not all stalemates are created equal. Sweden with a stalemate at about 1900 cases and Spain with a stalemate at over 33,000 are VERY different public health resource problems and disruption of life issues. The way to think about it is, with a stalemate, you will have a two-fold to four-fold increase in cases from where you are before you can declare victory. But this example is a difference of tens of thousands of cases.

A ‘good news first’ observation.

A short two weeks ago (Mar 7) over 95% of all cases in the world were in four countries: China, South Korea, Iran, and Italy. For many complex reasons, the medical response and societal response of each country differed. And of course one cannot look to the future without pausing to contemplate the devastation these four countries have experienced. But the good news is that, at least at the present time, all four of these countries are either winning or have declared victory. And because they got there by ‘different histories’ there seems to be a ‘yet to be understood’ factor that ends up putting a brake on absolute, exponential growth.

Now the bad news.

In five countries the virus is winning. In four of those the case number is low. This is like a team scoring on the first possession of the ball. If these countries can get to a DTFG above 10 in the next few days, they may end up looking like Switzerland or the UK. I think their window to end up like Sweden has passed.

But the US stands out for several reasons:

  1. It is at a DTFG of 8.5, the virus is winning, and it is not on the edge of 10, where the stalemate begins.
  2. It is over thirty-three thousand cases.
  3. When Italy was where the US is now, at roughly thirty-five thousand cases, they had a 13% 24 hour increase in cases; the US just had a 24 hour increase of 39%.
  4. The US is the first country in the world to have both more than thirty thousand cases and to have cases growing this fast.

The US trend line makes it impossible to know where it will level off but it is highly likely it will be above China’s eighty thousand cases.

Why is this happening in the US?

In a future blog I will lay out the data so you can make your own assessment but my conclusion is that there are three critical factors to change the dynamic to humans winning in this pandemic: frontier control to isolate pockets of cases and keep them from spreading (<10% of cases in China were outside the frontier lockdown of Hubei province, where Wuhan is located); shelter-in-place or social distancing to slow local spread (in Wuhan, <1% of the local population became infected); and virus testing to quickly find cases. Of these, virus testing is the least important.

Symptoms appear at five days, the virus test cannot pick up an infection before three days, and so spreading will occur during the symptom-free period in most patients or at any time in the one in five who have no symptoms (and when tested are equivocally positive) but can spread the disease.

Social distancing and frontier control, lock down, are what determine success.

The Twitter version of testing is: in a society that has universal symptom-based virus testing but the population are free-range humans, the virus will always win.

About Dr. Quay

Steven Quay is the CEO of Atossa Therapeutics Inc. (Nasdaq:ATOS), a clinical-stage biopharmaceutical company developing novel therapeutics for breast cancer and COVID-19. He received his M.D. and Ph.D. from The University of Michigan, was a postdoctoral fellow in the Chemistry Department at MIT with Nobel Laureate H. Gobind Khorana, a resident at the Harvard-MGH Hospital, and spent almost a decade on the faculty of Stanford University School of Medicine. A TEDx talk he delivered on breast cancer prevention has been viewed over 200,000 times. His 300+ contributions to medicine have been cited over 9,900 times, placing him in the top 1% of scientists worldwide. He holds 87 US patents and has invented seven FDA-approved pharmaceuticals which have helped over 80 million people.

The COVID-19 HOPE Clinical Trial​