Wednesday, 23 September 2020

Second Wave time?

SUMMARY

  • Summer testing and tracing has not prevented COVID19 from spreading.
  • COVID19 positive tests has been accelerated by the new school and university terms with the usual associated epidemic of respiratory symptoms
  • There is a real danger that the ability of hospitals to care for patients and schools to function is being compromised by the over-promising and under-provision of testing 
  • This is is not a second wave as the first wave was defined by hospital admissions, this spike by increased positive tests.
  • A second wave is likely, but there are reasons why is will not be as bad
  • Threats of a national lockdown are not helpful. Last time our reaction was too little too late, now it might well be too much too early.

Introduction

Well, all matters pandemic are moving along quickly and we have barely entered Autumn. I'm sure for many the coronavirus news is very depressing. After such a difficult year, are six more months of restrictions going to solve more problems than they create?

Increase measures have been announced by Boris Johnson and in Scotland you are not even allowed to visit friends in another house. The air is full of threats of worse and the measures are applied across all areas despite the local nature of outbreaks. Worse, the changes have been applied without proper parliamentary scrutiny, and for six months. 

Fears are increased by the fact that the virus seems to be spreading rapidly. This means our  summer scheme of testing and tracing, isolation and local lockdowns have not done what they aspired to do. The virus is behaving like the seasonal virus it is. It seems we have been out-thought by a virus that cannot think. Its simple task, to replicate and spread has seemingly overcome our high tech, scientifically advanced, complex, collective ability to respond. All those sacrifices in the summer have come to nothing.

It might also be the case that the technology available has outstripped our ability to use it sensibly and our Victorian political processes have been found wanting. There seems to be cycles of problems and promises, problems and promises....

However this is a novel situation and far less predictable than we might think. Mass testing, despite its lack of effect, has changed everything in terms of perception. 

Imagine for a moment if this testing technology was not available - COVID19 would be, right now, on the inside pages of the newspapers, and way down the list of threats to humanity. 

There are of course genuine concerns about increasing cases attending hospital, (134 today), nonetheless cases and thankfully deaths remain low (sadly, 37 today). Of course this might change, the virus is highly evolved to infect and spread, and right now, it seems to be on top.

So what is happening?

The return of youngsters to school (particularly large schools and universities) is an epidemiological phenomenon which heralds the rapid spreading of colds and flu, coughs and sneezes. I remember it clearly heralding the end of the quiet phase (if such a thing exists) in general practice. It is as predictable as Christmas. 

Atchoo!
The wave of respiratory symptoms combined with the rules for testing have created chaos for schools, families, employers and, the functioning of the NHS.

Children with symptoms need to be tested to get back to school, so the testing and tracing system has been swamped by affected children, their families and contacts trying to get their lives back on line with what is, in 98% of tests a negative result. The more testing you do, the more tracing is needed, so the system is grinding to a halt, meaning more blunderbuss measures released from the grouse shooters running Westminster.

Whole school years are being sent home for a fortnight after a single positive test affecting a child with minor symptoms. Millions of children will have their education fragmented and this will affect those who need it the most. 

Remember too that the PCR tests are very sensitive and can pick up the genetic signal from a single virus. The larger the number of tests done, the more the false positives which can have huge consequences for families as well as the running of education and hospitals.

Similarly the NHS is struggling due to similar absentee staff waiting at home for a negative test to allow them to get back to the work of trying to clear the backlog of work accumulated since spring as well as new cases of COVID19.

Our over-centralised, privatised system of testing, operated by poorly performing private companies and their many sub-contractors are staffed with people with no clinical skills following online algorithms. This result is bizarre advice including driving for hours to get a tested in infection hot spots. Answer - operation Moonshot - more on this later.

Fundamentally, many with infections have not been tested, either failing tor report symptoms, or because they have none. ONS results suggest that for everyone coming forward for testing, 5 people with infections are not. So contacts have not been properly traced, and the system has failed. The solution to this is operation Moonshot, an attempt to fly before we can walk.

What I think of when I
imagine Operation
Moonshot!


We now paying the price for the lack of integration of new services with tried and tested NHS public health teams and primary care. 

This is what chaos looks like, but it is likely to get worse as the weather cools, people spend more time indoors, and the air dries. Viruses like all that. 

What they also like is modern society -  busy airports and lots of travel, large schools with big catchment areas, teeming cities with polluted air and town sized hospitals. Many people come into contact with many people in so many different ways, the virus spreads and this leads to what is increasingly being called the second wave.

The "Second Wave"

The upshot of this testing is what is commonly termed a "second wave" and the graph show this clearly.  

 POSITIVE TESTS - A SECOND WAVE?

However the first wave on the left comprised hospital cases and the current peak on the right  total positive tests only. So its chalk and cheese, as I have blogged before, a confusion of what comprises a "case".  This particular graph means little.

In terms of hospital admissions, (or deaths) there really is no second wave at all as yet.

 ADMISSIONS - NO SECOND WAVE!

It may be that there will be a lag between viral spread and subsequent illness. We might be in for a bigger caseload as we are are barely into autumn as opposed to the first wave which started at the end of winter. I just wonder how this graph will look in a few months? I'm afraid there is lots of time to go. 

In France, there are now 750 COVID19 cases on ITU compared to a maximum of 7000 in the Spring and a low of 370 two months ago. Cases there have been steadily increasing and might be the start of a genuine second wave, but this is not certain.

In Spain, a closer look at the regions suggest that the wave in many of the regions is past its peak, suggesting that what is happening is comprised of many local outbreaks which need local management and are in decline.

In Sweden, whose initial management did not feature the use of face masks and shutting down of the hospitality sector, there has been little happening in terms of COVID 19. Cases and deaths remain low. 

Here, it's so far so bad. The testing and tracing performed over the summer may well have been pretty much a frustrating waste of time, as clinical problems from COVID19 were few in the warm season, just like any other seasonal virus and now it is spreading with seeming impunity. So its all bad news then? No, read on.........

Is a second wave just a matter of time?

Extrapolating the present trend to the future is tempting, but we have to remember the terrible predictions made in the Spring - 500,000 deaths were predicted, and this was out by a factor of 10. The Government, usually so reluctant to manage public health risks, from our dreadful food, polluted air and climate change, now seem to have become entirely risk-averse. The worst case scenario proved simply wrong last time, but is again driving policy.

There are many reasons why things might be different this time:

A different Influenza season. Interestingly we seem to have seems to have more or less abolished the flu season in the overwintering nations of the south. This is despite some very different approaches to restrictions.  This would be really helpful if it applies to the north this winter. Deaths in Australia have plummeted from an average of 130 to just one, and cases from the usual 86,000 to just 627. That is pretty amazing! With flu killing 300-650,000 people a year globally, this is a welcome respite.

Given that flu causes an average of 11,000 deaths a year in the UK, such reductions would certainly offset the overall number of winter deaths from COVID19.

Changes in behaviour.  The significant effect on flu suggests that behaviour makes a big difference to viral spread. Is it the more widespread wearing a masks in public places, or the fear of COVID19 causing isolation of anyone with any respiratory symptoms, or more simple measures of less hugging kissing and more distancing?  However, the reduction in flu rates in so many southern countries with so many different approaches suggests that government action may not be the key factor. 

Better Herd immunity -  herd immunity has increased, not only through the production of antibodies but also T cells and other 'front line' defences, doing and remembering their work. They only reason they feature so little in our decision making is that they are difficult to measure. This important aspect of innate immunity is why so many people with infections have so few symptoms and means that many people are immune to the virus and are less  spread it to family members. 

Vitamin D levels are currently higher than the were in the spring, and the glorious September till now will have helped - a little. However our levels will be now be dipping as the sun lowers in the sky and UV levels drop. More on this later, but the best evidence shows Vitamin D can reduce your risk of severe COVID19 significantly. Not to be taking 4-5000iu daily is missing a big opportunity to reduce your risk from COVID19 despite the governments startling silence. 

Better preparedness. Last year the first wave arrived at our hospitals with no public preparation and short warning for the health sector. The respiratory distress caused by the virus was novel and there was much learning to be done. Hospitals and care homes are now well equipped and experienced. Any significant outbreaks in care homes are simply inexcusable. 

Better management and treatment. If you do get infected, and develop the disease, then there is good news too. We now know so much more about the virus and how it operates. Its management and treatment are far better and ITU admissions and ventilation will be reduced by better understanding of what the virus actually does when we are infected, so the least invasive most effective treatments will be given. Steroids are helpful here and novel drugs are still being investigated, more on this soon. 

Vaccines are irrelevant at this point in time. By the time they are available we will be coming out of the winter and know far more that we do now. They might well stamp on the tail of the pandemic later. 

It would be wonderful to have a crystal ball. We might be in for something far worse than last winter, or it the inevitable second wave might be much smaller, it is just so hard to say. Much is drive by what you want to believe and how we see things more generally. 

My hope is for a smaller wave for the reasons I have laid out. There are some who think we have arrived at herd immunity already. I think we are further down the road than Government seems to think. In any case, severely restricting life right now seems to be just a little early to me.  We shall soon find out.

We clearly need more powerful local authorities to manage local situations and we need a healthier population. 

We shall soon find out. Whatever happens over the next decisive month, are you ready for the worst case scenario as possible? 

Are you ready?

Despite the chaos and recurrent fiascos in the UK in particular, and the uncertainties, we have to think of our own state of readiness should the pandemic take hold. 

I shall post on this shortly, but now is the time to stop smoking, improve the quality of the diet, lose weight, increase activity and exercise and ensure you have enough Vitamin D on board. For those with medical conditions, is your management as good as it can be? For those at particular risk, have you a pulse oximeter? 

Now is the time for whatever fine-tuning we can put in place.

Final word

That we have been laid low by what might be seen as the 'lowest' form of life is humbling. We need to be humble. The tragedy of the modern world is not COVID19 unleashes, but the reasons behind its arrival. 

I personally felt unable to watch Attenborough's look at the extinction of wildlife, but Im aware that he laid out clearly that our treatment of the planet in which we live has caused immense and ongoing suffering for wildlife and has led to COVID19.

As the remnants of the natural world are further compressed into what is left of their environments, ecologies break down and we come into contact with new pathogens. With all due respect to the suffering and loss it has caused, with COVID19 we have been lucky. The mortality rate could have been far higher if we had no immunity to it at all. 

There are many other pathogens waiting, mutating, jumping hosts, and further spillover is inevitable. This is not withstanding the pathological farming methods themselves destroying the environment and providing the conditions in teeming chicken and pig factories for mutation and spillover of new strains of influenza, many of which will be deadly.

The relatively comfortable post war era in which I have led my life is over. 






2 comments:

  1. thanks for taking the time to express your thoughts, I expect you heard on pm this evening the piece of kit developed at Oxford and able to inspect 20k samples a day. Things like this and our response move fast when there are so many billion of us sometimes for the better sometimes for the worse - chaos. I wondered if the low flu death rate is because those of us who would be vulnerable have already succombed to Covid - or Corvid as we say in the westcountry

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    Replies
    1. I don't think the low rates of flu are due to COVID deaths as in Australia and NZ death rates from COVIS are pretty low. I wonder if mass testing will help? Ill be doing a post on this soon.

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Thanks so much for your comment - I will get back to you shortly