Saturday, 31 October 2020

COVID 19 - October Update

SUMMARY

  • The second wave of the COVID19 pandemic is now a reality
  • Cases in the UK are climbing rapidly.
  • We are learning more about immunity; antibody levels drop with time, but an outbreak on a fishing boat suggests they do prevent disease and second infections still seem rare.
  • The herd immunity versus lockdown debate is a false dichotomy.
  • The private sector driven Test and Trace system has failed and needs to be redesigned with primary and public health taking the lead role.
  • The failure of testing and tracing means that more lockdowns are now inevitable - they also offer an opportunity to redesign FTTIS (Find, Test, Trace, Isolate, Support.
  • Our experience of COVID19 has meaning

Introduction

With winter some way off, COVID19 is extending its grip on society here and around the world. Despite evidence of immunity being more widespread than we think, there remain enough susceptible and vulnerable people around, enough poverty, enough malnourished and Vitamin D depleted individuals, enough polluted and crowded cities, and enough hyper-mobility for it to flourish once again on its accidental patch to temporary global dominance. 

One day it will all be over and the final graphs of its rise and fall will be drawn, but right now we are in our own big moment in history and a pivotal moment for humanity.

This tiny virus may have a big say, perhaps even be the deciding factor in the US elections with seasonal increases in American cases, hospital admissions and deaths highlighting the incompetence of Trump with an issue whose immediacy he cannot, unlike climate change, and the other multitude problems of society, evade, postpone or deny.

Over here the sad news that deaths are running at about 300 a day; once again I am glued to the news, anticipating further lockdowns, restrictions, full hospitals, personal suffering and tragedy for many individuals and their families. 

So is there any hope in this gloom? I think there is.

What is C19 up to?

Lots of amazing work is going o to try to define our predicament. The ONS community study of infections looks at rates of positive throat swabs and suggests that 430,000 people in England had COVID19 in the week of the 10th-16th Oct. The Kings symptoms tracker suggests slightly less at that time, increasing to 541,000 with COVID19 symptoms now. Imperial Colleges REACT project estimates 100,000 new infections daily. The actual number of course, is not known but will clearly be in that region and increasing. Neither of the estimates include children, so cases might well be more widespread than we think. 

Nearly two weeks down the line from the ONS estimate, we see about 1,000 daily admissions which equates to a chance of being admitted due to the illness of about 1.6%. Bear in mind too that at this time of the year there are the other 15-16,000 daily emergency admissions to deal with in a health service for which pre-COVID winter was already a continual cyclical crisis. 

It's hardly a surprise that hospitals in hot spots are struggling to cope. It is harder to establish the risk of death due to the delay of about two weeks between admission, death and its notification, but clearly this is stratified by age and where you sit in our pathologically divided society. 

Perhaps hospital admissions are the best measure of what is happening. These are easy to quantify and relate to day to day reality. As the shape of the curve evolves over the next week or so, we shall be able to predict the future with a little more confidence. Although the average of death is over 80, the average age of hospital admissions is 58.

UK hospital admissions - A longer lesser winter wave?


It seems almost optimistic to hope for a lesser, but inevitably longer longer winter wave. The scientists are rightly concerned that we might have a much bigger longer wave with all the implications that brings for the winter and our future. I did wonder if the curve is beginning to flatten already, but I think that might be hope over expectation. We shall shortly see.

Why do waves end? 

The graph below displays how seasonality is common to most viruses. The spring wave might well have been the tail end of COVID19's natural winter history. I hope not. On the other hand, that wave will have spread immunity in the hardest hit areas, London, from which many will now benefit. 

  

Seasonality of viral infections

Temperature and humidity levels played a part, as did the restrictions, but the second wave has come along with terrible predictability. I'm convinced that Vitamin D plays a key role in this seasonality, and despite the governments reluctance, could potentially be playing a big role.

It is not inconceivable that population wide supplementation with 4-5000iu daily would have a dramatic effect in reducing infections and their severity. A few politicians have taken up this cause and there seem chinks in the armour of the Department of Health. Despite the uncertainty, it's definitely an opportunity being missed right now. 

Predictions are notoriously difficult - remember the Imperial predictions of 500,000 deaths which drove our laggard politicians to take action back in March? Out by a factor of 10. There are plenty of gloomy predictions around once again and the numbers just keep rising.

Whatever happens, its clear COVID19's success lies in its transmissibility and a long pre-symptomatic, or even asymptomatic  phase under which is can covertly spread. Simple measures of distancing and hygiene really do work and masks too will become ever more a feature of day to day life. This really is a new normal. 

Immunity

Gloom too accompanied a recent publication from Imperial Colleges REACT study. This surveys antibody positivity in over 100,000 randomly selected people and has been repeated three times now. The reductions in immunity they detected made headlines and might seem like bleak news, but hardly unexpected and not by any means the end of the world. Why?

For one thing, immunity seemed to be maintained in 74.5% of participants across three summer months.

Antibodies
Positive antibody tests, according the dipstick method they use, dropped from an average of 6%, to 4.4%. Expectedly, older people had greater falls in positive antibody tests(40%) as compared to the young (15%).

Another problem is that the test is novel and might miss not be as accurate as we would like. It also, like a pregnancy test, gives a Yes/No result; so might mean that those with low levels of antibody are missed. Saliva tests, which more accurately reflect blood levels of antibody, are more encouraging with direct measurements detecting no decline in immunity over three months. 

There is more to the story of immunity that what we can, currently at least, measure. White blood cells called B cells can remember the antigens of the virus and when encountered once again, rapidly turn into plasma cells which have the ability to churn out anti-COVID19 antibodies. 

Don't forget T cells which can also kill the virus directly when encountered. These are hard to measure in any bulk and so we cannot quantify their contribution to immunity in the population, but the science continues to be encouraging. There are, however, plenty of susceptible people out there for the virus to spread and R0 numbers heading towards their natural levels means we are not anywhere near herd immunity as yet. 

One bottom line is how many people are getting reinfected? Thankfully so far his seems rare, which can only mean that protection does exist, even though it can't be taken for granted. 

Fishy business

An outbreak on an Irish fishing vessel provides an interesting case study of COVID infectivity and immunity. The crew members were extensively screened and all well before departure, with 3 members having positive antibody tests, indicating prior infection.

Thanks COVID!

Swabs gave the crew the all clear, but nonetheless 104 of the 122 crew developed the infection while at sea, according to results back on shore after their fishing trip, giving an attack rate of 85%.

The three with measurable antibodies to COVID19 were fine. Despite the lack of information on symptoms and outcome, this hints at the usefulness of prior infection and that antibodies as we measure them do offer immunity. 15 of the others without antibodies but with very close contact with infected crew mates somehow escaped infection; perhaps they had T Cell based immunity which protected them, or just perhaps they were lucky.

This tiny snapshot of a well defined outbreak gives hints that the virus is very infective, antibodies work, and there may be other aspects of immunity at play. With small numbers, it's interesting but speculative. 

Vaccines

These remain much in the news with reports of the Oxford vaccine inducing useful responses in the elderly, but they remain some time away from roll out. The reductions in antibody levels reported by Imperial, if correct, might have implications for vaccines but are not the end of the world. It may well be the vaccines will be finely tuned to elicit a stronger immune reaction than 'wild' infections, many of which will be mild and not evoke an antibody response at all. 

Trumps US Operation Warp Speed, (I kid you not) promises a vaccine this year, but this belies the reality of vaccine trials and development, indeed the first vaccine past the post will not necessarily be the best vaccine. If it not, then it may well be worse than no vaccine and it makes more sense to wait for the vaccine with the best trial results and least side effects before rolling them out globally. 

The endpoint of the Oxford vaccine trial, it has been pointed out, is not even next year. By the time they are available, we will know a great deal more about where we are. The second wave will be behind us  - by next April.

Barrington's versus Snow's.

These declarations take an opposite view on how to manage the pandemic. The former hopes for herd immunity by rapid viral spread in the less vulnerable with protection of vulnerable groups leading to less economic and social damage. Snow calls for a cautious approach based on the best science and maintaining the ability of the health sector to cope by restrictions and lockdowns if needed.

Differentiating them perhaps is their hosting. The "Great" Barrington Declaration platform is hosted by a US right wing think-tank and the John Snow response in the Lancet. Im always suspicious of the word "Great" being used for anything nowadays, be it Britain, or what to make America, again. Im with the Snow's, much as I wish the Barrington's were right.

The immense impact of the pandemic on the economy and culture are unmissable, but the single factor driving policy is the level of hospital admissions and the imperative not to overload the NHS. 

Any reading of the history of pandemics reveal the situation if hospitals cannot cope. For the 1918 pandemic, the problem was that the undertakers could not cope, and the operational problem in the Black Death was simply how to bury the corpses. We live in modern times and are lucky this pandemic is a mild infection for most, but what happens if hospital services are overloaded is an issue not addressed by the 'let it rip' brigade. 

Barrington's are also guilty of suggesting that the vulnerable are a discrete manageable group. They are light on detail about how to isolate the poor, those in crowded accommodation, the elderly, those with other illnesses, as well as members of the BAME community. The vulnerable in the UK number over 10 million, many of whom have important roles to play in all sectors of the family our culture and out economy.

Nonetheless it seems the Barrington's are winning, though not for long. Restrictions right now are piecemeal and complex, and nowhere near the lockdowns called for by those favouring the Snow view. The sad thing is that with nowhere really in control of viral spread it may even be too late, apart from that is, China and Korea, who got it right first time. Early complete lockdowns work. A short lockdown works if in place early. 

For now, BoJo and his team are sticking to their guns to the frustration of the scientists. This will change as hospital beds fill up and more severe lockdowns become inevitable. A number of circuit breakers (or longer) through the winter seem to be coming, and once again we can lament in the  knowledge that the later they are used, the less effective they will become. 

Of course here in Devon, paradoxically it might seem, containment is still potentially possible though testing and tracing, but as a recent local experience without system shows, (see below) this is unlikely to happen, and our current low levels of immunity means the first wave, down here in the South West, is yet to arrive.  

What to do?

Get healthy - Get as fit and healthy as possible, lose any excess weight, do what exercise you can, eat good food and in particular supplement with Vitamin D. Anyone smoking or vaping needs to consider the risks and enter the wonderful world of non smoking. This is now a matter of urgency. But what should we do as a society?

Testing Tracing Isolation Support: This is the bedrock of pandemic control. Our current system is only reaching 62% of contacts of those testing positive, well below the 80% estimated to be needed. Further, small numbers (11%) of people are isolating correctly and support is clearly not enough. Arrangements for isolation of cases in crowded households are not in place. 

We have wasted the opportunity of the summer to design an effective system. Ignoring the potential to use primary care and public health teams to Find, Test, Trace, Isolate and Support has been a catastrophic error. In reality we have not used the NHS to do this job and are now paying the price. 

Putting this right now will help with a third wave and mitigate the second, but the outsourcing of this vital task to the private sector has demonstrated the weakness of Conservative thinking and perhaps signal a new age where public services again take the lead role. This political failure could hardly be more vivid. Is the end of Conservatism as we have know it?

A recent case highlights the issue with testing. A friend with a child with relevant symptoms called 111 which led to advice to go to a testing centre. On arrival they were told the staff there were not trained to do the test on a child, but Dad could have a go! He tried half a dozen time before the swab was accepted. Two days later they were notified that the swab was inadequate and needed repeating.

Off they went again and repeated the testing, done again by Dad. The testing centre advised that they go to the paediatric department of the local hospital where staff would be trained to do the swab (bringing a potential infection into the hospital) but Dad persisted with the DIY swab. Two days later the test came back negative. 

If the tests were being organised by local experts, this would not have happened. It seems the current set up cannot test children. Farce is a reasonable term to apply to this experience, and if the test was positive then testing and tracing would be that more difficult and less effective. 

Now it seems, government have procured saliva tests in the hope of testing 10 million people a week, not quite the ambition of Moonshot, (which has been dropped) but in that direction. Some directors of Public Health have already stated that it is not all about testing, that the tests are not fully validated and if 10,000,000 tests are done with a specificity of 99% (unlikely) them 10,000 people a week will be isolating unnecessarily.  There are all sorts of issues with the likelihood of dogma driven mistakes being repeated.

So, that having failed, what is the next option?

Lockdowns; Perhaps now is the time for a national lockdown of a fortnight? The longer it is left, the longer it will need to be. This could reduce spread of the virus and flatten the various curves of hospital admissions and deaths, but also offer time to completely redesign our failed Testing and Tracing system which lies at the heart of tackling pandemics and at our failure to contain it.

Areas, like mine in the South West, with low but growing rates would benefit from this, shifting infections further into winter. Alas, Im beginning to see little choice.

COVID19 has a meaning.

In some ways my post-war generation has had it lucky. We have missed the horrors of war at home, the Great Depression, grinding industrial poverty, and miserable infections of the past. But now we are facing our own difficult age in which COVID19 is a symptom of what is to come.

The ultimate cause of the pandemic lies in a total disregard of the importance of the natural world. We now are acutely aware of the dangers lurking in the blood of monkeys and poo of bats and can no longer afford to ignore the critical importance of looking after and expanding these remnants of the natural world.

It is a pandemic caused by poorly regulated commerce and capitalism, spread by a irresponsible travel industry and impacting on divided unequal societies whose weaknesses are now shown in sharp relief.  Global organisations are needed to regulate them. Perhaps this will end the immature nationalism of Trump Bolsonaro and Brexit?

In terms of our organisation and collective effort, our failure to control it is the consequence of pathological, outdated politics. A belief in the power of technology and the private sector which now lie in tatters. The destruction of local government and many other local institutions also have weakened our ability to respond. 

The dishing out of contracts to private companies who subcontract out work to others is little less than systemic corruption at the heart of government. In terms of those vulnerable to its ravages, it is a disease of society. 

Let them eat sausages.

Pandemic proofing

We desperately need more regulation to harness the capability of out of control corporations and business, particularly in the food sector. Cancelling Brexit would help, unless we lead the world back to restorative farming which seems unlikely. 

Devolution of power back to local authorities and the ability to raise taxes to local levels would lead to stronger public health teams able to Find, Test, Trace, Isolate and support where it matters. This is beginning to happen and is now urgent.

A universal basic income for all citizens equating to the Job Seekers Allowance, would end poverty as we have know it and is affordable. 

Local systems of food supply with healthy good at its heart is essential for any sustainable future. We need cities designed for people not cars and a transformation of our old polluting transport system away from car ownership and towards readily available electric taxis buses coaches and trains for journeys that cannot be done by bike or on foot. All this would have meant a healthier population and far less impact from the pandemic. 

COVID19 has revealed that poverty, social inequality, polluted living spaces, low quality food and the indoor life can reasonably be seen as unaffordable as well as having been unnecessary, immoral and plain wrong for so long. 

We need less wealth and less poverty - perhaps in a less unhealthy, unequal, society, there would be no need for a lockdown.

If the lessons we learn from this pandemic are put into practice, then COVID19 could in the longer terms save lives. Pandemic proofing societies would lead to a better world. 






 




Monday, 19 October 2020

Can you get COVID19 twice? T-Cells to the rescue!

SUMMARY

  • Cases of reinfection with COVID19 have made the headlines creating worry about COVID19 becoming a recurrent disease.
  • A simple COVID19 symptom tracker is shining light on the natural history of the pandemic.
  • They have found re-infection to be rare, even in those hospitalised with COVID19 with no antibody response. 
  • The study was also the first to describe loss of smell and delirium in the elderly as useful diagnostic clues for COVID19 infection.
  • They, and others are showing there is more immunity than antibodies.

Introduction

A recent case of COVID19 made the news in that a young man from the US became infected by two slightly different strains of C19 with the second infection, unusually, being worse than the first. This followed four other reports from Hong Kong, the Netherlands, Belgium and Ecuador - in these cases the second infections were milder. 

Re-infection raises the issue of immunity to COVID19 once again, and the concern that immunity against the virus might be short lived with implications for us all and for the development of vaccines. 

These cases have been widely publicised, creating headlines around the world, but what do they mean in reality? Why am I not too worried about this?

Gathering the data

This week I read results of the Covid Symptom Study App, a symptom reporter designed and developed by Kings College and a health science company called Zoe. It has been led by Tim Spector, Prof of genetic epidemiology and someone who has been studying and making news about the poor health of the UK population for some time. I only wish he was Secretary of State for Health, but has clearly been too busy for party politics.

Today the survey suggests that there are 33,000 people with a new infection as compared to the 17,000 positive tests registered on the Government dashboard. Another big hint why Test and Trace has failed - half of people with symptoms are not even getting tested, never mind traced!

Compared to the publicity about the NHS Apps and their many glitches, this App seems to have been rolled out without much fuss; and, despite some initial difficulties with our creaking centralised administration, is now partially funded by Government.

4 million people have signed up to the App and so it has become a sort of National Register of what happens to people with COVID19. It's experience, and results so far are invaluable.

Learning more about COVID

Soon after its launch, it was the first to identify the loss of the sense of smell as 90% predictive of a positive Covid test. I clearly remember the dithering of the chief medical officer about this useful symptoms which is now recognised as very significant sign of COVID19 infection. The slow pick up of this marker was itself is a symptom of lack of momentum within PHE. 

It is also defining the symptoms which might predict the development of "Long Covid", where symptoms last three months or more and is thought to affect between 20,000 to 60,000 people in the UK. The ability to predict who will develop these protracted symptoms would be invaluable, perhaps, they suggest, to guide early treatment with steroids. (Vitamin D too, I would suggest!) So far it seems to affect more women than men, those overweight, those with asthma, and many who did not need hospital care. 

They also have defined that in older people delirium is a common feature of infection. Like with the lack of smell, this has not yet become recognised officially and it will not get you a tested according to our Test and Trace algorithms, highlighting another reason for our poor performance. 

So how common are re-infections?

Encouragingly, results tentatively suggest that we might not see a return to last winters chaos. For one thing, the results suggest that more people may have been infected than antibody studies suggest. 

Only half of people with COVID19 severe enough to end up in hospital develop antibodies and for them you would expect reinfection to occur, and this doesn't seem to be the case. T-Cells must be coming to the rescue and suggest longer term immunity for those infected with COVID19. This is good news.

The delayed increase in London as compared to the North, also suggests that there is immunity around, and this lack of reinfection should reduce the size of the second wave. 

The UK Twin Registry, another project at Kings, shows that 12% of this random group have antibodies to COVID19 and therefore Tim guesses that a quarter of twins in the Registry have been exposed to the virus; he suggests that it could be double that in care workers. All this is slowly moving us to some sort of herd immunity as well as suggesting a reduced impact on the health and care sectors where initial infections were, and subsequent immunity is likely to be more common.

Reassurance

This epidemiological approach is backed up by some good lab-based science too, with a  recent study adding to a wealth of data that T cells provide immunity and prevent reinfection.

That is why Im not too worried about re-infection. Coupled with, of course, the fact that 40 million people are known to have been infected with COVID19 and reports of reinfection are, so far, vanishingly rare.


Thursday, 15 October 2020

Living with COVID19 - illness in a sick society

SUMMARY

  • Our summer planning has not prepared us for the winter.
  • Testing and tracing has effectively failed
  • COVID19 is spreading in densely populated campuses towns and cities
  • Divisions are emerging in the "science" behind our response
  • Its going to be a long winter
  • Better get ready for COVID19

The nights are drawing in, autumn in here and COVID19 has it seems woken from the slumber of a seasonal virus and is now doing what these tiny packages of genes do, replicating and spreading. According to positive test results, it is surging, hospital admissions are increasing and deaths now on the up. 
If you consider that the first wave came on the back of a small number of initial cases, and that we now have thousands of people carrying the virus, there exists the potential for it to spread to a much greater number of people.

I feel gloomy that so little seems to have changed since the spring pandemic arrived and we seem so helpless before its inevitable winter spread - a genie well and truly out of the bottle. 
POSITIVE TESTS SURGING

I also feel frustration that the prospect of a functional testing, tracing and isolation system working seems to be a pipe-dream. The effect of the £25billion system has been described as "marginal". 

Local authorities are belatedly being given more of a role in contact tracing, bringing the hope, they say, of dealing with a third wave, because it coming to late for this one!

In the places it matters, our cities, tracing of large numbers of positive cases is no where near what is required to reduce spread. So blanket restrictions are back or on their way once again.

The virus has spread due to the season and our society. Our education system which by design brings together students from far and wide to Universities who dominate, as in Plymouth, so many cities and cultures. Every year, I was struck by the surge of viral illnesses in my clinic which accompanied the start of the academic year and this year it is no different, just with a far nastier virus. 

In health terms, this design of tertiary education seems crazy; kids going to adequate local universities would make more medical and social sense, but that would turn the elitism driving our university system on its head. So educational mass migration is the system we have and the young generation have come to rely on it. We now have a surge in positive cases in the young, spreading to vulnerable groups and thus onto our hospital wards. It in not their fault, they are simply doing what students do, the "old normal".

It's not the whole story - coupled with all this were attempts to head back to 'normal' with BoJo, quixotically it now seems, encouraging people to get physically back to their offices. Presumably this was to encourage the flow of cash into the city economy dependent on their presence. Big sectors of the economy, peoples livelihoods, depend on us going out and spending our cash on the normal daily functions of eating and drinking which we can now do at home.

The virus has been holidaying in crowded cities, grumbling along at low but discernible levels  all summer and is now back at work, infecting, replicating, spreading. 

March, the peak last time, is six long months away. The impact on hospitals is already evident in hot spots and whatever scientists, politicians and pundits are saying, they are the front line.

My cloudy crystal ball is unable to detect whether the uptick is a the early ascending tail of a much bigger, far more threatening winter wave, or the beginning of an expected ripple. Plan for the former, hope for the latter.

HOSPITAL ADMISSIONS CLIMBING
Either way, it's clear that we are heading for very difficult times, both in terms of health impacts, so easy to quantify and understand if not to deal with, but also the mind bogglingly complex economic and social effects, some as novel as the virus itself.

As a doctor helping patients face life changing moments, and with my own diagnosis of MS, the hardest thing is that unnerving feeling of deep seated uncertainly.  Individually, once you get through the treadmill of investigations to arrive at a clear diagnosis, then the fog can clear and for better or worse, understanding can mitigate fear and lead to acceptance. We can start to live with our diagnosis and adapt to it. Uncertainty is now a feature of daily life for us all.

With COVID19, essentially a disease of society, divisions among scientists and politicians have led to confusion and increased uncertainty in the population at large. In the US concern about COVID19 is mainly determined by political leaning, or vice versa. We follow these trends - to some degree it's almost like Brexit all over again with a "libertarian right" tendency tending to want to carry on as normal and take the pandemic hit, to the cautious "humanitarian left" who want to preserve life at all costs. Individual freedom versus collective responsibility. They both have their points.
New Zealand1 -  COVID 0


There is agreement that we have to give up ideas of 'defeating' the virus as they seem to have in NZ, where a crowd of 31,000  attended the draw between with their Aussie rivals

Up here in Europe, things have not gone so well,  here, and in most of the world, it's about containment and mitigation - we truly are in the COVID world.


So will have to learn to "live with the virus", but what does this actually mean?

Living with the virus - the "medical" view:


The harsh advice coming from the Chief Medial Office and SAGE might seem to come from a narrow medical standpoint. Critics say that it fails to take account the economic impact and significant collateral damage done by restrictions which dampen down viral spread so dependent of human contact, but also destroy quality (and quantity) of life for many, damage education as well as the unprecedented costs cash cash costs of lockdown.
SAGE - Sagacious?


It is driven by a desire to prevent illness and death, but also ensuring a functional NHS. The graph of hospital admissions above represents a national picture, but in Liverpool, and other Northern towns the number of cases is twenty times (600/100000) that of West Devon (36) from where I write. 

In cities, it seems, the virus is spreading rapidly, and already stretched local services can become easily overwhelmed despite less worrying national stats. This is simply unimaginable in peacetime. Neither is it simply a matter of shipping patients from one area to another - this can be done, but holds big risks for all. 

Being unable to access health care in an emergency is something my generation, uniquely, has never experienced or even contemplated. 
 
For anyone working in the NHS these are scary times. 620 frontline staff have already died. Even though much has been learnt from the first wave, the NHS was already stretched to breaking point before the crisis and now has to deal with a triple whammy of COVID19 cases, the reduced efficiency associated with distancing as well as the catching up the host of other illnesses knocking at the NHS's door. 

Seen like this of course, everything must be done to reduce the spread, slow down the virus and "save the NHS".  So Chris Whitty is full of foreboding, hinting at the significant restrictions on their way, miffed that they are not in place already.

His advice is that we need lockdowns, circuit breakers, and restrictions until the R0 is below 1 and then we can all go about our business until the R0 number goes above 1 and then repeat the cycle. 

Keir Starmer now agrees with a 2-3 week national lockdown - but how many times this winter will this be needed? Clearly if you are going to do this then the earlier its done the more effective it will be - perhaps it's a bit late already. 

This cycle continues till through the winter. until the whole thing is over, whenever that might be. A vaccine would help, but is not going to make much difference this winter and there are emerging issues of effectiveness, safety and compliance. Perhaps by next winter a vaccine will be ready, but even that is not clear cut
 
In a way, that is the pure epidemiological view of living with the virus.

Living with the virus - the "economic" view


The recent support for those made redundant by the restrictions makes for sober reflection. The Chancellor will pay a poverty generating 60% of income to those affected by COVID related redundancies. Early estimates suggest a cost of £100 billion a month - for 6 months. That equates to £30,000 per family in the UK in addition to the resources already spent. It is hardly surprising that we coming to a point when we have to ask  -is this simply unaffordable?

The Barrington Declaration seems to sum this up. This group of respected scientists have, for reasons I fail to understand, allied with a right leaning Koch Brothers funded American think-tank to deliver the most simple of messages - simply let everyone get on with their lives apart from those at risk who should be protected thoroughly. 

Wonderfully simple. Easy to buy into and headline generating. It is right that this must be debated. There are however, holes in their argument which are not clearly articulated in the declaration.

For instance, the Americans are already having a bad time.Their first wave was followed by a very thick "tail" with about 1000 deaths a day through the summer and now have more than 200,000 total deaths heading into the winter. They are really still in their first wave. This suggests the winter will be very tough for Americans. Their patchwork chaos of response, confused federal thinking, and poor population health have left them precarious, weak, vulnerable. Not qualities Trumpian Americans (Trumpists??) like to shout from the rooftops.

The "vulnerable" include the BAME community, the overweight, those with metabolic poisoning from the typical US drive "western" diet, and of course, those over 65. So those vulnerable are actually quite a large group to try to isolate. 30% of Americans are obese. In my surgery, diabetes had become ever more common, with 5% of people diagnosed and many others in a diet induced, "pre-diabetic" phase which also seems to fuel vulnerability to COVID19.

The "vulnerable" are also parents, grandparents,  carers, key workers, teachers, politicians  this list could go on - simply stripping them out of society is difficult. What about the vulnerable living in crowded housing? Those in care home rely on visits of loved ones for quality of life. 

They also fail to quantify the deaths in the young, (increasing in the US) in care workers, in the developing nations, and forever quote the average age of death as the foundation for "back to normal" approach.

This focus on death fails to consider the effects and costs of those who do not die, or sometimes even go to hospital. Sick leave, strained public services as well as the long term effects of COVID19, which are sadly far more common that we thought mean that the impact on society goes beyond the death and hospital statistics.

So although in the declaration is attractive, hinting at a straightforward solution to the problem, it has been criticised for its inability to actually look at what is happening on the ground. The infrastructure needed to isolate so many people suggests a social and political transformation which is not on anyones lips.

We can't have everything


What is self evident is that we cannot have our cake and eat it. We simply cannot have an economy which can function as is has in the past, a COVID19 pandemic kept in its box, and hospitals just ticking along their normal edge of the cliff.

At some point a balance will have to be struck between the competing demands of preserving life and livelihoods.

This is not easy. COVID19 is a nasty illness. Think of flu, but about four times worse. Some people think thats not as bad as it really is but for significant  chunks of the population it is life threatening. Then there is the suffering of patients and the intolerable demands on care staff to think about as well as the emerging long COVID to consider. These cannot be ignored. 

Middle ground?


I cant help but feel that there is some middle ground;

The young. Surely we do everything to  keep schools and universities open and functioning with young people allowed to mix in larger bubbles reflecting their normal scholastic life. The social aspects of education are critically important for the development of life skills. 

Sending a whole secondary year home because of one positive test is not practical and has led to significant reductions in education for up to 20% of UK school students as we speak and can only get worse with this policy in place. Stay at home is you have symptoms and take care of relatives might be better advice for school kids. 
Plymouth University


Isolating university students in their halls for on-line degrees without much personal input from academics and reducing the opportunities to meet the acquaintances, friends and develop social networks which define life for so many begs the question - what is the point of going at all? 

University accountants must be having sleepless nights as they realise that pure on-line courses hints at the end of physical universities. On-line lectures can be 'bought'  from Harvard as well as from Huddersfield. Put that into the COVID19 equation.

Perhaps Universities might head towards having giant bubbles including food, drink and social activity enclosed within a busy campus. Trips home could be sandwiched in between testing and those with symptoms isolated on site and supported with good food and on-line personal support.

It might seem selfish to put what might be seen as the hedonism of youngsters before the life of the elders, but the young are our future and their prospects are already compromised by many of the factors which have allowed the spread of the virus into their lives in the first place

If point of care testing comes along, if it does, then let's consider students as a priority group. 

The elderly in Care homes can be better protected, in particular with enhanced testing and any trials of rapid point of care testing focused on staff and residents to ensure their ongoing ability to function. Essentially homes should be kept COVID free. Here too, maintaining contact with families is essential and can be achieved with visiting rooms as well as novel electronic means. 

This all needs funding. De-fragmention of the care home system would help, but as a sector we have to try to make do with the privatised, publicly funded chaos from thousands of independent providers who have to be brought together and enabled to stay free from COVID19. This is not an easy task. 

The vulnerable: Perhaps our vulnerabilities might actually be started to be examined a bit more positively. Is is not impossible to lose weight, to take vitamin D, to stop smoking, to eat nutritious food, to enhance community, to strengthen local infrastructure, to beautify cities, to engage with politics. The majority of people the 4.8 million people living with type 2 diabetes can be cured with a healthy diet. Pandemic defining vulnerabilities can be slashed, but how many times have you heard this from the political briefings?

The illness itself. Nightingale style, or other dedicated hospitals could be useful to assess large numbers of people presenting in COVID19 hotspots as well as staging posts for the elderly to return to care homes, or to their own homes if crowded, with negative tests to ensure non-infectivity. Yet perhaps too we might have to admit that 100% success here is not likely and that there will be mistakes, infections and deaths. Hopefully not on the scale of the first wave.

COVID19 - An illness of Society


COVID in many ways is an illness of our society. Our collective health is poor and has been made poor by the politics which defines us. Food policy, air pollution, sedentary lifestyles, inequality and racism give the virus the fuel it needs. The lack of a sane food policy lies also at the pandemics origin in the dwindling habitats of China. We created the conditions for this virus to emerge and much of its subsequent pathogenicity. 

With better designed cities, food policies based on good farming and nutrition, social and racial equality, employment based on wellbeing, we would be able to deal with the pandemic without a hint of lockdown or economic restrictions. That is why I say it is an illness of society.

The time has come for Universal Basic Income, a buffer which would increase flexibility, freedom and help in the modern age of part time working. 
Universal Basic Income
  - the 21st Century
safety net!


Our politicians seem adrift because they are. Decades, even centuries of misbehaviour are catching up with us and we in simple terms, have a society which is destroying itself.

It seems to me the "medical model" will work, but it will cost many many trillions of pounds which we have not got or are likely to earn.

The "economic model" will work, it will keep our economy ticking along like the bomb it is, but cost many lives and much morbidity we are not prepared to accept.


Perhaps an economy based on generating good health, environmental improvement and wellbeing might bring together both models - its time has arrived. Indeed, it's now or never.












I

Saturday, 10 October 2020

Mass screening - Moonshot or Moonshine?

Summary

  • It is now widely acknowledged that our testing, tracing, isolation and support systems have failed to restrain the spread of the virus. With the return of children to school the system has been overwhelmed.
  • In response to this comes "Operation Moonshot", an ambitious project to test the whole population every week.
  • It seeks to expand testing from 350,000 to 10 million tests daily.
  • The project has has little input from health experts. It will utilise unvalidated technology encouraged by generous government contracts and low level of scrutiny. 
  • It will be led by the private sector, with a major administrative role for Delloitte who have a poor record so far. The fundamental failure to involve local services and expertise is being repeated.
  • New products need to be properly trialled and targeted at key workers and care homes once their accuracy is established. 
  • Moonshot is projected to cost "over" £100billion, one hundred times our expenditure (for example) on Carbon Capture technology. 
  • There are many better, ands more urgent ways of spending £100bn.  

Introduction

Boris Johnson has repeated what he likes to do best. Answer questions about the failings of current projects by announcement of bigger better projects. A strategy which seems to deal with problems by issuing promises and repeating the process. 

This time he has announced another world-beating project for mass testing which he announced is the "only hope for avoiding a national lockdown before a vaccine, something the country cannot afford". This makes me feel rather angry. Not only will vaccines be some time in coming, but they may well not answer all our problems. I agree that national lockdowns are simply no longer affordable, creating far too much damage and may not even work at this time of the year, so let's have a critical look at his most recent promise, Operation "Moonshot".

What is Moonshot?

Essentially a project to increase COVID19 testing to levels which would allow everyone to know whether they are infective on a weekly basis and allow those with a negative test be able to continue normal activities. Or, if they are confirmed positive, isolate and trace contacts. With rapid widespread testing, BoJo thinks, we could all go about our business and get the economy back to normal. 

Its ultimate aim is to keep the Ro number below 1, and so for the outbreak to fizzle out. It will be organised by consultancy firms like Deloitte, and involve a whole new logistics infrastructure and workforce. It will be unique in that no other country has yet contemplated such as system. It needs the development of new tests and technologies.

Sounds sensible? Think again....

Testing Tests.

Testing technology is far from perfect. Our current PCR tests are right now the best we can do, but have plenty of problems of their own. They can miss early infections, give positive results in people who are no longer infective, generate false positives and miss up to 30% of people with infections. When performed for people with symptoms, this is not so much of a problem, but the more tests you perform and the more people you test, the more significant these errors become. 

The new tests proposed for Moonshot are what are termed point of care tests, rather like pregnancy tests. They need to be calibrated against the gold standard which is culturing the viruses themselves, though with viruses even this is tricky and expensive as the only place you can grow them is where they live, inside cells. 

Some use a variety of non-PCR based technologies and there is an admission in the leaked documents that the tests are likely to be less accurate and thus introduce more risk. The notion is that these tests are more likely to pick up an infection even though they might also miss more, meaning repeat testing becomes important.

Might new tests come to the rescue? In the UK we have the NudgeBox machine which uses the PCR tests from nasal swabs and gives results in 90 mins. 6% of its results are false positives, though it doesn't miss any infections. 5,000 are being trialled in London hospitals. 

The LamPORE test uses nasal swabs or saliva with 1% false positive with again few infections missed. They have been bigged up by "Handsfree" as giving results in 90 mins, though again the reality is different - results in about 6.5 hours. These will soon be available more widely. 

Saliva based tests might be better, and Optigene have developed one which they say is more accurate; its being trialled in the University of Exeter. A Korean company has made a pregnancy test type kit and Germany has bought 20 million already. This is despite missing 25% of early infections.

So quality control seems poor, and there are not common standards here or elsewhere. This might be seem as splitting hairs in the middle of a pandemic, but it is critical for the tests be be properly trialled. 

Tests are rather like drugs, they have benefits and harms. Proper evaluation is therefore important, yet many of the tests proposed for Moonshot have not been subjected to scrutiny with information on their accuracy coming from trials run by the manufacturers and as yet not peer reviewed. 

More to healthcare than testing?

Once again, for testing to work, it needs to be rapid, backed up by effective contact tracing and then support for those who require isolation. This has not happened, and testing is now leading to blunderbuss restrictions due to the detection of otherwise healthy "cases", in particular causing chaos in the educational system and for society at large. 

Missed cases: The ONS conduct a survey of asymptomatic people every week and for the week of 12-19 of September, for example, they estimate that there were 103,000 people in England with the infection. During that time we conducted an average of 230,000 tests a day and picked up 25,700 positive tests over the week. If the ONS survey is an any way accurate, this means that for every "case" we are detecting, we are missing four. This goes some way to explaining the spread of COVID19, so often a silent infection. How can this prevent the spread of COVID19?

In other words, many people with the infection have no idea they are infected and so will not seek a test. Further, some may be reluctant to do so if it compromises their ability to provide an income. 

Now imagine, with all these uncertainties and proven problems, expanding testing to 10,000,000 tests a day. If the test is 99% specific, (very optimistic) that means it will generate 1 false positive in a 100 tests, in other words, 100,000 people will test positive when they are not infected and who will then isolate needlessly. This would create economic damage and expense in the need for further confirmatory testing with current PCR technology with all its delays and inherent problems.

Better targets? 

Rather than trying to screen the whole population in one big monster project, it might really be better to target key workers and those most vulnerable. The case fatality rate could, for instance, be halved by protection of care homes which means rapid testing for staff there as well as in hospital. 

Moonshots wobbly launch-pad

The whole thesis of the scheme is based on computer modelling rather than any actual evidence. But, as we have seen in Scottish students, that aim might well be confounded by finding the virus is more widespread and transmissible than we think. 

Multiply the significant numbers of false positives and negatives and the administrative nightmare we are seeing right now and it is reasonable to wonder if Operation Moonshot might have to abandon and crash back to the ocean, sinking with it huge amounts of resources, pollution and the lost opportunities for more sensible spending.

I wonder what is happening in the back room at Number 10? The project seems to tick boxes for quick dazzling headlines, transfer of future income to the private sector as well as playing to Johnsons insatiable appetite for world beating fantasies like the Thames garden Bridge, Londons Island Airport and water cannons with which to blast green protesters. Our Health Secretary, "Handsfree" Hancock, also gravitates towards technological solutions, even when the problem is not technological. World Beating" is becoming more hackneyed each week. 

Added to that is the dash for the mountains of cash available to the winner of the race to produce the first point of care test, governments keen to spend billions and the winter approaching, then it seems to me we are heading for more problems and failures.

The underlying thesis is that this pandemic needs a fix, and there must be one out there! The reality is far more complex. 

Further, if Moonshot will not launched until sometime next year, by then we will know a great deal more about the pandemic and how to respond to a winter long pandemic experience. 

Waste,

One other aspect of this scheme is the physical waste it will generate and Im sure the environmental considerations will not have been considered. We are already generating a mountain of waste from masks and cleaning equipment, estimated to contribute to a 20% increase in solid waste in Cornwall. 

Images of face masks floating in the oceans and those I have seen discarded in the lanes of Devon are a reminder of the need for whole systems thinking in planning. The tests will, once done, end up in the bin; 60 million of them a week - and for how long? 

Financial Cost

The proposal will cost over £100,000,000,000, that is £1,500 for every person in the country. It is also likely to be a significant underestimate. Anthony Costello, former director of Maternal and Child health at the WHO has called the funnelling of such massive sums to the private sector as "waste/corruption on a cosmic scale". I agree, it will immediately fell much of the Chancellors recently planted money forest.

Opportunity Cost and Morality

Opportunity cost is not a loose economic theory. Think of the problems that could be solved by an injection of £100billion. The transformation in health generating cycling and walking facilities in our cities; establishment of a system of Universal Basic Income to increase freedom and reduce poverty; a much needed boost to carbon capture industry; the cash encouragement needed for modern faming to embrace the new age of quality food and carbon sequestration which can enhance rather than destroy the environment; effective marine management to increase biodiversity and fish stocks...this list could go on. 

To spend this sort of money on a project which is not based on sound evidence, on the back of failure with simpler systems, and in times of economic suffering is simply immoral.

I rest my case.







Friday, 2 October 2020

Trump Time

SUMMARY

  • Donald Trump and Melania have tested positive for  COVID19.
  • He now has to quarantine for two weeks.
  • Though he is in a higher risk group for significant illness, there is a high chance he will have a mild illness
  • The most important American election in history is just a few weeks away.
  • The outcome will be 'played' for electoral gain and might make a difference.
  • The outcome of his infection and election will have significance for us all.

Introduction

So Donald Trump has tested positive for COVID19. 

He is likely to have picked up the virus from a young and healthy aide whose infection was detected by the daily (YES DAILY) testing performed on Trump and his team. 

This really is huge! For one thing the election is only a few weeks away and he now has to follow the guidelines and quarantine for two weeks. Mass rallies will be cancelled and the next head to head debate with Jo Biden may well not go ahead. After the last one, the world gasps sigh of relief with that news.

 

COVID19 infecting cells

In the human sense, Trump is another overweight elderly American among the millions to be infected with the virus, but as I reflect on the news, its significance sinks in. Just as the American people are looking forward to the opportunity to continue or end the most bizarre presidency in history the importance of this single positive test cannot be understated.

Is Trump at particular risk of a significant illness?

Yes. He is old and obese. He is in a highly stressed job and his diet might not be optimal. However, there are also plenty of reasons why he will not be severely affected. 

For one thing, unlike care workers and those looking after people who are ill with COVID19, or those living in cramped conditions, he is likely to have been exposed to a low viral load. The aide, I presume without symptoms, was also likely to be shedding low levels of virus and this is important in determining how the virus can take hold. 

Highly sensitive PCR testing can pick up infinitesimally small amounts of viral RNA in well people.

Coupled with this, I am sure that Trump will have had every medical intervention to lower his risk. I can guarantee, like his leading medical expert Dr Fauci, who has stated he takes Vitamin D supplements, he will be have enough of this fundamental Vitamin on board. He has already stated he is taking hydroxychloroquine, shown to be ineffective in the unwell, though with some potential if poorly defined benefits in preventing illness. 

Reports suggest he is also being given the higher 8g dose of an antibody cocktail which is currently being tested in trials. Add to this Vitamin D (thought so!), zinc, famotidine ( an antacid) zinc, melatonin and aspirin. An interesting cocktail! Dexamethasone has not been mentioned, though I'm sure will be considered if his condition deteriorates. 

I am sure, if his diet is anything like the typical Americans, he will have his nutrition monitored and adjustments made with supplements. There have, however, been questions asked about he quality of his diet. He is partial, it seems, to health damaging highly processed food.

So I am certain that while his risks of significant illness will have been lowered as much as possible, his poor overall shape might be less than ideal. He has been reported as being in the obese category, just. (BMI 30.5)

Despite being president of the USA, surely one on the most time consuming jobs in earth, he has played plenty of golf, however, with electric golf buggies and caddies taking the physical load the presidential exercise involved in this could be minimal. 

So he is more likely to do well than suffer the fate of the over 1 million people who have now succumbed to the disease? Time will tell. Of course, as common with COVID19, he might remain well for a week or more and then become unwell making the impact on the election more decisive still.

As I write, he is being helicoptered off to the military hospital reserved for ailing American presidents, as a precautionary measure it is said. We shall have to wait and see.

Playing the infection.

If he does well, expect "Superhuman" Trump to emerge just before the election triumphant against the scourge of COVID19.  There may be Americans who see this as divine intervention, others not so. Any sight increase in his popularity would seal another four years of Trumpism.

On the other hand, he now joins Johnson and Bolsonaro, who despite the resources, facilities, advice and wealth available to them, have been careless enough to become infected, each with their own brand of reckless behaviour. Trump has shunned masks, and been keen on the mass rallies which are the bedrock of his campaigning, indeed appeal, where social distancing has not taken place.

Social distancing - Trump style

This might play into the hands of his opponents who have taken COVID measures more seriously. Trump was almost spitting at Biden only a few days ago. What are the odds on Joe Biden testing positive? This too would have a big impact on the election.

A significant illness, now or later, or the development of "long COVID" would leave Pence in charge. Might this improve the Republicans chances amongst the 10% of American voters who incredibly remain undecided? Pence is another climate denying radical evangelist keen on undeserved wealth and guns and would be unlikely to be less damaging than Trump.

I can see strategists, and there are lots of them in the Whitehouse, moulding this result and the daily medical briefings to the needs of election victory. There willI I'm sure be those who consider this to be staged for electoral gain. I can perhaps understand why and indeed, with politics as they are today, anything is possible.

Trumpism.

One of the first things Trump did in the Whitehouse was to reduce spending on global family planning, cancelling any comprehensive programmes for women in the developing nations. This has resulted in thousands of deaths due to increases in unwanted pregnancies as well as the reduced access to safe abortions across the globe.

This set the tone for many interventions which damage all our prospects. He is a climate denier and if elected, would seal the departure from the Paris Climate Convention, reducing prospects for addressing this most fundamental and critical of issues we face. He has been lucky to be able to appoint three conservative Supreme Court judges in his term, the last an anti-abortion, advocate of extreme religious beliefs and guns, that paradox of so many American Christians to whom he plays.

In suspending funding for the WHO he was branded guilty of crimes against humanity by the Lancet, one of the worlds most respected medical journals.  

His dithering and differing comments on the COVID pandemic cumulated with his comments on "Herd Mentality" when faced, almost uniquely, with real people asking real questions - a format unlikely to be repeated.

For these and many other reasons, he is the wrong leader taking the wrong actions at the wrong time. I am gloomily convinced that another four years of accelerating Trumpism or perhaps the age of Pence is something our species and many others cannot afford.

What next?

So my mind is now intermittently focused on Trump's most inner workings, both within his own body and within the network of strategists he has established in the Whitehouse. He will want to maximise the 'deal' his is currently negotiating with this virus. 

In this age of global phenomena, the American election is important for us all. 

There will be regular updates Im sure, and I expect that Trump's Twitter emissions will be as loud as ever, and if not, perhaps an early sign he might be genuinely unwell. 

Another dice has been rolled and the future has just become that little bit more unpredictable.