COVID-19

[mikeh]

And have been told okay to share the transcript (to clarify, I have not heard the audio/video of the interview, so am assuming this is correct)


The modelling seems to show that the current cause would have lead to a huge no. of deaths?

We are one of several groups working hard to inform the gov, including LSHTM. We have struggled as know what this policy means for economy and social impact. Looked for other ways that would be acceptable, unfortunately we have concluded based on mortality and experiences around the world, including Italy, that it is not possible to adopt any other strategy than this one which is supressing transmission.

And otherwise it could have resulted in 260,000 deaths?

I mean I think no country in the world thus far has seen an epidemic that large – that data is an extrapolation based on early data drawn from China. We have no reason to believe that is not what would happen if we frankly did nothing. Even if we did all we could to slow but not reverse spread we would still be looking at a very large number of deaths and the health system being overwhelmed.

And what is was crucial in you changing your conclusion? Was it more informing coming in from other countries?

It’s not so much changing our conclusions. We don’t recommend policy. It has been a refining of estimates. When we first came up with these estimates they were reviewed as reasonable worst case but as information has been gathered in recent weeks from Italy and other countries it has become clear that this is the most likely scenario. The second piece of info that was critical was NHS planners going away to judge their healthcare capacity, particularly in critical care, and while they are planning an expansion it still would not be enough to fill the gap left. So we are left with no option but to adopt this more draconian strategy.

And does that mean that the strategy we previously heard about – to slow down the peak and use mitigation – that that’s no longer feasible?

So I think the measures announced in previous weeks are still valid but we need to go much further in terms of reducing the transmission of the virus.

And when will we know if these have had impact or not?

Not immediately. We are basically seeing case in hospitals and ICUs who were infected 2 weeks ago or more so we will have to wait about 2 weeks to see the effect on the epidemic. So we will continue to see cases grow over that time. We will be monitoring the situation closely and feeding into the gov resposnse to see if more moves are necessary.

So more moves could be necessary?

Yes as the PM outlined yesterday nothing is off the table. Hopefully currently measures will turn cases numbers into decline but there can be a need to escalate still further.

From a epidemiological point of view would it have been better to have these stricter measures earlier?

I think we are still behind the epidemics seen in other European countries so there is a balancing act involved to balance the cost to the economy with the change in the epidemic and I personally think we have got the timing right.

What about the assumption that the UK is in a better position that other countries in Europe?

We are 3 weeks or so behind Italy, 2 weeks behind France and Spain. So we are making these decisions in a more timely manner than other European countries. But certainly there was no time to lose.

What did modelling say about closure of schools and universities?

From a purely epidemiological point of view we think with a lot of uncertainty that closures would further reduce transmission. We don’t fully understand if children are transmissing the virus in the same way they do with other viruses. It would also have negative impacts on the health service due to childcare so there is currently a big review of what the likely impacts of school closures would be – positive and negative. It may be necessary in coming weeks.

[headshot]

Thanks again for your cool-headed and measured responses Mike. It really is very useful and reassuring to have proper information from a qualified professional.

[mikeh]

Faced with a potential shutdown of our main business yesterday my boss half-seriously decided to research the potential of importing COVID-19 antibody kits as an alternative revenue stream.

He is Chinese originally so was able to navigate the chinese-internet and reckons he's found a Chinese supplier of a home blood kit which detects IgG and IgM within 15 minutes, a box of 20 is £6.

He hasn't gone ahead with it yet and that has to come with a metric f.ck-tonne of caveats but even if that particular supplier is shipping boxes of lolly-pop sticks dyed green there must be other legitimate ones doing the same. A quick google search brings up a number of US companies shipping similar sounding kits. Or as above we could always make our own in the UK.

That has to beat the precautionary self-isolation for a fortnight everyone and their family who wakes up with a sore throat.

Would be very cautious about doing that. Current tests looking at this are not yet demonstrated to be reliable ((I don't think anyway, useful to know if good quality evidence is out there)
As in, is a positive test very likely to be positive, and a negative test very likely meaning no prior infection? Don't want to be responsible for sending dodgy kit around healthcare/public health settings.

CMO at yesterday press conference said Public Health England are working on precisely that, to develop a reliable test. Unsure on timescales.

[veravista]

I did some work on a ventilator a few years ago and the trick was that everything patient side was enclosed in a plastic bag, it's pretty simple to move air through a polythene membrane - so make it cheap and burnable. The thing about modern ventilators with all the variable feedback and stuff is they are complex for multi-use situations - cheap and cheerful and disposable may not be as effective but if it's a choice between that and f.ck all I know what I'd choose.

[mikeh]

Thanks again for your cool-headed and measured responses Mike. It really is very useful and reassuring to have proper information from a qualified professional.

I'm someone who knows a bit about aspects of COVID19, and tries to be pragmatic.

Behind the scenes, I worry as much as anyone else!

But thank you though

[Woodchopper]

https://twitter.com/hancocktom/status/1 ... 04032?s=09

Can this really be true? The models were based on viral pneumonia instead of Covid?

Better link: https://twitter.com/hancocktom/status/1 ... 5586604032

To clarify, COVID causes viral pneumonia (lower respiratory tract infections, essentially).

Flu is typically upper respiratory tract, as is the common cold (for example caused by a different type of coronavirus). If flu or the common cold virus (much more rarely, of course), invades the lower respiratory tract that is then typically described as a pneumonia.

I'm slightly baffled by the widespread assumptions that modelling different kinds of viral pneumonia, when we're talking about a cause of viral pneumonia, is wrong.
Elsewhere, you can for example have a look at the Every Breath Counts Coalition, which covered advocacy around coronavirus in the recent conference https://stoppneumonia.org/open-letter-t ... -covid-19/

Neil Ferguson, he of the Imperial modelling, gave an interview on (I think) the Today programme. I've been sent a transcript of the interview, am asking permission if I can share it. (But for now, I don't reckon his responses really don't equate to "we modelled the wrong disease"....)

The shutdowns in much of the the rest of Europe since late last week were, as far as I know,* precipitated by this 12 March ECDC advice that “ a rapid, proactive and comprehensive approach is essential in order to delay transmission” which included school closures, suspending mass gatherings etc.

https://www.ecdc.europa.eu/en/publicati ... -increased

That ECDC advice specifically included the UK.

ETA some general questions not specifically directed at mikeh

So last week, was the UK using very different models or data compared to the ECDC?

If so are the two now closer in terms the data used and assumptions made?





*based on what I’ve been told by people working on these issues in a European national government.

[purplehaze]

Thanks Dave. Appreciate it.

I've recently had an upper respiratory chest infection following a cold. It's on the mend now. However, at night there were times when I struggled with breathing. It only happened twice and I have to say good old fashioned Vicks sorted it out. I went to see my doctor during that time regarding another health matter and he assured me it was the cold.

[OneOffDave]

The proper ones are incredibly complex - always feeding back and adjusting with every breath. I think it sort of puts resistance in so the lungs have to keep working a bit, and this resistance must constantly change. They self-check themselves every second and give clear messages to nurses.

You could have grades A, B and C - but even C would need to be far beyond what you are talking about.

I wonder what happened to old ventilators when new and better versions came along. It would have been sensible to stockpile them, and have old 1990s versions lying around ready for a really bad flu season or a pandemic. No doubt the UK never had the foresight, but other countries?

Pre-hospital ventilators are much simpler and use a mechanical feedback loop rather than something electronic.

The last two trusts I worked for both had 70+ old ventilators in storage but there was an issue with maintenance, consumables and training. Once a machine stopped production, the support and maintenance for them drops off fairly quickly. Things like back-up batteries and filters are the consumables that are hardest to source. Eventually we had to scrap them

[OneOffDave]

Would be very cautious about doing that. Current tests looking at this are not yet demonstrated to be reliable ((I don't think anyway, useful to know if good quality evidence is out there)
As in, is a positive test very likely to be positive, and a negative test very likely meaning no prior infection? Don't want to be responsible for sending dodgy kit around healthcare/public health settings.

CMO at yesterday press conference said Public Health England are working on precisely that, to develop a reliable test. Unsure on timescales.

Current UK testing is PCR based so very accurate but needs 'proper' labs to carry it out in. There are a number if 'kit' tests out there but they are of varying reliability. I've heard from a reliable source that some have a 20% false -ve rate which isn't great. PHE have been assessing alternative tests since the 3rd week in January.

[OneOffDave]

Oh, and not just complex stuff like ventilators - there's not even basic stuff ready like PPE. How hard is it to build a hospital bed? f.cking easy, that's how hard.

So it's got to decontaminatable, adjustable, mobile, able to support different matresses for pressure relief, solid enough for CPR to be carried out on it. I'm sure you can have one that meets all of that by the end of today then.

[Little waster]

Would be very cautious about doing that. Current tests looking at this are not yet demonstrated to be reliable ((I don't think anyway, useful to know if good quality evidence is out there)
As in, is a positive test very likely to be positive, and a negative test very likely meaning no prior infection? Don't want to be responsible for sending dodgy kit around healthcare/public health settings.

CMO at yesterday press conference said Public Health England are working on precisely that, to develop a reliable test. Unsure on timescales.

Current UK testing is PCR based so very accurate but needs 'proper' labs to carry it out in. There are a number if 'kit' tests out there but they are of varying reliability. I've heard from a reliable source that some have a 20% false -ve rate which isn't great. PHE have been assessing alternative tests since the 3rd week in January.

Question then is it worth having more spreaders in circulation if it gets the "worried well", who would have otherwise self-isolated, out and about keeping the economy and society's lights on?

[purplehaze]

<sub>What did modelling say about closure of schools and universities?

From a purely epidemiological point of view we think with a lot of uncertainty that closures would further reduce transmission. We don’t fully understand if children are transmissing the virus in the same way they do with other viruses. It would also have negative impacts on the health service due to childcare so there is currently a big review of what the likely impacts of school closures would be – positive and negative. It may be necessary in coming weeks.</sub>

I'm wondering about the negative side effects of teachers educating children when they know that they are simply there for child care. Older students will know this - from the dreaded year 9 onward.

Discipline will, in my view, deteriorate. Plus there will be the extra added complication of pupils being sent home - they will pump up the drama.

I know that certain students will disrupt classes by coughing - they do this in mock exams when they are bored.

I certainly wouldn't want to be in a classroom right now.

[lpm]

Oh, and not just complex stuff like ventilators - there's not even basic stuff ready like PPE. How hard is it to build a hospital bed? f.cking easy, that's how hard.

So it's got to decontaminatable, adjustable, mobile, able to support different matresses for pressure relief, solid enough for CPR to be carried out on it. I'm sure you can have one that meets all of that by the end of today then.

They haven't got to be all these things. In the movies WW2 casualties aren't lying on these. And actually we are not after hospital beds, we are after Treatment Centre beds.

[lpm]

And what is was crucial in you changing your conclusion? Was it more informing coming in from other countries?

It’s not so much changing our conclusions. We don’t recommend policy.

There's that thing with pilots and co-pilots - each one thinks the other has control , so no-one has control. And they announce to each other to prevent this.

I suspect the politicians thought the experts were recommending policy, and vice versa.

[calmooney]

Thanks again for your cool-headed and measured responses Mike. It really is very useful and reassuring to have proper information from a qualified professional.

+ lots, it's much appreciated.

[purplehaze]

Oh, and not just complex stuff like ventilators - there's not even basic stuff ready like PPE. How hard is it to build a hospital bed? f.cking easy, that's how hard.

So it's got to decontaminatable, adjustable, mobile, able to support different matresses for pressure relief, solid enough for CPR to be carried out on it. I'm sure you can have one that meets all of that by the end of today then.

That's care home beds essentially. With the exception of probably one resident (there's always one), most care homes have a DNR order on each resident.

[OneOffDave]

They haven't got to be all these things. In the movies WW2 casualties aren't lying on these. And actually we are not after hospital beds, we are after Treatment Centre beds.

We aren't going to be having fit young men recovering from trauma on them for a relatively short period of time before being moved to the rear on to more conventional beds. It's going to be poorly people who are going to be at much much higher risk of pressure sores and the like than the wider population. Pressure sores kill. I have a friend who was hospitalised for 127 days last year with one including three weeks on a ventilator. They need to be adjustable as lying totally prone is not ideal in people with pneumonia. In casualty clearing stations on the front line in a war zone, cross-contamination was seen as an acceptable risk.

During the war we treated people in tents with no running water or heating so lets do that too

[FredM]

Meanwhile, in France you need to fill out, sign and carry one of these if travelling outdoors.

[shpalman]

And have been told okay to share the transcript (to clarify, I have not heard the audio/video of the interview, so am assuming this is correct)

...
And otherwise it could have resulted in 260,000 deaths?

I mean I think no country in the world thus far has seen an epidemic that large – that data is an extrapolation based on early data drawn from China. We have no reason to believe that is not what would happen if we frankly did nothing. Even if we did all we could to slow but not reverse spread we would still be looking at a very large number of deaths and the health system being overwhelmed.
...

No country in the world thus far has seen an epidemic that large because they've all implemented very restrictive containment measures.

Aside from Codogno, the other Red Zone set up in Italy at the beginning of the emergency was Vò near Padua; today they had no new positives.

In such a small town it was feasible to swab literally everybody.

If I understand the TV news correctly, the virus reached about 3% of the population.

Maybe in the beginning there could have been the assumption that China is covering up the true number of positives but it's harder to cover up the true number of deaths; or that Italy has an aging population and is somehow third world in terms of its health service and isn't testing everyone anyway.

These assumptions could have led one to believe that there were a huge number of mild/asymptomatic infections for every detected or serious one, meaning (a) that the virus is a whole lot less serious than it appeared and (b) that you can't hope to stop it infecting just about everyone.

Interesting article in the NYT by a senior WHO type on what he saw in China
https://www.nytimes.com/2020/03/04/heal ... lward.html

In Guangdong, they went back and retested 320,000 samples originally taken for influenza surveillance and other screening. Less than 0.5 percent came up positive, which is about the same number as the 1,500 known Covid cases in the province...

There is no evidence that we’re seeing only the tip of a grand iceberg, with nine-tenths of it made up of hidden zombies shedding virus. What we’re seeing is a pyramid: most of it is aboveground.

In Vò Euganea they really swabbed 95% of the population, so that the Università di Padova could run the epidemology. Of course this is only feasible in a small town.

https://www.repubblica.it/salute/medici ... 251474302/

They found that 50-75% of cases are asymptomatic but need to be isolated anyway.

Testing literally everyone in a large country is not feasible. But there's a massive difference between "in Hubei they had 70000 cases and 3000 deaths and that's out of a similar population to the UK so we can expect similar numbers" and "in Hubei they had 70000 cases and 3000 deaths having managed to limit the infection to a few percent of the population via social distancing and lockdowns"

[shpalman]

Meanwhile, in France you need to fill out, sign and carry one of these if travelling outdoors.

In Italy there's something similar; I printed one of the forms, filled in my details, and scanned and printed a few copies of that. I think you can fill in the form on the spot when they stop you but this saves time and effort. I haven't been stopped yet because I haven't been out of town.

[Opti]

Meanwhile, in France you need to fill out, sign and carry one of these if travelling outdoors.

In Italy there's something similar; I printed one of the forms, filled in my details, and scanned and printed a few copies of that. I think you can fill in the form on the spot when they stop you but this saves time and effort. I haven't been stopped yet because I haven't been out of town.

Here, you have to carry all your papers, only one person in a car and you need to explain your reason for being out. Big trouble if you don't comply. It's all ok, people complying without complaining. Except the few 'ex-pats' who think they're special. A few €1000 fines will stop that pretty quickly.
I did a supermarket run yesterday. That's ok. We're good for a while.
However, beach is closed. Still, we can go and look at it.

[lpm]

They haven't got to be all these things. In the movies WW2 casualties aren't lying on these. And actually we are not after hospital beds, we are after Treatment Centre beds.

We aren't going to be having fit young men recovering from trauma on them for a relatively short period of time before being moved to the rear on to more conventional beds. It's going to be poorly people who are going to be at much much higher risk of pressure sores and the like than the wider population. Pressure sores kill. I have a friend who was hospitalised for 127 days last year with one including three weeks on a ventilator. They need to be adjustable as lying totally prone is not ideal in people with pneumonia. In casualty clearing stations on the front line in a war zone, cross-contamination was seen as an acceptable risk.

During the war we treated people in tents with no running water or heating so lets do that too

I really don't understand your point. Unless we get more beds, we are going to be treating people in tents with no running water or heating. That is the path we are locked into. This first April-June wave could easily peak at 50,000 critical cases. It's either accept Grade C beds now, or hold out waiting for the ideal Grade A beds and then watch the army breaking into the Bensons warehouse and commandeering all their mattresses.

We can't keep thinking in old United Kingdom terms, about sophisticated hospitals with ideal beds and fully trained ICU nurses and the best ventilators ever made, all efficiently acquired. Policy makers must adjust fast to Pandemic Kingdom needs - substandard beds, new nurses trained to deal with only a single task for a single disease, ventilators that don't meet regulations and have a higher breakdown rate.

[gosling]

Meanwhile, in France you need to fill out, sign and carry one of these if travelling outdoors.

What do you do if you don't have a printer at home?

[Boustrophedon]

From Mike Galsworthy:
https://www.pscp.tv/w/1MnGnQyoRPyKO

Short version; Government have f.cked up because they used the wrong viral model and are backtracking wildly.

[FredM]

Meanwhile, in France you need to fill out, sign and carry one of these if travelling outdoors.

What do you do if you don't have a printer at home?

You can use a handwritten version following the same format.