Coronavirus - worldwide spread and control

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Editorials
The UK’s public health response to covid-19
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1932 (Published 15 May 2020)

https://www.bmj.com/content/369/bmj.m1932
  1. Gabriel Scally, visiting professor of public health1,
  2. Bobbie Jacobson, senior associate2,
  3. Kamran Abbasi, executive editor3
I haven’t read all of it but looks like a really good article so far:

“Membership of SAGE and its national committees reflects England’s marginalised public health infrastructure. Reorganisation of public health in England, largely resulting from the Health and Social Care Act 2012, led to a critical loss of senior posts and staff.22 The Health Protection Agency, regional public health teams, and regional public health observatories were abolished, and the remnants incorporated into a slimmed down Department of Health agency, Public Health England. This new agency lacks an independent voice and clear public health leadership. England’s chief medical officer is no longer seen as the leader of public health. With these reforms, England’s new public health system was born critically flawed.

By the start of the coronavirus pandemic only one of the UK’s four territories had a trained public health physician as its chief medical officer. At a local level in England, many public health responsibilities were sensibly transferred back to local authorities with the 2012 act. But since then, close to £1bn (€1.1bn; $1.2bn) has been cut from public health budgets and the position made worse by cuts to other local authority services such as environmental health.2324

Public health approach
The UK government’s decimation of public health during years of austerity, and its impact on vulnerable groups, is for a public inquiry to investigate, although any inquiry report will be hollow without legislative change. The system failings are being exposed brutally by covid-19. For now, the focus must be on a strategy to minimise harm from ill advised relaxation of physical distancing in ways that will trigger further epidemic spikes with prospects of a vaccine or treatment still distant.

Firstly, SAGE must exclude political advisers and recruit more public health experts. Secondly, a clear population strategy based on case finding, testing, contact tracing, and isolation is required for each of the four nations to inform and justify future decisions about how the lockdown can be safely relaxed. The plans for case finding, testing, and community contact tracing must be adequately resourced, decentralised, and led by local public health teams who know their communities and the nature of the outbreaks in their localities. Public Health England and the NHS must fully support these plans. And implementation of testing, data monitoring, and reporting must be optimised from all sources: hospital, primary, and social care.

In time, findings from the first population surveillance study will help effective targeting.25Meaningless political soundbites promising to recruit 18 000 contact tracers, test 200 000 people a day, or invest in unjustified contact tracing apps, divert focus and could lead to more deaths.26 These headline grabbing schemes should be replaced by locality led strategies rooted in communicable disease control.“
 
I don't think the problem is with the idea of shielding the most vulnerable to the virus - it makes sense to try to avoid catching an infection if you are particularly likely to suffer badly if you catch it. The problem is what you do with everyone else.

Effectively shielding the most vulnerable means you need to also shield those they have to come in contact with as well, such as household members. And you also need to provide effective PPE for those they need to come in close contact with such as carers, whether the caring happens at home, in care homes or in hospital.

I think the dispute is more about what to do with the rest of the population. The choice seems to be between:

- the herd immunity approach that aims to get a high level of immunity among the rest of the population, with varying levels of voluntary and compulsory control measures to slow the spread to avoid overwhelming health services

- or the elimination approach using rapid early lockdown alongside getting a very effective testing, tracking, tracing and isolating infected individuals.

The herd immunity approach is likely to lead to the necessity for shielding the vulnerable for ever unless an effective vaccine can be found - as in the UK and USA

The elimination approach is likely to lead to shielding for some months until elimination is achieved - as in South Korea and New Zealand

As an elderly sick person who chooses to shield, I know which approach I prefer. At present it seems likely my daughter and I will be shielding for years, unless the UK can get its act together to eliminate the virus which seems highly unlikely, or there is a vaccine.
 
Trish said:
I don't think the problem is with the idea of shielding the most vulnerable to the virus - it makes sense to try to avoid catching an infection if you are particularly likely to suffer badly if you catch it. The problem is what you do with everyone else.

Effectively shielding the most vulnerable means you need to also shield those they have to come in contact with as well, such as household members. And you also need to provide effective PPE for those they need to come in close contact with such as carers, whether the caring happens at home, in care homes or in hospital.

I think the dispute is more about what to do with the rest of the population. The choice seems to be between:

- the herd immunity approach that aims to get a high level of immunity among the rest of the population, with varying levels of voluntary and compulsory control measures to slow the spread to avoid overwhelming health services

- or the elimination approach using rapid early lockdown alongside getting a very effective testing, tracking, tracing and isolating infected individuals.

The herd immunity approach is likely to lead to the necessity for shielding the vulnerable for ever unless an effective vaccine can be found - as in the UK and USA

The elimination approach is likely to lead to shielding for some months until elimination is achieved - as in South Korea and New Zealand

As an elderly sick person who chooses to shield, I know which approach I prefer. At present it seems likely my daughter and I will be shielding for years, unless the UK can get its act together to eliminate the virus which seems highly unlikely, or there is a vaccine.
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Yes, but the term “shielding” and “cocooning” has only ever come into play in countries which didn’t go for a strong elimination strategy. So staying at home, because you feel more at risk, isn’t called “shielding” in other countries. I don’t know what people do in China or South Korea but it doesn’t look like the elderly or vulnerable had a specific policy or were mandated to stay at home (or even if that many chose to), while others went about close to normal.

When they had lockdown, they used lockdown for the entire population- not for certain sections of the population. When they needed tracing or testing, again they used it for the whole population. Possibly some, but I’m sure not all, elderly and/or chronically ill people decided to stay at home at times when the govt didn’t mandate it as a form of lockdown - but that’s not been called shielding. “Shielding“ and “cocooning“ seems to be very much a western concept and has been used in a specific context - it’s this policy that Prof Sridhar isn’t keen on.
 
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lunarainbows said:
Yes, but the term “shielding” and “cocooning” has only ever come into play in countries which didn’t go for a strong elimination strategy. So staying at home, because you feel more at risk, isn’t called “shielding” in other countries. I don’t know what people do in China or South Korea but it doesn’t look like the elderly or vulnerable had a specific policy or were mandated to stay at home (or even if that many chose to), while others went about close to normal.

When they had lockdown, they used lockdown for the entire population- not for certain sections of the population. When they needed tracing or testing, again they used it for the whole population. Possibly some, but I’m sure not all, elderly and/or chronically ill people decided to stay at home at times when the govt didn’t mandate it as a form of lockdown - but that’s not been called shielding. “Shielding“ and “cocooning“ seems to be very much a western concept and has been used in a specific context - it’s this policy that Prof Sridhar isn’t keen on.
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Ah, OK, I think I understand what you mean. In Wuhan, as I understand it, they lockdown everyone and used effective testing tracking and isolating until the disease was all but eliminated, then they could unlock everyone and continue tracking and tracing to deal with odd cases that arose. So shielding specific groups wasn't necessary.

And in South Korea, the disease was coming from China so they had some warning of what was coming, so they were able to shut down people travelling into the country, and they were already prepared for testing etc since SARS. So they didn't need to do a complete lockdown. But they have done some control measures like shutting down nightclubs and other places of large gatherings. Because they got on top of this from the start, they didn't need to bring in shielding for the vulnerable as a specific group as far as I know.

I don't think the UK brought in shielding until the disease was already out of control in the community after they gave up very quickly on quarantining people coming in and had no testing system set up. So our situation was different. If you don't have a testing tracing etc system ready to run as soon as an epidemic arrives, and you don't lock down immediately and quarantine incomers, you end up inevitably with wide community spread. And if you're half hearted about lockdown and relax it while there is still wide community spread, and before effective testing and tracing is up and running, as is happening in the UK, then the vulnerable are at high risk and you either need a shielding policy or you accept high death rates.

So I agree shielding in an ideal situation of rapidly initiated and effective control and testing systems isn't necessary. Sadly, in the UK, it is necessary.
 
Jonathan Edwards said:
The point that shielding on its own is not a good approach is entirely right. But the bit about people living all together in Eastern countries is irrelevant
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It is about the spread dynamics. How people live and therefore the way they contact others will be a key component in how spread happens. If there are common households with people who are expected to go out and act normally and people who are vulnerable then this clearly is an issue and a strategy based on shielding won't work. If vulnerable people live in separate households and can separate then a shielding strategy may work but there are still points of contact where spread could occur that need managing. Some of the vulnerable people need more contact in terms of care workers - which I assume is part of the problem with spread in the care homes (as well as hospital discharges).

Hence the overall way vulnerable people in the population live is important and I suspect that it has to be looked at in more complex terms than overall trends. If say 10% of the vulnerable people live in households where they interact with non-vulnerable people who are at a higher risk then that could still be a lot of vulnerable people with a higher chance of getting cov19 and the associated healthcare issues.

Hence I think the statement that it is hard to manage Covid by just shielding vulnerable populations. And that is not even considering the health of the less vulnerable and possible long-term health issues.
 
Trish said:
Ah, OK, I think I understand what you mean. In Wuhan, as I understand it, they lockdown everyone and used effective testing tracking and isolating until the disease was all but eliminated, then they could unlock everyone and continue tracking and tracing to deal with odd cases that arose. So shielding specific groups wasn't necessary.

And in South Korea, the disease was coming from China so they had some warning of what was coming, so they were able to shut down people travelling into the country, and they were already prepared for testing etc since SARS. So they didn't need to do a complete lockdown. But they have done some control measures like shutting down nightclubs and other places of large gatherings. Because they got on top of this from the start, they didn't need to bring in shielding for the vulnerable as a specific group as far as I know.

I don't think the UK brought in shielding until the disease was already out of control in the community after they gave up very quickly on quarantining people coming in and had no testing system set up. So our situation was different. If you don't have a testing tracing etc system ready to run as soon as an epidemic arrives, and you don't lock down immediately and quarantine incomers, you end up inevitably with wide community spread. And if you're half hearted about lockdown and relax it while there is still wide community spread, and before effective testing and tracing is up and running, as is happening in the UK, then the vulnerable are at high risk and you either need a shielding policy or you accept high death rates.

So I agree shielding in an ideal situation of rapidly initiated and effective control and testing systems isn't necessary. Sadly, in the UK, it is necessary.
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Yes, Now it’s too late in a lot of the country, we don’t have much choice at all except to stay put. Prof Devi Sridhar is advising the Scottish govt, and if they move quickly, and set up a good testing and tracing system, while keeping lockdown for longer, they could potentially get into a better situation soon - I think perhaps that’s her hope.

I found this interesting from the article which is relevant:

“Professor Sridhar would like to see a policy which gives the elderly or the supposedly vulnerable a greater say in deciding their fate.

“We have to listen to people who want to make an informed choice,” she said. “The thing we are really missing and which I think could be transformative is local-level data. If people knew in their neighbourhood, whether in Glasgow or in Edinburgh, or if they are in a rural area, what the rates of transmission were, that would help.

“You could have some kind of rating, where red means you have active community transmission, green means very few cases, or transmission is almost non-existent. Then I think people could make choices about how much they want to circulate. If you know transmission is high you will be more cautious, if it’s just a handful then it’s OK.””

And this way - it wouldn’t be a blanket “shielding” policy. This red, green etc policy is similar to something China has as well. But for this to happen, so much needs to be change, as that BMJ article above talks about. It is very frustrating that we don’t already have local data and tracing, cordon sanitaires to protect areas that have little or no transmission from areas that have lots of transmission, local decisions...
 
@sTeamTraen has published an interesting blog about some of the failures of a modelling paper
https://steamtraen.blogspot.com/2020/05/the-perils-of-improvising-with-linear.html

With reference to the paper
Stedman, M., Davies, M., Lunt, M., Verma, A., Anderson, S. G., & Heald, A. H. (in press). A phased approach to unlocking during the COVID-19 pandemic – Lessons from trend analysis. International Journal of Clinical Practice. https://doi.org/10.1111/ijcp.13528

which has been claiming that >25% of the population have Covid19 based on their model.
 
I thought this was quite an interesting article around the evidence about whether it is safe to reopen schools. Unlike a lot of press coverage it does talk about the limited but various pieces of research looking at children mentioning population studies including children such as one in Vo where they tested 80% of people and found 2.8% had Covid19 but no children under 10 (but this could just be a function of how the town works and random effects). They also mention things like the German study showing children have similar viral loads.

Its nice to see an article from a journalist trying to talk about the range of evidence and suggesting its complex rather than just promoting a paper from a press release.

https://www.theguardian.com/world/2...oronavirus-risk-to-children-if-schools-reopen
 
This is interesting given that the main argument against lockdown is an economic one. At least in Scandianavian culture it may be a lot less relevant than commonly thought.

My take:

Lockdown requirements don't make much difference to most people's behaviour, they just stay home anyway because it's the sensible thing to do, rules or no rules, and consequently spend less.

Lockdown requirements do make a difference to a few people's behaviour, if allowed to they go out if they want to or feel they need to. As a result there was a little bit of extra spending going on in Sweden - and a lot of extra virus-spreading.
Abstract

This paper uses transaction data from a large bank in Scandinavia to estimate the effect of social distancing laws on consumer spending in the COVID-19 pandemic. The analysis exploits a natural experiment to disentangle the effects of the virus and the laws aiming to contain it: Denmark and Sweden were similarly exposed to the pandemic but only Denmark imposed significant restrictions on social and economic activities. We estimate that aggregate spending dropped by around 25 percent in Sweden and, as a result of the shutdown, by 4 additional percentage points in Denmark. This implies that most of the economic contraction is caused by the virus itself and occurs regardless of whether governments mandate social distancing or not. The age gradient in the estimates suggest that social distancing reinforces the virus-induced drop in spending for individuals with low health risk but attenuates it for individuals with high health risk by lowering the overall prevalence of the virus in the society.
Click to expand...
From: Pandemic, Shutdown and Consumer Spending: Lessons from Scandinavian Policy Responses to COVID-19
https://arxiv.org/pdf/2005.04630.pdf
 
Opinion piece in Svenska Dagbladet about Sweden being left out when other Nordic and European countries are starting to open their borders. The Swedish Foreign Minister is frustrated and claims Sweden's strategy has been misunderstood.


https://www.svd.se/nar-europa-oppnar-granser-ligger-sverige-daligt-till

"When Europe opens borders, Sweden is poorly positioned
The Nordic neighboring countries are considering discriminating against Sweden when borders around Europe begin to re-open. It's no wonder. High death rates and a shoddy strategy discourage."

"In Denmark several parties wants to open to Germany and Norway, but not to Sweden. Intensive negotiations are ongoing and our Nordic Minister Anna Hallberg tells Sydsvenskan that it would be unfortunate if this would happen. Unfortunate, yes. But not a coincidence. Finland has also opened up for Sweden to be treated differently. What the countries that open to each other have in common is a confidence in the other country's corona strategy. Ann Linde is frustrated: "Me and my colleagues have been very careful in saying that one should discriminate against various countries when trying to open now." But Sweden has nothing to oppose from a legal standpoint. "

" Internal borders should be opened between countries with the same epidemiological situation. It is said that it should be done in a non-discriminatory way, that is, if one country opens to another with a certain spread of infection, it should be opened to everyone with a corresponding situation .

In practice, it could mean that Denmark can open to Germany before opening to Sweden, unless we can credibly show that we have the same control over the infection. But our death tolls are causing headlines all over the world and give reasons for keeping closed. Yesterday, Sweden ranked 8th on Worldometer's list of the most deaths per million inhabitants in the world. 365 people per million, dead in Covid-19. Denmark was ranked 24th with 94 dead per million inhabitants. Germany came close in place 23."

" The Swedish corona strategy has been so unclear and fuzzy on the edges that our Foreign Minister must begin her negotiations with convincing the outside world that we are not at all investing in herd immunity and that we certainly care about keeping the spread of infection down just like other countries. Even if we accept the idea that this is a communication problem - that the outside world has only gotten our strategy backwards- that in itself is a major failure.

In the short term, the government has managed to avoid major interferences with individual freedom, and been proud of that. But the gains might be lost if it turns out that our reputation has become so damaged and our death tolls so high that we are shut out when the rest of Europe opens again."
 
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New Times article

https://www.thetimes.co.uk/article/...-scientists-picked-the-wrong-remedy-nmk8lsrr7

Coronavirus: fixated on the flu and shrouded in secrecy, Britain’s scientists picked the wrong remedy

How the U.K. response was based on flu
Interestingly, mentions the code that prof Neil Ferguson released and they say that it had different outputs when run on different computers!

“The history is revealing. UK thinking was shaped by the Asian and Hong Kong flu pandemics of 1957 and 1968. Sars and Mers — both coronaviruses — barely registered. Exercise Cygnus, a simulation carried out in 2016, was based on flu. In early 2020 the UK was still preparing for pandemic flu, stockpiling Tamiflu and Relenza. Even as community transmission of Covid-19 was detected, the recommended protective equipment was in line with flu. When an updated document on school closures was submitted in February 2020, it said: “For the purpose of this paper, we assumed that children have a role in transmission similar to that of influenza.”

Looking back on the seminal press conferences of early March, you can see flu hovering like an apparition. The logic of “Contain, delay, research, mitigate” is based on flu. The trade-off that dominated UK thinking — namely, the balance between suppressing the first wave and reducing susceptibility to a second — assumed that containment was not feasible. It was the prism of flu — not evidence emerging from Asia — that led Chris Whitty, the chief medical officer, to assert on March 12 that containment was pointless. It is why Jennie Harries, his deputy, said on the same day that community testing was “not appropriate”. It is why there was so little urgency to build testing capacity in that crucial window.

In a fine analysis last week, the historian Sir Lawrence Freedman pointed out that UK policy was based on a “mature conceptual framework”. But the problem is that the framework had matured through a covert process of conceptual narrowing, and was shrouded in secrecy. Many scientists disagreed with the cessation of community testing, but they couldn’t look at the reasoning because it was confidential. Experts were also surprised when the Imperial model was finally published, a program with 13-year-old code. A group at Edinburgh University found that the model gave different outputs when fed the same inputs, and different results when run on different computers.”
 
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Trish said:
Interesting graphical comparison.

This is the source website of the graphs above:
https://www.endcoronavirus.org/countries
It shows countries all over the world divided into 'winning', 'nearly there' and 'need to take action'.
And this is the information about the person who runs it, Prof Yaneer Bar-Yam.
https://www.endcoronavirus.org/about
Click to expand...

Yes - he is also the founding president of the New England Complex Systems Institute - which produced an analysis paper about the Imperial model, which we talked about on this thread earlier, - how they missed out modelling contact tracing and testing, ignored super spreader events, etc:

https://necsi.edu/review-of-ferguson-et-al-impact-of-non-pharmaceutical-interventions?rq=Imperial
 
On worldometer, the UK, on deaths per million of population, is on track for a bronze medal in the 'how to handle a pandemic as badly as possible' olympics.

https://www.worldometers.info/coronavirus/?utm_campaign=homeAdUOA?Si

Only Spain and Italy are above us, on official figures (and there is every reason to doubt these in the case of the UK).

The US, and Brazil, are not in the same league as us, their performance in killing off their own populations through incompetence is quite frankly underwhelming, when compared to the results achieved by the UK.

It's really saying something when our Government is even less competent, than the US administration.

Both Italy, and Spain to some extent, have the excuse that they got caught off guard, and overwhelmed, but what excuse do we have?

We knew it was coming, even to the extent of saying how many weeks behind various countries we were. Our health system was not overwhelmed so, we are told, that no one in the UK went untreated and died, for lack of staff or respirators.

Best scientific advice my dodgy right foot.
 
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