Here is a new paper from Imperial College, this time by a team with David Miles, Mike Stedman, and A into the implicit cost per QALY that the UK spent via lock downs and other repression policies. They use a somewhat different methodology from mine, estimating marginal effects of policies from cross-country variation rather than with some notion of the previous status quo, but they end up with almost the exact same answer that “The lowest estimate for lockdown costs incurred was 50% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimation they were over 50 times higher“. In other words, they estimate that for every life-year saved by restrictions, an estimated 50 will be lost down the line whom we can no longer afford to save. And that’s just solely within the UK. They hence say it was all a huge mistake that we should undo as fast as possible. Here’s their full abstract:
The COVID-19 pandemic has transformed lives across the world. In the UK there has been a public health driven policy of population ‘lockdown’ that had enormous personal and economic impact. We compare UK response/outcomes including excess deaths with European countries with similar levels of income/healthcare resources. We calibrate estimates of the economic costs as different %loss in GDP against possible benefits of avoiding life years lost, for different scenarios where local COVID-19 mortality/comorbidity rates were used to calculate the loss in life expectancy. We apply quality-adjusted life years (QALY) value of £30,000 (maximum under NICE guidelines). The implications for future lockdown easing policy in the UK are also evaluated. The spread of cases across European countries was extremely rapid. There was significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non-COVID-19 was 79.1 and 11.4years respectively while COVID-19 were 80.4 and 10.1years; including for life-shortening comorbidities and quality of life reduced this to 5QALY for each COVID-19 death. The lowest estimate for lockdown costs incurred was 50% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimation they were over 50 times higher. Application to potential future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst-case £3.7m (125xNICE guideline) was needed to justify the continuation of the lockdown. The evidence suggests that the costs of continuing severe restrictions in the UK are so great relative to likely benefits in numbers of lives saved so that a substantial easing in restrictions is now warranted.
here’s a whole UK website which runs analysis after analysis on the horrendous cost of the UK’s policies: https://lockdownsceptics.org/
When reading the various articles on it, it feels like walking into a pub where everyone agrees with everything we’ve been arguing here at Troppo for three months, but the contributors all add their own perspective and unique knowledge as well. Refreshing.
Refreshing if you ignore its frequent resemblance to various other sceptic agendas.
Here’s the main website on the excess deaths in Europe, tracking the regular mortality rates in over 24 countries, starting in 2016, so you get to see the previous flu-seasons of 2018 and 2019. The graphs basically show the covid-19 wave in Europe is over and was not much bigger than previous flu-waves. https://www.euromomo.eu/graphs-and-maps#
Interesting points to note:
– the total excess deaths relative to the same date in 2018 are about 80,000 people (now even declining). Since the data represent about 350 million people, that’s a total mortality rate of 0.023% above the 2018 flu-season (which was a relatively bad year). Its 0.06% relative to “baseline” (essentially the decade before 2016). Basically an extra week or two of normal mortality rates.
– there is no clear second wave anywhere in Europe, despite places open for over a month now (Switserland). Belgium and Spain show weak hints of a second wave.
– Sweden had unusually low-mortality flu-seasons in 2017-2019 relative to the rest of Europe.
– these excess deaths are all-causes, so will include any deaths from people with other illnesses who didn’t get the necessary treatments because hospital operations were cancelled or whatnot. Hence, so far, stories of masses of Europeans dying from other preventable causes don’t seem correct either. The lack of continued spikes for the elderly is in line with this: if there is a longer-term loss from lack of normal care, it will be of the preventative kind that will take a much longer time to show itself (and will thus be hard to causally prove).
– the pattern between previous flu seasons and this one is not so clear. You’d think that places with clear previous higher-than-ordinary flu-season deaths would have a low current first-wave, but you dont see that. Berlin had no noticable previous wave or current wave. Spain had quite pronounced previous seasonal waves, and did so again this time round. The UK, Netherlands, and Sweden had little in terms of strong previous waves, but a pronounced wave now. This means stories on previous immunity build up via other flu-waves are hard to maintain unless that previous immunity comes from “regular waves” that are in the baseline, come from further back than 2016 or are due more due to continuous infections rather than abnormal seasonal waves.
Paul
Significant stuff:
Prof Keith Neal, Emeritus Professor of the Epidemiology of Infectious Diseases, University of Nottingham, said:
On “Fortieth SAGE meeting on COVID-19, 4th June document”
“The SAGE meeting notes from the 4th June on the situation update make interesting reading. Numbers 5,6 and 7.
“They confirm that a significant amount of the total cases are acquired in hospitals or care homes. Including these cases in overall community models is highly inappropriate as control of COVID-19 is different for the different routes. Social distancing in all it’s nuances for the community and infection control in hospitals and care homes. When meat plant and similar outbreaks are added into the R currently being published there will be further distortion as these are managed as specific outbreaks, not more social distancing.
“The fact that models (on 4th June) were reporting 35,000 cases daily compared to actual people based methods such as the ONS and the Zoe app of 7-8000 is clearly worrying. They can NOT both be right and highlights the problems for the decision makers with such disparate key information.”
In a recent LSE podcast, Tim Beasley said that the containment policies involved a huge distributional shift from the young to the old. That claim wasn’t disputed by other presenters/commentators in the LSE podcast.
If this distributional issue had more attention in public discourse (and the media), I wonder what effect it would have on policy.
https://www.medrxiv.org/content/10.1101/2020.06.21.20132449v1
Here’s an interesting little study that should have gotten a lot more attention because it is saying something important that I have been saying for months: many people catch this virus but do not show up positive on those anti-body tests. Rather, their immune systems deal with it in other way. You might say they shrug it off. Or that the T-cells take care of it. This little study found a family of 8 who had all contracted the virus (something you can measure if you’re there at the start), but in a follow-up only 2 out of the 8 developed anti-bodies and 6 out of the 8 did not (but did have a T-cell response).
That’s just huge. It’s exactly the ratio you’d expect from the Diamond Princess data where only 700 out of 3,700 showed up positive in ex-post tests, but where everyone surely got some exposure.
It would mean the serology tests underestimate the percentage of the population that have had it by a factor of 4. Multiply the estimates on serology by 4 and you are close to herd-immunity already in many countries and cities in Europe. All you need to add on that is some prior immunity via other diseases and you explain the lack of second waves. This should be headline news. It suggests the corona outbreak in Europe might truly be almost over and will only return in countries that had an insufficiently small first wave, like maybe Germany.
Why haven’t such studies been conducted on a larger sample size?
I’ve heard lots of people talking about other forms of immunity, yet I’m seeing very little research being done to validate this. Everyone is solely focused on antibodies.
Hi Aaron,
maybe it has been done on bigger samples, I dont know for certain. There is now so much coming out at such a pace that we might simply not have heard about it yet.
There is another element though, which is that scientific training has become very narrow in recent decades. There are now hordes of scientists raised with the idea that if it hasn’t been shown to exist in a randomised trial or via some trusted test, then the status quo belief must be presumed to hold. So information like “those other passengers were surely exposed so the tests dont pick up everything you want to” is a kind of data and thinking no longer taught or appreciated. It doesnt fit the canon. But its exactly that kind of thinking and data that leads to new hypotheses and that good model builders look for.
https://www.reuters.com/article/us-health-coronavirus-usa-new-york/new-york-citys-low-income-minority-areas-hit-hardest-by-covid-19-cuomo-says-idUSKBN22W2IG
I guess 172% of the people in the Bronx’s Morrisania neighborhood must have immunity then..
Conrad
It is possible that for ,possibly multiple different reasons in some people the virus struggles to get a foothold in the first place.
For example there is a hypothesis that in some people their ACE2 receptors are less receptive of the virus .
https://journals.sagepub.com/doi/10.1177/2040622320935765
I’m sure there must be — What I don’t really understand is when they say you lose immunity to what extent you lose it all. Surely it can’t be all otherwise every new encounter would be completely novel — or can it?
The above comment was just to note that if you predict 3 cases going missing for every one found, the most you can ever predict is 25% found. If you assume herd immunity then a result of 43% missing means the most you could be missing is 1 for each found (giving 86% immunity).
It could be like the flu most of the time you have some kind of resistance ;most of the flu’ I’ve had were relatively mild. but sometimes something really gets through the defences; when I was 35 I had a flu that knocked the crap out of me ; for about ten days I could barely get out of bed , I went from weighing about 68 kilos to weighing just 58 kilos , i looked like I’d come out of Changi.
funnily enough, I brought up the exact same numbers as the main “problem data” about a month ago when discussing this issue (in one of my herd-immunity posts). I then also argued that the 50% serology test rates in some NY neighbourhoods made the “other immunity” story harder. Now I think there’s enough evidence of various sorts (small studies, slowing death rates, lack of second waves, regional puzzles, children) to suggest one should look for other explanations for those NY neighbourhoods rather than doubt the “other immunity” story.
Maybe the ventilation in those NY neighbourhoods is so poor that they got deep infections there (because we know almost everyone who has had this thing in a bad way gets anti-bodies). Maybe some previous viruses passed those neighbourhoods by. Maybe there is a genetic component. We dont know. But there are further dimensions to play with on this.
I’m not quite sure what you can infer from NY given it was only very recently let out of serious lockdown and, as far as I am aware, people are still pretty restricted by rules, as well as self restricted (wearing masks etc.). That being said, they never stopped getting 1K cases a day, which is hard to reconcile with herd immunity. I assume you’ll admit you are wrong if the numbers go up again and I’ll admit there is more to it if the state stops enforcing rules and people give up being careful (like happening now in many states in the US), and the cases go down.
It’s funny that you should talk about air-conditioning and randomized trials. These first of these I brought up (possibly on Facebook), and no-one thought anything of it, despite it being a likely factor in some cases of SARs-1 (including one major outbreak). As you may know, I also don’t think too highly of randomized trials (often a waste of money run that could be better on smaller scale theoretically motivated experiments). However, in this case, I don’t think it is too bad because quantitatively, it bounds both the top-end and bottom-end, which is useful for planning. I also think it’s up to people like you arguing for an anomaly for telling us what the reason is that your prediction is out by 300%, as that is clearly a huge effect size, and so tiny factors are not going to cut-it. So good luck finding them.
On that note, it is pity there is no big data collation site as I think many of the possibilities could be answered. For example, at least for the data here, it should be easy to tell if it is (a) a built-up neighborhood effect (there are many which called be compared); (b) an African American effect (there a largely white states going through the roof right now like Arizona, so perhaps that will be answered soon); (c) a low-SES effect; or (d) a obesity/poor health effect.
I saw this study that finds the antibodies drop off after 2 to 3 months: https://www.nature.com/articles/s41591-020-0965-6
This might explain some of what’s going on. Not entirely clear what the implications of this are: whether immunity is short lived, or whether immunity is present through T cells even after the antibodies drop off. It seems unlikely to me that these people are all susceptible again because we’d be seeing lots of reinfections by now, given that we’re 6+ months into this.
yes, indeed, another article saying the serology tests miss people who had been infected, even a few of the symptomatic cases. Quite a few more of the asymptomatic, relatively quickly. The timing aspect creates another twist in this puzzle. Working out the true number who were infected at what time would then need a whole path of data to reverse-engineer.
And of course this is based on those picked up by other tests. Less severe cases again might show yet other variations. This is one tricky disease. Standard cases hardly exist it would seem. So much individual and contextual circumstances of importance: infection level depending on ventilation, humidity, length of exposure. Then individual immunity characteristics, involving prior related diseases, age. Then testing outcomes depending on timing, place of testing (nose, blood).
Easy to get the propagation and mortality rates very wrong when so many things matter. Only large-scale real outcomes can then tell you how lethal it is overall. On the memory of the body against it, drops in anti-bodies suggest some forgetting, but then the link between previous related diseases suggest some longer-term remembering as well. And of course, once you’ve had it, this virus is probably a reasonably effective vaccine for itself at low doses.
This is going to be very difficult to explain to the general public.
The levels of false negatives are nothing like you are claiming.
Paul – I wouldn’t be surprised if other respiratory viruses have similar properties. They simply don’t get so much scrutiny, so we don’t know. I think you’re absolutely right that only large-scale real world outcomes can tell the true story. We really want the total population fatality rate.
The mathematical models are all very well, but they simply don’t work here. Michael Levitt’s curve fitting sounds more and more compelling to me than any of these junk models.
It would seem that NY like the UK transferred significant numbers of ‘burning embers ‘ from its hospitals to aged care facilities…
https://apnews.com/4042f05613ee4259b7a44d4466a0a02a
Maybe of interest
Prof Neil Pearce, Professor of Epidemiology and Biostatistics, London School of Hygiene & Tropical Medicine (LSHTM), said:
“This updated report from ONS strengthens the evidence that, for working age people, COVID-19 is largely an occupational disease. The occupations which are at increased risk are those which involve regular contact with patients or the public. These include security guards, taxi drivers, bus drivers, chefs, and sales and retail workers. All of these occupations should be supplied with appropriate PPE and required to use it – this is a workplace health and safety issue. It is not just health and social care workers who need PPE – it is anyone working with the public.
“As you would expect, there are also increased risks for social care workers. However, the rates are not so high for health care workers. This probably reflects a major problem with the data that ONS has to work with. For this group, many probable Covid-19 deaths are being referred to Coroners. In England and Wales, these deaths are not ‘counted’ until the Coroner has completed their investigation – which can take months or even years. In the meantime, these deaths don’t appear in the official statistics. This problem doesn’t happen in Scotland because act-of-death must by law be registered within 8 days of death having been ascertained. An emergency system should be in place in England and Wales so that the Office for National Statistics is informed immediately about any death referred to coroners so that fact-of-death is registered.”
“Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 25 May 2020” was publsihed by the Office for National Statistics on Friday 26 June
https://www.ons.gov.uk/releases/coronaviruscovid19relateddeathsbyoccupationenglandandwalesdeathsregistereduptoandincluding25may2020
Conrad
Penny for your thoughts seems plausible that some may have been exposed to an earlier ancestor of Covid19 ( many of the people I know last year had some kind of viral thing that left them very tired for months)
https://www.biorxiv.org/content/10.1101/2020.06.22.165787v1
Just read about this: https://news.ki.se/immunity-to-covid-19-is-probably-higher-than-tests-have-shown
It’s supposed to be available as a pre-print soon.
“Our results indicate that roughly twice as many people have developed T-cell immunity compared with those who we can detect antibodies in.”
https://www.biorxiv.org/content/10.1101/2020.06.29.174888v1
thanks for digging this up. Circumstancial evidence has been pointing to this for months, but only small studies. This is a reasonably big study. The headline number is that according to them 30% of the blood donors had a T-cell immunity in May. So that’s after getting ill maybe 2 weeks before (T-cell immunity is not immediate either). Fast-forward that to the present day with the rate of observed cases and Sweden must have something like 60% immunity (at least among the clientele of the blood bank). So they are there! Other countries will basically play catch-up.
So a total fatality rate of maybe 0.06% is the price this virus enacts in Sweden. 1 in 17,000. The normal fatality of 2-3 weeks.
It’s got to be possible to achieve herd immunity quicker with less deaths (and less socio-economic disruption).
I don’t really see how they are “there”. The numbers are still going up. Surely you should see an asymptote and a reversal. Why has it become easier to catch the virus?
Apart from that, people were claiming 20% in Stockholm some time ago, so the number is not much different to what the previous tests were saying, despite the claim they are missing a whole lot of people.
You might like to consider the sample too. I don’t what percentage of people think it’s a good idea to go to a hospital in the middle of a pandemic to donate blood (I can certainly resist), but presumably this is a high risk group, and not the people staying at home. People were dieing here because they wouldn’t go to emergency.
if you look at the test and death data in Sweden you see a huge upswing of mild cases and a continued reduction in numbers of deaths or even critical cases (only 170 of those last time I looked). They, like places in the US and Brazil have changed test regimes and are seeing this huge upswing in those positively tested, so I dont put much faith in the changes in tested positive as an indication of much of anything, but I suspect its just about different test regimes, not a real increase in actual cases. I knew the hysterics are doing their usual spiel on it, but at some point the narrative is going to flip to its opposite: huge numbers of positive tests and almost no deaths tell you how innocuous this thing is for the vast majority.
Now, the 20% was basically a serology-test projection for early June. 60% would mean double to trebble that projection. A bit less than the 1 to 4 I have been using in the back of my mind sofar, but definitely the right ballpark. And dont forget, you probably need about 80% for herd immunity so you’d expect quite a lot of active cases in the months that the population is going from 40% to 80%. So I dont see a contradiction at all. On the contrary. The main thing to note is that they seem to managed to shield the most vulnerable population (or they have only a few of those left) from the ongoing wave.
I still think Sweden has been far too reckless in the authorities telling the population to voluntarily distance. I think they would have gotten it all over with much quicker with fewer casualties and less socio-economic disruption if they’d have told the vast majority to get on with normal life, only making some arrangements for the most vulnerable (on a voluntary basis!).
Its Germany and the other Scandinavian countries that are a bit of a puzzle. Did they have prior immunity unbeknown to them or do they still have a largely vulnerable population? I am sure various groups are trying to figure this out as we speak. This is the sort of thing science eventually gets right.
I agree some of the difference is likely to come from more testing.
However your statement here is really empirical: “huge numbers of positive tests and almost no deaths tell you how innocuous this thing is for the vast majority”
The alternative is that people who are in danger (which on current wisdom is, I guess, people > 55 or people with other diseases) or who have enough worries about it (like a fair chunk of the world) minimise their risk. Perhaps we don’t care about the latter, but the other group forms a decent chunk of the population (even obese people alone do in some places). I imagine avoidence would be pretty easy in Sweden compared to many places which are much more built up (or perhaps it’s my imagined stereotype).
Also, given all the weird symptoms people are getting (including younger people), we don’t really know how innocuous it is, even if the death rate is as you claim (and that would be especially the case if it ends up that we don’t get reasonably long immunity to it — hopefully we do given it is clearer tougher on people’s immune systems than a common cold, but who knows). So people have some reason to worry about it.
oh, I am definitely making empirical statements here which means I can be proven wrong. I have been making empirical statements for months, particularly my 0.2% which is looking ever more overly pessimistic by the day.
On the testing, its not just a question of more of them. It’s also a question of how well they pick up even low infection level. And there are many questions of administration at least as important. For instance, a health authority looking to maximise the information on the spread, uses the tests it has to randomly tests over the populations it want to keep track of. A health authority less interested in tracking changes but more into being seen to find cases would, for instance, give into the pressures from households wherein one person is found to be positive to test the rest of the household. A couple of positives virtually guaranteed, and the household members involved will want them. One can probably treble the number of positive cases per test just by that admin rule alone (ie testing the others in a household with a positive case).
There are other admin issues. Test regimes are quite decentralised, so lots of different rules apply as to who gets them and who is gets forced to take them. Those rules will change over time with cost, availability, remuneration, demands from employers, etc.
God knows what all that does to the number of positive tests over time versus actual cases. Too many free parameters to keep tabs on, and no one seems to keep tabs. I have not found an article or website that has tried to track the admin around these tests. Its possible no-one knows. So I discount the information in those tests very heavily, particularly for places where we know from the serology and T-tests that there is a huge population that has got to have had this thing, much, much higher than shown in direct tests of infections.
Yes, the number of cases is a totally meaningless metric, yet the media is obsessed with it. I really don’t know what has gotten into people because the death rate is dropping in the US while cases are rising and various states are rolling back into forms of lockdown. Bars and beaches closed in some states, restaurants closed back down. It almost feels like they want to keep everyone in fear and keep doing cyclical lockdowns until there’s a vaccine or we get to zero cases. The whole thing is out of control.
yes, as I said in my “5 surprises post”, the ongoing popularity of draconian policies is the biggest surprise. The grasping on the fear as something to be desired and held onto. It now seems it will get Biden elected.
But, once again, my hope is competition. No matter how strange some states and people get, the sight of others enjoying life more is a powerful tug.
The UK is still outlawing fun at marriages, meaningful football (you know, with a crowd), real parties (with toilets and close-formation dancing), etc. And its not just the conservatives either. The Scottish National Party, rulers of Scotland, are making it their business to be even more totalitarian than England. They are, dont laugh, talking about eliminating, but not eradicating, that virus (wow! You cant make it up.). Wales, also not run by conservatives, is in competition with Scotland for who can be most prescriptiveand destructive towards its own economy. I feel like Alice in Wonderland.
Who is actually enjoying life I wonder? I don’t see any state going back to normal, not even NY. Or even Italy for that matter. It seems they’ll keep the economy half-alive and not care about people’s happiness one bit, and this will continue until a vaccine is found.
The only places I can think of right now are unlikely spots like Serbia or Tanzania, but going there isn’t exactly very appealing. Sweden isn’t letting in foreigners. It feels we’re going to be stuck in this insanity for years.
And yes Biden will be re-elected most likely.
good question. Who is enjoying life? I suspect several hundred million holiday planners will want to go there!
In all honestly, I think Southern Europe (Greece, Italy, Spain) is re-discovering its joie de vivre. The Netherlands is regaining it. The “lower classes” in the UK seem to be trying with all sorts of illegal raves and parties. The Swiss.
Is there really no place in the US that is resisting all the bs and is trying to hang on to the joy of life? Some hippie community in California must be holding on to its principles. No?
The column width keeps shrinking. I wonder if you can change the comment formatting. Anyway, to answer your question: Georgia and South Dakota are staying the course. Might consider them.. but some of the photos/videos from Serbia do look quite nice. If they are real, then it appears they are totally back to normal..
Sorry about the graph being on Dan Andrew’s Facebook page, but here’s a good example of behavioral change and what it means to your inferences. These are the new cases from Victoria and what age they are.
https://www.facebook.com/DanielAndrewsMP/photos/a.149185875145957/3202194336511747/?type=3&theater
You can see, almost no infections in people from 65 and over. This suggests that people likely to get bad outcomes from Covid have modified their behavior to avoid it and/or people who think they are not at risk are taking more risks. If you didn’t know this and calculated the death data from it (which will presumably be very small), you would clearly underestimate the danger of the virus. Indeed, any data collected apart from random samples is going to be problematic because of what looks to be a behavioral change in a large proportion of the population.
By the way, one reason I haven’t commented on the T cell stuff is that I don’t what the false-positive/negative rate is. For example, you seem to assume it is perfect as far as I can tell — but I am not sure how one knows this.
Try looking at Table S1. I flicked through that, and I am not sure where this double figure comes from — If you look at the ACUTE patients here, of which there are all of 10 in the moderate group, only 5 show antibodies (50%), so perhaps it is there (but I doubt it this because we know the tests only sensitive after some time). If you look at the COVALESCENT group, i.e., those that are recovering and thus have had the virus for some time, the identification rate is 85% for those even in the moderate group.
Perhaps they are talking about the exposed relative group, which at 64% is closer to double (certainly not quadruple), but it isn’t clear that they all even had Covid responses of any type (“Anamnestic responses in the CD4+ and CD8+ T cell compartments, quantified as a function of CTVlow IFN-g+ events (Figure 4A), were detected in most convalescent individuals and exposed family members (Figure 4B, C).”. So if you add a bit for “most” you are getting a smaller effect again. Apart from that, as they note: “It remains to be determined if a robust memory T cell response in the absence of detectable circulating antibodies can protect against SARS-CoV-2.” which seems important to investigate.
Interesting angle on this
Covid-19 expert Karl Friston: ‘Germany may have more immunological “dark matter”’
he is just noting, like me, that Germany has an unusually low number of covid-deaths and that “something we dont yet see” might be going on. I too have speculated that it might be prior immunity from a related virus, in which you might say they are lucky now, though of course unlucky at a prior point in time.
However, you cant see a major prior wave since 2016 in the excess death graphs (link above). So alternatively, we might find out that Germany is a victim of its supposed initial “success” and that it now has very little immunity to the disease so that it will either have to allow a real wave to pass over it, or muddle on till the vaccine comes with suppression strategies at huge ongoing social and economic cost. The same choice is faced by Australia.
Alternative, and presumably with quite a reasonable probability, both won’t have any great immunity, something that should be factored into current calculations.
https://www.sciencemediacentre.org/expert-reaction-to-preprint-paper-looking-at-t-cell-response-in-people-with-mild-or-asymptomatic-covid-19/
Prof Francois Balloux, Professor of Computational Systems Biology and Director of UCL Genetics Institute, University College London (UCL), said:
(Comment more generally on T-cell responses)
“Over the last weeks, a substantial amount of new evidence has become available about immunity to SARSCoV2. This information can be difficult to process and integrate.
“The immune system is highly complex and comprises a series of different arms. Innate immunity represents mostly first-line responses with no memory of prior infections. Acquired immunity can be broken down into ‘antibody-mediated’ and ‘T-cell-mediated’ immunity.
Antibody-mediated (humoral) immunity is based on B‐lymphocytes that are reactivated to produce antibodies when exposed to a pathogen upon reinfection. Until recently, all the attention in the SARSCoV2 debate has been on antibodies.
“Antibodies are fairly easy to quantify which is the basis of serological tests that inform whether someone has been infected with SARSCoV2. Though, it is becoming apparent that not everyone infected mounts detectable levels of antibodies.
“Antibody levels to SARSCoV2 also wane fairly fast, in line with other coronaviruses. As such, antibody tests can fail to detect prior infection in particular for asymptomatic or mild infections. Serological surveys may underestimate the proportion of people infected.
“T-cell-mediated immunity against SARSCoV2 has received little attention until recently. The main reasons are that T-cell response is less straightforward to measure and it is generally considered less important for vaccine efficacy.
“T-cell response is a late immune response and does not generally make the host refractory to infection. As such, a vaccine blocking infection would need to elicit a strong antibody-mediated response. Though, T-cell immunity is essential for controlling an infection and reducing symptoms. SARSCoV2 seems to elicit robust T-cell response even in asymptomatic/mild patients. There is also evidence for widespread cross-immunity with ‘common cold’ coronaviruses.
“There are four known coronaviruses (229E, NL63, OC43, and HKU1) that cause 15-30% of “common colds”. They circulate primarily in young children. Most people get infected with one or more of these viruses at some point in their lives.
“In contrast to antibody-mediated immunity, T-cell response is extremely long-lived. For example, people infected in 2003 with SARS (SARSCoV1 ) still mount a robust T-cell immune response to SARSCoV2 17 years later, which suggests they should be largely protected from developing severe symptoms when infected with SARSCoV2.
“While there is still no established case of SARSCoV2 reinfection to date, it is likely those will be observed soon due to fairly fast waning antibodies. Though, anyone with a prior exposure to SARSCoV2 is expected to experience far less severe symptoms upon reinfection.
“Most ‘hight-tech’ vaccines tend to focus on eliciting narrow antibody responses as they generally target a single SARSCoV2 protein. Such vaccines are not expected to generate a robust T-cell response. Indeed, T-cell-mediated immunity works best when a host is exposed to the entire diversity of a virus. This raises the question whether there should not be more efforts towards ‘traditional’ vaccines (i.e. attenuated/inactivated).”
Interesting for lots reasons. I like this one the best, mainly out of self interest: “There is also evidence for widespread cross-immunity with ‘common cold’ coronaviruses”. I might stop complaining that it appears the main goal of childcare is to make your children and then parents sick :).
One interesting thing would be to look at parents with young children and childcare workers who are exposed to these viruses constantly and see how they went with Covid. One might also expect that people in countries with more children that roam more freely might also get some extra protection by being to exposed to more germs more often.
re “ T-cell-mediated immunity against SARSCoV2 has received little attention until recently. The main reasons are that T-cell response is less straightforward to measure and it is generally considered less important for vaccine efficacy.”
Another aspect could be that vaccines can be patented, on the other hand can Tcell related stuff be patented ?
very interesting. Thanks for digging this up. Nice to hear someone who knows a lot about the immune system putting the various immunity issues into perspective. His comments on the potentially limited use of the vaccines being made is particularly interesting. We’ll get to hear a lot more about all this in the mainstream media, rest assured.
And the evidence piles up further..
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31483-5/fulltext
Prof Mark Woolhouse, Professor of Infectious Disease Epidemiology, University of Edinburgh, said:
“The Independent SAGE report proposes a strategy of COVID-19 “elimination” from the British Isles. Elimination means zero cases. This is a worthy but extremely ambitious aim; neither China nor South Korea has yet achieved elimination, and they were the first countries to bring their COVID-19 epidemics under control. To achieve elimination for the UK and Ireland within a reasonable time frame would presumably require a contact tracing system as good as South Korea’s and a lockdown as strict as China’s. The former is already UK government policy but the latter is not; every country in the British Isles is currently attempting to relax lockdown as quickly and as safely as possible.
“Given the enormous challenge of achieving elimination the key questions are ‘how long would elimination take?’ and ‘how much additional damage would be done by extending the lockdown for that period?’. Before an elimination strategy is attempted it would be sensible to have answers to those questions. The Independent SAGE report does not provide them.
“The long term vision of the elimination strategy is equally unclear. There is no prospect of eradicating COVID-19 from the whole world in the foreseeable future. Even with a highly effective vaccine, this would be a huge challenge. So we may arrive at a position where regions of the world (small or large) have achieved elimination or something close to it, but the remainder have not. That dichotomy could only be sustained through extremely rigorous travel restrictions and quarantine regulations. New Zealand, currently the country closest to elimination, is already grappling with the implications of this for its tourism and higher education sectors.
“We need to think very carefully before embracing any COVID-19 response strategy that could result in more long term damage than can be justified by the public health gain. This is the case for any strategy to respond to this pandemic. The worrying truth is that, as of now, none of the available options are the least bit attractive. For all that we have been through in the past few months, the full impact of the COVID-19 pandemic is still to be felt.”
“The Independent SAGE report proposes a strategy of COVID-19 “elimination” from the British Isles. Elimination means zero cases. This is a worthy but extremely ambitious aim; neither China nor South Korea has yet achieved elimination, and they were the first countries to bring their COVID-19 epidemics under control. To achieve elimination for the UK and Ireland within a reasonable time frame would presumably require a contact tracing system as good as South Korea’s and a lockdown as strict as China’s. The former is already UK government policy but the latter is not; every country in the British Isles is currently attempting to relax lockdown as quickly and as safely as possible.
“Given the enormous challenge of achieving elimination the key questions are ‘how long would elimination take?’ and ‘how much additional damage would be done by extending the lockdown for that period?’. Before an elimination strategy is attempted it would be sensible to have answers to those questions. The Independent SAGE report does not provide them.
“The long term vision of the elimination strategy is equally unclear. There is no prospect of eradicating COVID-19 from the whole world in the foreseeable future. Even with a highly effective vaccine, this would be a huge challenge. So we may arrive at a position where regions of the world (small or large) have achieved elimination or something close to it, but the remainder have not. That dichotomy could only be sustained through extremely rigorous travel restrictions and quarantine regulations. New Zealand, currently the country closest to elimination, is already grappling with the implications of this for its tourism and higher education sectors.
“We need to think very carefully before embracing any COVID-19 response strategy that could result in more long term damage than can be justified by the public health gain. This is the case for any strategy to respond to this pandemic. The worrying truth is that, as of now, none of the available options are the least bit attractive. For all that we have been through in the past few months, the full impact of the COVID-19 pandemic is still to be felt.”
https://www.sciencemediacentre.org/expert-reaction-to-commentary-about-potential-airborne-transmission-of-the-sars-cov-2-virus/
this is obvious stuff. You’d think high-school stuff. But apparently not. Here we are still, 5 months in. Sigh.
Paul
“ The worrying truth is that, as of now, none of the available options are the least bit attractive. ”
That’s so true, I can’t blame our leaders for opting for at least appearing to know what they are doing, opting for dramatic symbolic crap.
Conrad
If the figures in the lancet piece you referenced are a true indication of the total number of infections in Spain then surely Covid19 is not that, infectious , needs special circumstances ?
I would have thought the opposite — 5 million out of about 47 million people — despite a severe lockdown, a population that doesn’t want to catch it too much (c.f., the US where people won’t even wear masks in many places), and a population that is relatively spread out compared to many other places.
One of the nice things about the paper is you can see how much difference this makes — the provinces which are more sparsely populated have very low rates.
A interesting read
https://forecasters.org/wp-content/uploads/Ioannidisetal25062020-1.pdf
Forecasting for COVID-19 has failed
John P.A. Ioannidis (1), Sally Cripps (2), Martin A. Tanner (3)
(1) Stanford Prevention Research Center, Department of Medicine, and Departments of Epidemiology and Population Health, of Biomedical Data Science, and of Statistics, Stanford University, and Meta-Research Innovation Center at Stanford (METRICS), Stanford, California, USA
(2) School of Mathematics and Statistics, The University of Sydney and Data Analytics for Resources and Environments (DARE) Australian Research Council, Sydney, Australia
(3) Department of Statistics, Northwestern University, Evanston, Illinois, U
ABSTRACT
Epidemic forecasting has a dubious track-record, and its failures became more prominent with COVID-19. Poor data input, wrong modeling assumptions, high sensitivity of estimates, lack of incorporation of epidemiological features, poor past evidence on effects of available interventions, lack of transparency, errors, lack of determinacy, looking at only one or a few dimensions of the problem at hand, lack of expertise in crucial disciplines, groupthink and bandwagon effects and selective reporting are some of the causes of these failures. Nevertheless, epidemic forecasting is unlikely to be abandoned. Some (but not all) of these problems can be fixed. Careful modeling of predictive distributions rather than focusing on point estimates, considering multiple dimensions of impact, and continuously reappraising models based on their validated performance may help. If extreme values are considered, extremes should be considered for the consequences of multiple dimensions of impact so as to continuously calibrate predictive insights and decision-making.
From the above paper.
Box 1. John Ioannidis: a fool’s confession and dissection of a forecasting failure
“If I were to make an informed estimate based on the limited testing data we have, I would say that COVID-19 will result in fewer than 40,000 deaths this season in the USA” – my quote appeared on April 9 in CNN and Washington Post based on a discussion with Fareed Zakaria a few days earlier. Fareed is an amazingly charismatic person and our discussion covered a broad space. While we had focused more on the need for better data, when he sent me the quote that he planned to use, I sadly behaved like an expert and endorsed it. Journalists and the public want certainty, even when there is no certainty.
Here is an effort to dissect why I was so wrong. Behaving like an expert (i.e. a fool) was clearly the main reason. But there were additional contributing reasons. When I made that tentative quote, I had not considered the impact of the new case definition of COVID-19 and COVID-19 becoming a notifiable
46 38 despite being aware of the Italian experience where almost all counted “COVID-19 deaths”disease, had also other concomitant causes of death/comorbidities. “COVID-19 death” now includes not only “deaths by COVID-19” and “deaths with COVID-19”, but even deaths “without COVID-19 documented”. Moreover, I had not taken seriously into account weekend reporting delays in death counts.
Worse, COVID-19 had already started devastating nursing homes in the USA by then, but the nursing home data were mostly unavailable. I could not imagine that despite the Italian and Washington state47 experience, nursing homes were still unprotected. Had I known that nursing homes were even having COVID-19 patients massively transferred to them, I would have escalated my foolish quote several fold.
There is more to this: since mid-March, I wrote an article alerting that there are two settings where the new virus can be devastating and that we need to protect with draconian measures: nursing homes and hospitals. Over several weeks, I tried unsuccessfully to publish this in three medical journals and in 5 top news venues that I respect. Among top news venues, one invited an op-ed, then turned it down after one week without any feedback. Conversely, The New York Times, offered multiple rounds of feedback over 8 days. Eventually, they rewrote entirely the first half, stated it will appear next day, then said they were sorry. STAT kept it for 5 days and sent extensive, helpful comments. I made extensive revisions, then they rejected it apparently because an expert reviewer told them “no infectious disease expert thinks this way” – paradoxically, I am trained and certified in infectious diseases.
42-52% of deaths in the US (and as many or more in several European countries) eventually were in nursing homes and related facilities37 and probably another large share were nosocomial, hospital- acquired infections. An editor/reviewer at a top medical journal dismissed the possibility that many hospital staff are infected. Seroprevalence and PCR studies, however, have found very high infection rates in health care workers 48-50 51,52 and in nursing homes.
Had we dealt with this coronavirus thinking what other widely-circulating coronaviruses do based on medical or infectious disease (not modeling) textbooks (=they cause mostly mild infections, but they can 20,21,53 devastate specifically nursing homes and hospitals), ridiculous.
Why was my article never accepted? Perhaps editors were influenced by some social media who painted me and my views as rather despicable and/or a product of “conservative ideology” (a stupendously weird classification, given my track record). As I say in my Stanford webpage: “I have no personal social media accounts – I admire people who can outpour their error-free wisdom in them, but I make a lot of errors, I need to revisit my writings multiple times before publishing, and I see no reason to make a fool of myself more frequently than it is sadly unavoidable.” So, here I stand corrected.
Fabulous passage John – thanks. As good an illustration as one could want of the tyranny of the comms folks. Someone with the knowledge, intelligence and humility (proven over the decades) to be put right at the centre of the conversation (and I note his disagreements with others whose perspectives should likewise be central). Instead, he gets stuffed around and bossed about by the thicket of comms know-nothings all keeping themselves busy trying to entertain the troops.
Nicholas
Thought this bit would appeal.
“ they rejected it apparently because an expert reviewer told them “no infectious disease expert thinks this way” – paradoxically, I am trained and certified in infectious diseases.”
“ experts live at the cutting edge,of conformity “
Btw the whole paper is worth a read, unusually clear.
The unbelievable repeated tale of infectious people being bundled off to nursing homes in the UK and in the US ,along side the unbelievable ‘insecurity ‘ guards viz the Melbourne quarantine hotels sums my reasons for judging so many of the western worlds expert health systems as, not fit for purpose.
yes, very interesting. I have very similar experiences with various coms people the last few months, who invariably protect their boss, who invariably is reading the tea leaves as to the message he or she needs to be seen to support. You have to hope to get lucky with a good boss now and then. Pushing out an unwelcome message ends you in a vat full of molasses where you have no idea who you are really arguing with, but the going is tough and even if you get out of the vat you remain sticky.
Interesting also is that this guy is not on social media. One of my suspicions around this virus is that those regularly on social media have found it near impossible to escape internalising the majority opinion very early on with this, and that the independent voices are largely those who dont engage with social media much. There are some exceptions, of course.
More on modelling :
https://www.spectator.co.uk/article/how-strong-was-the-scientific-advice-behind-lockdown
Dr John Lee is a former professor of pathology and NHS consultant pathologist
“ Let’s go back to the idea of Covid taking half a million lives: a figure produced by modelling. But how does modelling relate to ‘the science’ we heard so much about? An important point — often overlooked — is that modelling is not science, for the simple reason that a prediction made by a scientist (using a model or not) is just opinion.
To be classified as science, a prediction or theory needs to be able to be tested, and potentially falsified. Einstein is revered as a great scientist not just for the complexity of general relativity but because of the way his theory enabled scientists to predict things. This forward–looking capacity, repeatedly verified, is what makes it a scientific theory.
The ability to look backwards and retrofit a theory to the data via a model is not nearly so impressive. Take, for example, a curve describing the way a virus affects a population in terms of the number of infections (or deaths). We can use models to claim that lockdown had a dramatic effect on the spread, or none at all. We can use them to claim that social distancing was vital, or useless. Imperial College London has looked at the data and claimed lockdown has saved three million lives. A study from Massachusetts looked at the data and concluded that lockdown ‘might not have saved any life’. We can, through modelling alone, choose pretty much any version of the past we like.
The only way to get an idea of the real-world accuracy of models is by using them to predict what will happen — and then by testing those predictions. And this is the third problem with the current approach: a wilful determination to ignore the quality of the information being used to set Covid policy.
In medical science there is a well-known classification of data quality known as ‘the hierarchy of evidence’. This seven-level system gives an idea of how much weight can be placed on any given study or recommendation. Near the top, at Level 2, we find randomised controlled trials (RCTs) where a new approach is tried on a group of patients and compared with (for example) a placebo. The results of such studies are pretty reliable, with little room for bias to creep in. A systematic review of several RCTs is the highest, most reliable form of medical evidence: Level 1.
Further down (Levels 5 and 6) comes evidence from much less compelling, descriptive-only studies looking for a pattern, without using controls. This is where we find virtually all evidence pertaining to Covid-19 policy: lockdown, social distancing, face masks, quarantine, R-numbers, second waves, you name it. And — to speed things up — most Covid research was not peer- reviewed.
Right at the bottom of the hierarchy — Level 7 — is the opinion of authorities or reports of expert committees. This is because, among other things, ‘authorities’ often fail to change their minds in the face of new evidence. Committees, containing diversity of opinion and inevitably being cautious, often issue compromise recommendations that are scientifically non-valid. Ministers talk about ‘following the science’. But the advice of Sage (or any committee of scientists) is the least reliable form of evidence there is.
Such is the quality of decision-making in the process generating our lockdown narrative. An early maintained but exaggerated belief in the lethality of the virus reinforced by modelling that was almost data-free, then amplified by further modelling with no proven predictive value. All summed up by recommendations from a committee based on qualitative data that hasn’t even been peer-reviewed.
Mistakes were inevitable at the start of this. But we can’t learn without recognising them.“
I imagine part of the problem with predicting what will happen are events that change things massively, but are essentially impossible to predict (or certainly not in your model). So even if you could predict things in stable conditions and things you might hope to understand (e.g., transmission in lockdown), you still can’t predict when exceptional events will happen (what science people like to call a fat-tailed distribution) and these may be very important.
For example, in the US, to make decent predictions, you would have needed to predict Trump would have delayed things, that he would have tried to get states to open up early, and the fact that white English speakers don’t like to wear masks even if they obviously work (unlike the Froggies who apparently all wear them now).
Now, depending on the outcome of this, the US will reach herd immunity, immunity won’t wear off quickly, and after people see that, the world’s behaviour will change, all thanks to things Trump probably didn’t evaluate too hard. Alternatively, perhaps massive numbers will die, immunity will wear off quickly, and they will look like fools. Then the behavior of people and many governments will change again in the opposite way. These are all real possibilities, and would clearly change any outcomes.
None of these variables are in people’s models and they may well be more important predictors in the long run than the type of data discussed above which is all trying to predict what happens in stable conditions, with the parameters updated post-hoc when things like behavior changes.
Conrad
Most of what you discuss is covered in some detail in the Ioannidis paper
https://forecasters.org/wp-content/uploads/Ioannidisetal25062020-1.pdf
Paul Conrad
The following report is based on reports by the Blavatnik School of Government.
It really seems that it’s not the stringency-extent of lockdowns that counts.
And economics wise we are to varying degrees all stuffed , possibly for years and years to come.
https://www.bloomberg.com/graphics/2020-opinion-coronavirus-europe-lockdown-excess-deaths-recession/
“In Europe, roughly three groups of countries emerge in terms of fatalities. One group, including the U.K., the Netherlands and Spain, experienced extremely high excess mortality. Another, encompassing Sweden and Switzerland, suffered many more deaths than usual, but significantly less than the first group. Finally, there were countries where deaths remained within a normal range such as Greece and Germany.
Yet the data show that the relative strictness of a country’s containment measures had little bearing on its membership in any of the three groups above. While Germany had milder restrictions than Italy, it has been much more successful in containing the virus.
The overall impression is that while restrictions on movement were seen as a necessary tool to halt the spread of the virus, when and how they were wielded was more important than their severity. Early preparation, and plentiful health-care resources, were enough for several countries to avoid draconian lockdowns. Germany, with better testing and contact tracing and more intensive care units than its neighbors, could afford to keep the economy a bit more open. Greece, by acting quickly and surely, appears to have avoided the worst, so far.
As one would expect, the countries with the most intense lockdowns look likely to suffer the most economically. What’s not clear yet is how much economic benefit countries with relatively lax curbs really stand to gain, given the integrated and trade-driven nature of the European economy. The export-led Swedish economy is set to shrink 7% this year, its government said on Tuesday. Germany, whose economy was shrinking before the pandemic, is already in recession. These countries may bounce back earlier than others next year, but this is a painful moment for all.”
I’ve never thought it was stringency — all the countries in Asia show that tight stringency isn’t necessary despite the massive population density, but the people were also more willing to take sensible precautions early on like wearing masks. In that respect, I just saw a photo a few days ago of my wife’s friend who is a teacher in Thailand, and he was wearing a plastic face protector with a microphone mounted to it. In Melbourne, you could have gone to Chadstone and almost no-one was wearing masks and nor were people in schools. It appears people in Melbourne prefer lockdowns than simple precautions. I feel sorry for all the business owners.
My suspicion as to why France used such a draconian lockdown is that, unlike the Germans, the people don’t care about government rules as much, so perhaps the government thought they had to use it to get anywhere.
Re Melbourne the use of poorly trained security guards at the quarantine hotels seems to be a big factor, apparently some of them even had sex with the quarantined.
Overall the quality( or lack of) of national responses re aged care facilities is an obvious big factor. In the US and the UK about 50 percent of all deaths, in Sweden about 75 percent of all deaths.
Haven’t seen anything re aged care facilities in say Japan, have you?
No, I haven’t — There are lots of interesting things that people don’t seem to know about Japan and how it coped with such comparative ease.
It’s pretty silly to say people in Melbourne prefer lockdowns over wearing masks. I’m sure they don’t, and we don’t know how much of a difference the masks would have made exactly. Maybe they’d be enough, maybe they wouldn’t. You can’t just use one factor like that and ignore all the other differences between Thailand and conclude “oh yes, it’s the masks”.
As far as I can’t tell it’s one of the cheapest and easiest ways of reducing transmission. My favourite study on this is on hamsters https://academic.oup.com/cid/article/doi/10.1093/cid/ciaa644/5848814, because I sometimes felt like a mouse or hamster in a cage when living crowded cities.
Of course, since your position is that 2 million people should catch coronavirus each month until we have heard immunity, which then won’t wear off, it makes no sense to wear masks since you would want to increase, not decrease transmission. But I doubt you can convince Dan Andrews and the Victorian population of that, so the next best option appears to be minimising transmission to a level where the government doesn’t shut things down.
You might be of the opinion it reduces transmission, but how can you claim the people of Melbourne would prefer lockdown over masks? Even if masks are as effective as you feel they are, the claim that all these people agreed with you and willingly chose lockdown over masks is completely unfounded and silly.
It’s interesting to see how masks are like a religion for you. A study on hamsters is the best evidence at hand. At least be honest and say we don’t have any definitive evidence one way or another.
I think that yes if you’re going for herd immunity, then masks are likely to slow it down, if they do have any effect. You’re still stuck on 2 million per month. Viruses don’t grow linearly.
Conrad
Inexplicably the Victorian government , unlike every other state and territory , did not use a mix of police and ADF personnel to supervise the quarantine hotels. Instead they hire 3 private security firms. Procedures were not up to scratch and some of those private security guards transferred the virus to their extended family networks. The Victorian government three weeks ago was urged by national health authorities to enact sharp local containment measures, but that was not done. The Victorian health system has a reputation of being over centralised – suspect that tactical ,local level, measures are not their forte.
Don’t see statewide mask wearing or not wearing ,as being of any relevance to the above true story.
It was an amazing story of incompetence. But politically, I think what it showed is that people still think you can get numbers to zero and expect it.
Mask wearing is important because now they need to think of some way to contain it — and the faster the better. If it makes it, say, 20% faster, that’s great. This is presumably why Dan Andrews is pushing it, although now it has become a politicised issue it may be harder. Alternatively, in France, they are now all wearing them in enclosed spaces as it didn’t get politicised like here or the US.
Agree re public expectations.
Below is a like to a recent interview with John Ioannidis
https://thehealthcareblog.com/blog/2020/07/09/a-conversation-with-john-ioannidis/
One takeaway is that because the virus is very contagious but often asymptomatic in people under say fifty, it’s more dangerous in particular special situations.
For example the consequences of a young asymptomatic person who works in several aged care facilities could be severe.
And I’d guess that it’s exactly those qualities that make mask wearing a good idea.
There’s quite reasonable evidence masks work from many studies now. I don’t use masks as a religion, but they are one of the few things that appears to help that doesn’t close your city down and doesn’t annoy most people in the world too much (apart from white English speakers) that is currently not used. I’m sure the average person would like to do nothing (who wouldn’t), but they’d also like the Covid numbers kept down. Even if you don’t care about the Covid numbers, you probably wouldn’t want the city locked down again, and that’s what our politicians are clearly willing to do.
Given this, and given I think there is quite reasonable evidence masks work from multiple sources (you must too, otherwise you wouldn’t think it would slow transmission down), it seems like a good proposition. Basically, you need to think of a subset of things that keeps the virus down enough such that the government decides not to lock everyone down again. So you can tell people to clean their hands, use social distancing (which people don’t seem to do), wear masks, stay home from work if they are sick etc. As far as I can tell, masks are one of the common things in this set in many countries where cases have been contained and not used here much. This includes places in Asia where even restaurants are still open (although patronage is down in places I know about). If you can think of a better subset, feel free.
Incidentally, I just thought the hamster was funny because it made me imagine hamsters running around with masks on (which they didn’t). I found that funny.
I honestly don’t know about masks. It’s possible they work, yes. It’s also possible they don’t. I’d like to see a RCT. It really shouldn’t be that hard to do. I also don’t think it’s productive to shame people who dislike masks because (a) you’re not going to change their minds that way and (b) it ignores how masks are affecting them.
I’m probably even ok with wearing a mask if that’s what it takes to open up and we can conduct the studies and reach a conclusion. What’s not ok is to keep pushing masks without ever doing the studies (by saying it’s too hard to do such studies or it’s obvious and no study is needed) and turning this whole thing into a big political issue. It’s tiresome and it’s getting us nowhere.
But, again one has to go back to the overall strategy. If you want low risk people to build herd immunity, is the mask adding any benefit at all?
The top two things I’d place in the subset are: (1) taking very draconian measures to protect nursing homes, and (2) having a clear strategy to protect the elderly and other vulnerable people. Everything else is secondary. These are the highest impact action items IMO.
Aron
Worth a read
https://thehealthcareblog.com/blog/2020/07/09/a-conversation-with-john-ioannidis/
Thank you. That’s an excellent interview. He is such an articulate speaker and so humble too. It’s really sad how he’s been treated :-(
Wearing a mask as a safety measure seems equivalent to wearing a seat belt cost inconvenience is trivial. In comparison widespread mandated lockdowns as a safety measure seems equivalent to banning cars altogether.
I see lots of differences between masks and seat belts. There are crash tests that show seat belts are beneficial. Ironically, they found that seat belts caused more accidents because people felt they were safe and drove faster. So, the safety aspect of mandating seat belts is questionable. The laws stayed in effect, though. The seat belt law really makes no sense to me at all – each person should be free to choose. Is the government supposed to go around policing every action? Ensuring people eat healthy so they don’t die of heart disease? It really doesn’t make a ton of sense to me.
The big difference with masks is they protect others, not you. So it changes the dynamic quite a bit and I see them as making more sense if they do work as we think. I do wonder, though, about providing N95 masks to people and letting them choose. That way people can protect themselves if they choose instead of requiring everyone else to wear a mask. Wouldn’t require all that enforcement or controversy.
Aaron
Mask science is really not my area… I think that the main disputes are about how effective they are ,which type is good enough and the like. Don’t think there’s much dispute that masks to some degree or another reduce the amount of droplets emitted. After-all that’s the reason the are standard kit in operating theatres and at the dentist.
Re seatbelts my understanding is that the ‘overconfidence’ factor is not that big. Personally putting on a seatbelt doesn’t bother me. It certainly doesn’t stop us from driving.
Wear a mask is definitely not in the same class as nation wide ‘stay at home’ order.
I didn’t think masks protected you either at the start of this pandemic (I’ve probably said so somewhere..). However, I think they probably do now to some extent as they potentially reduce the amount of virus you are exposed too (although even viral load appears controversial, so who really knows).
The reason I like masks is the same as John — it’s no big deal to wear one so the cost vs. annoyance ratio is good, say, unlike forcing businesses to close down where someone then goes broke (which the government appears too happy to do). I’d rather see people forced to wear masks than businesses forced to close. So if they have some efficacy that’s a good deal.
As for seatbelts — they do have externalities. If people injure themselves permanently they cost the state huge amounts of money via free medical services, disability pensions and so on (and indirectly, removing people who received free education from the workforce). So there are externalities to your tax bill. Since it takes 2 seconds to stick a seat-belt on, is a simple thing to do, and has no other ramifications (c.f., e.g., eating “decent” food) I don’t really care that the government forces people to do it.
Conrad
As I understand it , Ioannnidis believes that it’s because Covid19 is a small threat to the vast majority I.e. most under 50 show no symptoms, that it poses a severe risk to the slice of the population that is a high risk ,those over 65 and or those in hospital wards because of a prexisting comorbidity factor.
I’d guess that therefore that if masks reduce the chances of transmission by say 50 percent then that would make quite a difference overall.
The latest from the UK is that their high death toll in aged care may have really been due to asymptomatic care workers who worked in multiple facilities.
It’s certainly true that in Japan people who feel a bit ill have always worn masks as a matter of everyday routine .
I don’t think most people under 50 show no symptoms. They’re just not serious enough to put them hospital at such a high frequency. Those over 50 are also not an insignificant proportion of the population either (34% in Australia) — and if you add other at risk groups (e.g., obese people, about 20%, asthmatics…) you can probably get close to half the population. So I wouldn’t ever say it isn’t a threat to the vast majority. That just isn’t true. This is a problem with focusing just on death data (where I agree with him — my guess is the death rate is about .5% in places where the hospital system isn’t overwhelmed. I also agree with you this is inflated by certain groups, but I also think it is deflated by avoidance behavior of high risk groups).
The other problem now is the data coming out on long-term recovery looks bad. If you hadn’t seen it, this came out a few days ago: https://jamanetwork.com/journals/jama/fullarticle/2768351 and relates to people who had been in hospital. Basically, they all still feel terrible in multiple ways after recovering, and it is unclear how long it will last (so even though the sample is small — 176 — the effects are so large it is really saying something useful).
I note numerous anecdotes popping up about people who had mild systems that are also getting persistant problems later on as well. So it could be really nasty, and not just to the groups we think about now. But we’ll find out about this in the future.
Conrad
Just curious , has anyone gathered figures for the average national rates of mysterious syndromes like chronic fatigue etc?
As far as I am aware, there are no decent surveys of it as far as I am aware (the Italian one is one of the better ones — obviously if you bad enough to go to hospital, you will be affected). Obvious the prevalence in people that didn’t go to hospital would be really useful given people with mild initial symptoms have been claiming they are also getting strange symptoms. But who knows what the real rate is right now.
Whether masks are a big deal or not is a bit subjective. Either way, there should be studies done to get to the bottom of it rather than just doing something because we think it might have some effect. That should hardly be controversial.
I don’t buy the seatbelt argument at all. It’s not the role of government to be setting rules to protect people from themselves. There isn’t free medical care in the US anyway.
Aaron
Intuitively anything that reduces the amount of droplets in the air should have at least some benefit.
Masks and seatbelts are not expensive, no big deal to use , have little negative impact on my life when at home etc-there are plenty enough other government interventions that are far worse more deserving of argument push back.
Conrad
Am curious about how many people, every year, develop mysterious ailments such as chronic fatigue , that possibly could be an after effect of some kind of viral infection.
For example last year a fairly large number of people of my acquaintance came down with some kind of flu like fever and subsequently felt incredibly tired for many months afterward. GPs couldn’t say what just,’ it’s probably some kind of viral thing’ :rest, drink water, eat fruit and green Vegies.
I had a similar experience after getting influenza that year the vaccine didn’t work well — I was strangely tired for about a month and half and my heart rate which I measure cycling was doing strange things.
In terms of weird symptoms, and not just fatigue, off-hand Lymes disease is a good example of one where people can get strange symptoms long after having the disease has left their system (c.f., glandular fever) — Apparently about 10-20% of people do. https://www.lymedisease.org/lyme-basics/lyme-disease/chronic-lyme-disease/.
That’s the CDC site. https://www.cdc.gov/lyme/postlds/index.html . They have even done an experiment where they keep using antibiotics versus a control and find no difference, suggesting it is not because the initial courses of antibiotics they give people don’t work.
Conrad
A virus such as Covid19 is not much more than a string of instructions :RNA and a spike to enable that RNA to be absorbed into a cell. Therefore much of the information needed to reproduce I.e. ’perform or interpret the virus ’ is not in that virus.
The apparently very wide range of ‘individual interpretations’ of Covid19 might be unusual or equally it could simply be the first time a phenomena has been intensively studied , no ?
It think could be either — it’s a known unknown in Rumsfeld terms — something we will find out about. We really need better studies (although even the hospital ones give some reason to worry).
The main reason I used Lymes disease is that it causes neurological damage (unlike SARs) and you get lots of weird symptoms, and who knows what the longer term effects are.
I imagine one of the big problems will be if people’s immunity wears off quickly, in which some of the effects could be cumulative if you catch it twice. Things like lung scarring would be in that category, but as for the neurological damage, who knows. People didn’t work out that the damage from being concussed multiple times was cumulative for ages (despite reasonably large effect sizes), so I imagine we won’t find out soon here either.
Knew somebody who got Lymes in the US and had decades of problems not least of which was a reluctance by many medical types to accept that it was a result of Lymes disease
I had a friend in that category too. She got it in the late 90s, so perhaps things are better now.
Yeah I’d agree with John. These people in the study were hospitalized after all. It’s not terribly surprising they felt fatigue 60 days later.
Pragmatically.
I’m told that many senior thoracic specialists are very pessimistic re the chances of a working vaccine ever turning up.
The costs to health as well as the economic costs of repeated large scale lockdowns are already enormous.
Better ,less costly ,more sustainable strategies and tactics are a necessity.
While it’s clear that Covid19 mortality is very skewed to those over 70, the long term outcomes for younger people who get it are not clear.
All the data is concentrated on those who needed hospital or medical treatment. We don’t really know the true numbers of those who were infected but for whatever reasons ‘shrugged it off’.
Somethings that do seem clear are:
in nations such as Japan where wearing a mask if you feel a bit off colour is quite normal, outcomes have been better. (And in the scheme of things wearing a mask is not that much of a burden).
much more care needs to be taken re aged care facilities.
Many of the west’s public health authorities and preparations for pandemics have proven to be not fit for purpose.
For example in NZ stocks of PPE were not regularly turned over ,with the result that most of the elastic in the masks and other gear had perished .
And Victoria’s handling of the quarantine hotels simply beggars belief.
I agree with more or less all of this, except that I am less pessimistic about vaccines (I have also seen high flying doctors talking pessimistically about it) given the amount of private money being spent on it and also because it is such a hot political issue that various governments will speed things up. I think I’ve said it before, but I imagine the Chinese government would probably rather get a working vaccine than a man on Mars right now (for the sake of nationalism — great Chinese state saves the world…), and Trump certainly has lots riding on it. If a vaccine doesn’t turn up before the election, I assume he will have zero chance of winning especially now death rates are going up again.
Politically, I don’t really know how you can convince governments not to lock down everything rather than force people to wear masks in enclosed areas (which even the French do) and take other evasive measures which don’t destroy everything. By the time opinion changes on this, who knows what will be left of the economy.
Re vaccines a bushie I used to know used to say “ always look on the dark side, that way you’re more often ,pleasantly surprised”.
Re government attitudes
Necessity doth rule us all.
When ,not if, things get desperate enough ,policies and attitudes will change.
Conrad
It seems to me that the numbers, frequency of younger people with chronic significant conditions resulting from Covid19 is critical to judging whether mandated lockdowns are justified or are a large overreaction .
By now Australia has a significant number of people ,often youngish, who have had the virus and have apparently recovered . Is there any local data on the frequency of chronic serious aftereffects for that group ?
The article in today’s Guardian regarding the short duration of immunity to covid 19 is not supportive of the idea that promoting infection is a good strategy.
Murph
A nobody is promoting anything. If immunity is not possible then I’d guess that the chances of a working vaccine are also very poor.
And in the current context, your consistent seeking to promote fear and panic is the sort of insubordination that in other situations would end up with you facing a firing squad:-)
It is more relevant for people to realise we all know very little about this virus and the consequences of being infected.
Pursuing herd immunity through disseminating infection is effectively dead as a policy.
The public will prioritise health over the economy and live with the changes.
Not that I know of. There is a Dutch study examining people who had mild symptoms with an average age of 53, and 85% still had symptoms which means many in the lower range must have had symptoms too. All I found was report here so I wouldn’t trust it too much (and I hope Google translate is correct :).
Given more evidence has come out that people lose their antibodies to covid pretty quickly (and presumably can get reinfected), I assume the cost of these symptoms should be weighted more highly than previously, especially if it is knocking a few months out of every few years of life people have (c.f., glanduar fever which hits most people only once).
‘antibodies’ are not the full story re resistance to it , no ? And subsequent infections could be because of for example Tcells be less dramatic,no?
Re translation of the Dutch study , Paul Frijters can you help?
Sorry
Too quick to press publish
Immunity is more complex than antibodies, no?
that Dutch study doesnt make it clear how they selected its sample, but it does mention that they all reported problems with their lungs, so they were not mild cases but somehow self-reported problem cases. Having said that, 90% didnt go to hospital, 45% were not diagnosed by a doctor, and 85% said their health was good beforehand. So its clear there is a group of individuals whose health takes a serious and quite long knock from having this virus. What is not clear is just how large that group is. One UK doctor said it was 10% of the cases reported to them (which would make it a smallish group).
On anti-bodies, there is indeed the point that there is more to immunity than anti-bodies (T-cell immunity now seems more prevalent), but equally important to say is that waning immunity would have an entirely different consequence for policy, which is the importance of keeping up the immunity rather than run away from the virus the whole of the rest of one’s life.
Still, there is other evidence that immunity probably lasts quite a while. Particularly the seeming immunity due to having had other coronaviruses in previous years indicates some form of remaining immunity.
You can look at the flip-side too. You apparently can still get re-infected even with antibodies, and it is well established that you can get reinfected with other types coronavirus. Here’s a fun study on camels examining this with MERs. Be glad you didn’t have to take the swabs.. https://www.tandfonline.com/doi/full/10.1038/emi.2017.44
We have had nearly 10,000 confirmed cases ,most of which are listed as recovered. We must have quite a few thousand younger people who have had it.
I’m surprised that we have no data on the frequency of Covid19 related ongoing chronic conditions.
Conrad
An interesting interview with Dr Soo Aleman. She has been both on the front lines of the Covid-19 epidemic as a senior physician at Stockholm’s leading Karolinska hospital, and on the research side, as Assistant Professor at the Karolinska Institute and one of a group that last week published new data around T-cell immunity.
We talked to her about the findings of that study, and how it matches what she is seeing in her hospital.
Link to the Karolinska Institute T Cell study:
https://news.ki.se/immunity-to-covid-…
Key quotes:
“Intensive care units are getting empty, the wards are getting empty, we are really seeing a decrease — and that despite that people are really loosening up. The beaches are crowded, social distancing is not kept very well … but still the numbers are really decreasing. That means that something else is happening – we are actually getting closer to herd immunity. I can’t really see another reason.”
“I can’t say if the Swedish approach was right or wrong – I think we can say that in one or two years when we are looking back. You have to look at the mortality over the whole period.”
“I don’t think that we have more new cases, I think we are just detecting more cases”
“We found that if you have a mild case you can be negative for antibodies afterwards … in those almost all of them had strong T-cell activity. This study says that there are cases that you can have a strong T-cell response even though you have not had antibodies, meaning that you have encountered the virus and built up immunity.”