The Covid-19 pandemic has caused much consternation within the public and tremendous pressure on governments. However “lockdown” means that we do not really know what is happening outside our houses, apart from how we are informed by the media. Much of what happening is sensationalised. I personally am not aware of anyone who has become ill or died from Covid-19.
With lockdown I have a great deal of time on my hands. There are limits to the detail to which I tend my garden. Decorating has come to an end as I have run out of paint and delivery from internet purchase is slow. I have plenty of time to read and think.
The daily supply of international Covid-19 data from Worldometer gives a good opportunity for the adult game of “The Spreadsheet”. This game has been occupying some of my time each day and it led to some interesting questions. There is little access to any detail of the individuals who have died, but no doubt such details will emerge from individual countries in due course.
The main puzzle is the variation of case incidence and deaths in different countries, Such comparisons require data to be standardised for population size, and I have used cases and deaths per million population.
Cases. The selection is mainly European nations or countries that interest me.
We do not hear about Luxembourg because the data that we are given by the government and media look at total deaths and Luxembourg is a small country with a population of less than one million. However Luxembourg has the highest number of cases per million, four times that of the Netherlands, Germany, Austria and the UK, all of which are very similar. Poland and Russia have very low numbers, similar to Malaysia. China has many fewer cases per million.
Why is this, and what is “a case”? It should mean someone who is ill with respiratory symptoms and who tests positive for the Covid-19 antigen. The problem is that testing is itself not tested. The government advice is that testing will be a “game-changer” and that we must move as quickly as possible to 100,000 tests per day. The UK government has spent £3m on tests that “do not work” and have now been thrown away. Testing the tests takes a long time.
The main problem with the tests that have been available is that they give many “false positives”, they overestimate the number of “Covid-19 cases”. It appears that they detect the presence of several coronaviruses other than Covid-19.
Despite lockdown, Switzerland and Belgium have overtaken Italy in the number of cases per million, with Ireland and France close behind.
A country might be searching for new cases by extensive testing, perhaps of people who are not sick. Assessment shows that between 50% and 80% of individuals who test positive are symptom-free. And we know that extensive testing will produce a lot of “false-positives”, that is people who test positive but do not have Covid-19.
Deaths per million is equally if not more interesting.
We hear little or nothing about Belgium in the UK media, other than its excellent national soccer team. But we have not heard that Belgium has the highest number of Covid-19 deaths per million population, now even higher than Italy and Spain. The UK and the Netherlands are similar to each other. Although Luxembourg has the highest case incidence, the number deaths is modest. Denmark, Germany, and Austria have low numbers of deaths. China and Russia have the lowest.
Within European countries there is a remarkable variation of deaths per million population, explanations of which are not clear.
We can look at a few north-west European countries that we might consider to be similar in terms of population structure, good government, affluence, and advanced medical provision. In this daily active graph I added Belgium only when I realised how serious a problem it seemed to have. The UK and Netherlands are again close together, with Switzerland and Luxembourg tending towards a peak. The end results of this graph of total numbers will be a steady-state plateau and there will be no dip (assuming no resurrection of the dead).
There is a striking difference between the highest number of deaths per million in Belgium and the lowest in Germany, adjacent affluent countries. The explanation of the ten-fold difference is not obvious.
But is it true? Or is it apparent with greater similarity than meets the eye? Is it an issue of reporting? Is over-reporting or over-diagnosing more likely than under-reporting or under-diagnosing? This applies both to cases and deaths.
One thing is becoming clear from information about deaths from Covid-19. Death certification is far from clear: people can die with Covid-19 or of Covid-19. The two are very different but this will not be clear on a death certificate.
Underlying health conditions
Deaths from Covid-19 are very rare among the fit and healthy but are mainly among the frail, sick, and elderly. It is suggested that at the most 5% of deaths from Covid-19 are among the young fit and healthy. The bar chart show the dominance of underlying health conditions in “death from Covid-19”, and how variations between countries can be apparent rather than real. We might never know for certain.
When we see in the media the tragic news that a young person has died from Covid-19, the background appears later. For example, on the television I saw a photograph and description of a 21 year-old girl who had died, but it later emerged that she had advanced liver disease and was awaiting a transplant. What was really the cause of death? Fransisco Garcia was a 21 year-old Spanish youth team football coach. He developed Covid-19 pneumonia and went to hospital, where he died. It was found that he had undiagnosed leukaemia.
However we are experiencing deaths in people of working age, and without obvious underlying conditions. They are nearly all of black African and Asian ethnicity. The reason for this has been been the subject of a previous post, and also an explanation of vitamin D and how deficiency of it results in reduced immunity.
The panic mode means that strange medical practices are taking place in care homes, and indeed in hospitals. A German palliative care physician states: “Very wrong priorities were set and all ethical principles were violated. There is a very one-sided orientation towards intensive care; the balance between benefit and harm is often not good. A new diagnosis of Covid19 would turn elderly patients, who in the past had mostly been treated palliatively, into intensive care patients and subjected to a painful but often hopeless treatment (ie ventilation). Covid19 is not always an intensive care disease as the severely affected people are typically people of old age who have multiple pre-existing conditions. When these people get pneumonia, they have always been given palliative care (ie peaceful death). With a Covid19 diagnosis, however, this would now become an intensive care case, but of course the patients still cannot be saved.”
An elderly person in a nursing home might have existing illnesses such as diabetes, high blood pressure or, perhaps and, heart failure, all of which will be controlled. Subsequent death “with” Covid-19 will create a dilemma as to how to record the cause of death. Even without these underlying conditions, the inevitable rapid deterioration over a few days that will precede death from old age might now lead to Covid-19 testing. If positive, the test is likely to change the cause of death from “Old age” to “Covid-19”. This is when variation between nations might occur. Would “Old age” be more likely in Germany and “Covid-19” be more likely in Belgium?
“Lock down”
The Covid-19 pandemic emerged in Wuhan in China. It spread rapidly and Wuhan was locked down and isolated from the rest of the world. But nevertheless it did spread throughout the world. The Chinese authorities acted very quickly and successfully as far as spread in China was concerned. However the epidemic escaped into the world at large.
The world was informed that the virus had “jumped” from bats to humans in the Wuhan food market. But Covid-19 is a respiratory virus and eating a dead and presumably cooked bat would not be expected to cause pneumonia. It is suspected that the route of the virus from bat to human took place through for practice in the nearby Virology Institute in Wuhan, and emerged from the laboratory in its contaminated new human host, by then containing millions of copies of the virus. Once again, we may never know for certain.
The world was informed that the virus had “jumped” from bats to humans in the Wuhan food market. But Covid-19 is a respiratory virus and eating a dead and presumably cooked bat would not be expected to cause pneumonia. It is suspected that the route of the virus from bat to human took place through for practice in the nearby Virology Institute in Wuhan, and emerged from the laboratory in its contaminated new human host, by then containing millions of copies of the virus. Once again, we may never know for certain.
The apparent success of lockdown in Wuhan led to it being adopted in Europe, particularly in Italy which was the first European nation to experience a widespread epidemic. Italy was followed by Spain. Lockdown was rigidly enforced, but the epidemic progressed in both countries.
Other nations followed. In the UK the initial policy was to slow down the spread of the epidemic to avoid a sudden peak that would overwhelm hospital services, as had happened in Italy. The objective was to allow the development of herd immunity as this always brings an end to an epidemic.
Herd immunity is widespread immunity in a population. It comes about when a large proportion of the population develop immunity following a non-fatal and possibly symptom-free infection. The acquired immunity is locked into DNA and is thereby passed to offspring. This depends on young people acquiring an infection to which they are resistant but not initially immune.
As the epidemic developed in the UK, the popular feeling was that the approach of the governments’s medical advisor (Professor Chris Whitty) and scientific advisor (Sir Patrick Vallance) was not adequately active. This was fuelled by the mathematical modelling that the worst scenario forecast would be a possible 27 million cases in the UK with a need for 220,000 intensive care beds and 380,000 predicted deaths, assuming 1% morality rate. The government led by prime minister Boris Johnson had to change its approach and lockdown was introduced.
 |
| Chris Whitty – Boris Johnson – Patrick Vallance |
The need for lockdown has also been based on another mathematical model, this one called R0 (R nought) first used in epidemiology in 1952. This is a calculation of the infectivity of a micro-organism, the number of people that an individual can pass on the micro-organism. Once again it makes assumptions that might not be robust and which might change over a short period of time.
"All models are wrong, but some are useful”, attributed to the US statistician George Box in 1978. Models make assumptions and the weakness of the Covid-19 model is the assumption of a 1% mortality rate in those infected by Covid-19. This model might have amplified the mortality risk by a factor of ten, as it is now suggested that the overall mortality rate is closer to 0.1%.
"All models are wrong, but some are useful”, attributed to the US statistician George Box in 1978. Models make assumptions and the weakness of the Covid-19 model is the assumption of a 1% mortality rate in those infected by Covid-19. This model might have amplified the mortality risk by a factor of ten, as it is now suggested that the overall mortality rate is closer to 0.1%.
The problem is that we know neither the numerator nor the denominator. We do not know the overall infection rate (the denominator), only those who are also ill, that is the number of cases. We do not know the true death rate (the numerator). Is it closer to the German or the Belgian experience? Is the Covid-19 death of a 21 year-old who is fit and healthy equivalent to the Covid-19 death of a 21 year-old with either leukaemia or advanced liver disease, or the same as the Covid-19 death of a lady aged 108 in care home? Would my death from Civ-19 be equivalent to the death of one of my young grandchildren?
We simply cannot give the risk of death in the population as a whole, whether it be 1% or 0.1%. We can however give a realistic guidance to specific groups. The risk of death might be 0.1% in young healthy people. How many deaths would we anticipate in a school of 1,500 children? 1% would be 15 deaths, but I would regard this as very unlikely. 0.1% is 1 child, but it likely that no child would die without having a serious underlying illness.
Perhaps we might expect a mortality rate of 1% in those with black African and Asian ethnicity who are not taking a vitamin D supplement. The death rate might be close to 10% in the elderly (70 and above), and perhaps 25% in the very elderly nursing home residents.
It is necessary to protect those at greatest risk. We have effectively stopped cytotoxic chemotherapy, and also organ transplantation that requires immune suppression. We need to provide or recommend vitamin D supplement to those with a high probability of deficiency, those with black African and Asian ethnicity. The elderly need to keep within their homes and gardens.
But what of the great majority, those who are well and below the age of 70? Do they need to isolate in lockdown? Do all children need to kept off school? Keeping them away from at-risk grandparents would be sensible. Do universities need to close? Does the economy need to come to a halt?
Has lockdown been effective? The UK government insists that it has been, but it would not be in the traditional of a government to say, “Sorry we have got it wrong. Lockdown can end today”, after it has had such a devastating effect the national economy and the incomes of many individuals. Other governments are having second thoughts and are easing lockdown.
Lockdown cannot easily be evaluated but we have a control nation in Sweden. The Swedish government decided against lockdown. Schools and restaurants remain open, life goes on. Other nations watched anticipating that the epidemic in Sweden would be catastrophic, but not so. The experience of the epidemic in Sweden has shown very similar characteristics to that in the UK. In the UK the cumulative cases per million is 1610.3 and in Sweden 1308.5.
In the UK deaths per million are almost twice those of Sweden. The graph show the cumulative deaths per million population in the two countries.
In the UK deaths per million are almost twice those of Sweden. The graph show the cumulative deaths per million population in the two countries.
It is difficult to see how lockdown introduced in the UK on March 23rd (3-23) gave the citizens of the UK an advantage over the citizens of Sweden.
Compared to the UK, Sweden has modest numbers of deaths, but in all countries Covid-19 deaths are predominantly in the old and frail.
Let us look at the number of cases in the UK. The graph shows a cumulative number and we are anticipating that it will flatten, showing no increase in number. We have not quite reached this point. We can see the situation when lockdown was introduced on March 23rd. By that day we had recorded 5,683 Covid-19 cases, now 108,692. There had been 281 deaths, now 14,576. I regret to say that I cannot see that lockdown has been of any benefit.
I heard on the radio just as I was having lunch today (April 18th) a government minister telling the population that lockdown has been and still is of great importance, and that without it the epidemic would have been very much worse. This, I am afraid is a sterile argument. A friend of mine has been praying to God every day for deliverance from this pandemic, and she tells me that without her prayers it would have been very much worse.
Covid-19 seems to close to its peak in Europe. The value of antigen and antibody tests is uncertain. Active treatments are being put to clinical trial. Vaccines are being developed.
This is my main criticism of the handling of the Covid-19 epidemic and the government's responsibility to minimise deaths.
