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Monday, August 03, 2020

Oxford epidemiologists: suppression strategy is not viable

An interview that will make lockdown fanatics upset touching on, among other things:

- the lack of evidence for masks
- considering covid-19 as a seasonal infection rather than a pandemic
- why lockdown is an inappropriate and blunt tool
- mistakes in care homes and infection in hospitals
- the toll of covid-19 vs influenza-like illnesses not being as different as people think
- how 'flatten the curve' sneakily became 'squash the curve'
- how we need to live with covid-19 instead of eradicating it
- how lockdown wasn't responsible for as much of the decrease in cases as people think
- the covid-19 pandemic compared to 3 other pandemics within living memory
- how media sensationalism is driving covid-19 hysteria
- the psychology behind championing government interventions, and how science works

Oxford epidemiologists: suppression strategy is not viable

‘Hello and welcome. This is LockdownTV from unherd.com. Today we are joined by not one but two epidemiologists and experts to find out what the state of play is in the coronavirus pandemic. First of all, we have Professor Carl Heneghan, who is the director of the Oxford University based Centre for Evidence Based Medicine. Also on the line down from Rome in Italy, we have Tom Jefferson, who is also an epidemiologist, part of the Cochrane Center, which is a charity that works on improving the evidence base for medical interventions. So thank you both very much for joining us.’

‘You're welcome.’

‘I understand that you actually are talking almost once or even more than once a day during this pandemic. So you've kind of, you've worked as a team already.’

‘Yeah, well, Tom and I have been working together for about 12 years ago, and we can go right back to 209 to the swine flu pandemic. And subsequently throughout this pandemic, we've been really interested in the evidence in, we've been interested in the transmission dynamics, what's happening on the ground. And Tom and I speak daily about the issues trying to understand a lot of the uncertainties out there.’

‘So let me start Carl with you then with a, with a kind of a bit of a broader question, which is that you’re the director of the Centre for Evidence Based Medicine, I mean, this is what we want. We want to make decisions on the basis of evidence. How do you feel the medical response and the government policy response has been in terms of evidence based medicine? Has this pandemic been a good period for evidence based medicine?’

‘I think what we'll find as we go through this, that this has been a period where there have been lots of issues with the production of evidence and its interpretation. What people have found very difficult is to deal with uncertainty. And often what really riles me and makes me concerned is when I hear people in the media or talking and saying, it's without question, this is what's going to happen next. So I think there's been a significant problem with predictions. None of them so far have been shown to be right. The second area where we try and do a lot of work is in evidence synthesis. That's where Tom is *something*, and we both work with Cochrane. But we try and review the evidence to try and understand its quality, what it means in terms of informing policy. And while the evidence has been produced in a way that we've never seen before for coronaviruses, what a lot of it is poor quality and it doesn't help us actually inform the policies. And a good area for that would be an area like masks. One of the issues we've come to, say. is look at the evidence and Tom can come in because he's done the reviews in this area for about 15 years now is, is to say, really to inform policy, what you need to do is have an approach to develop high quality evidence. To do randomized control trials. And while we seemingly understand that for drugs, given the recent evidence from dexamethasone versus hydroxychloroquine, we, we get it there. But when it comes to non drug interventions, things like masks, we want to throw all of the ideas of high quality evidence out the window, and then use poor quality information to inform what we should do next. And that's been a persistent problem over the last 10 or 12 years, that we've failed to address the deficiencies in the evidence for areas like masks and what we do in the wider community.’

‘Okay, so you brought us straight into masks there. So let me go to Tom then. You've been studying these non medical or these physical interventions for years, what is your view of the wisdom of requiring mask use among the wider community?’

‘Specifically on masks, those, there's no evidence that masks apart, aside from people who are exposed in frontlines, so healthcare workers, that masks actually make any difference. But that is extraordinary. So, but what is even more extraordinary, is that what I'm describing is uncertainty. We don't know whether these things make any difference. We don't know whether they make any difference by the type of agents that we're looking at. We don't know whether the materials or anything like that and the way they're fastened, the length of use and so on make any difference. These are non healthcare worker settings, okay. So what does science usually do when there is uncertainty? Well science deals with uncertainty by doing experiments like Carl described. The randomized control trials. Now, the time for the randomized control trials was in February, March and April. No longer now, because the viral circulation is low. And we would need huge numbers of enrollees to show whether, to know for certain whether there was any difference with mask wearing’

‘On masks though, I have seen studies that have been widely shared on social media but that investigate the, you know, on the kind of physical level how much a mask can reduce the spread of particles and, you know, there is evidence that masks work, in that setting as you know, even though there may not be evidence of the kind of in a kind of controlled sample style’

‘Freddie, we're dealing with some of the most slippery customers in the market, respiratory viruses. It's not just a question on the bug and the person. It’s also the setting, which is why, all these laboratory-based experiments with plumes for instance, there are studies looking at the plume of droplets coming out of mask A versus mask B and so on, have to be treated with extreme care. What we really should be doing is our experiments, trials in the population. We have to, we have to do them when there's virus circulating’

‘But isn't it a matter of common sense to it at all? I mean, do you, do you believe that wearing a face covering reduces the amount that a respiratory virus can be transmitted, even though you may not have a population wide study to prove it?’

‘The problem, the problem with that particular belief is that the one arm of a randomized control trial, which was published in 2015. So one, one section of the people that took part in a study in Southeast Asia wore cloth masks, okay, and they found that these cloth masks not only didn't work, but actually probably saliva and secretions and the wetness made them more permeable to incoming agents. So what I'm describing really is complete uncertainty.’

‘From 24th of July in the UK, it's gonna be mandatory to wear masks in shops. It sounds, would I be right in saying that you don't think that sounds like a necessary or wise step or?’

‘Well look, the job of evidence based medicine is to inform decision. Not to be the decision. And this is an incredibly important point that I think a lot of people don't get when you're actually in healthcare and actually they're making decisions. So both Tom has been a general practitioner and at the weekends, I still work as an urgent care GP. I use the evidence to inform you about the benefits and the harms. So the question is, if you were in policy in our stores about what are the benefits and harms, we will tell you now that there is significant uncertainty. Any evidence that you bring to the table will be mechanistic, will be weak observational evidence, which has been shown over decades to have flaws. So by all means, people can wear masks or not wear masks. Policy can make the decision. But what they can't do is say it's an evidence based decision. And I think that's really important and there is a real separation, it seems in my mind, the difference between an evidence based decision and something which is becoming very opaque to me is Science. Is we’re being led by the bait, the Science. The Science is the mechanism, the plumes, but it isn't the evidence. So by all means wear or don't wear your mask, but the current evidence cannot reduce your uncertainty when it comes to the policy.’

‘Okay, so if we if we move on from from masks, and Carl, maybe if not, I can ask you about the sort of wider question of the overall shape of the pandemic at the moment. I mean, what we've seen in countries across Europe, is that it seems to be very strongly on the way down. In some countries, it's sort of almost down at mill. Meanwhile, in America, we are seeing some resurgence or what looks resurgence in a number of states. What's your overall picture of where we are in the lifecycle of the pandemic?’

‘Well, look, I think it's real, it's been a very interesting phenomenon from an epidemiologist’s perspective. The first thing is to say we have seasonal effects every year, we see increases in infectious illnesses. And there are about 40 or 50 that we know about that cause illnesses and the predominant one that everybody's focused on has been influenza. Now we see in Coronaviruses come to the fore. For lots of people, it seems like this is a new infection, but there are seven now coronaviruses that we're aware of that are in humans. What's different about this infection was the sharp uprise particularly in the number of deaths. And if I take Italy was very similar to the UK, we had a two, three week very steep uprise in the deaths. And here in the UK, we peaked on April the Eighth. And since then, they've been coming down. Today we've just had our Office for National Statistics number, which has said for the 12th week in a row deaths have come down. And actually now the number of excess deaths are below the five year average and have been so for three weeks. So we are trending in a direction where we're seeing reductions in admissions, reductions in critical care use and reductions in, in deaths. But we've never seen this sharp uprise before. Now that's been pretty consistent in countries like Spain, Italy, Belgium, and here in the UK. And one of the keys about the infection is to look at who's been affected. And this is quite interesting because Tom and I wrote about this, the difference between pandemic theory and seasonal theory. And in a pandemic, what you expect to see is young people disproportionally affected. However, I think we've had in the UK now I'd have to check today but we've had six deaths in children. That's far less than what we normally see in a pandemic. The flip side is more than 75 percent of the deaths have been in over 75 year old, which fits with the seasonal theory much more so. So that's an interesting observation that we first noted.

Interestingly, what's come with that, while we've been in lockdown and lots of people are talking about lockdown strategies: has it worked, has it not? What we found in the UK is that while we've been in lockdown, what happened and what went wrong is, more than 50% of care homes had outbreaks of the infection. That means two or more people have the infection. So while the community transmission may be as low as 5%, it's tenfold higher in care homes. They’ve accounted for nearly half the deaths here in the UK, and more than half in areas like Spain. So some things have gone radically wrong. So that's an interesting area as well to think about. In terms of where we are now, just to come, when you look at the USA it's really interesting because USA, if you go to New York, and the areas around New York, New Jersey, they had a very similar pattern to what was happening in Europe. Lots of sharp uprise of deaths. But if you go to places like Texas and California today, in fact, they have nearly as many cases as we do in the UK now, about 75%. But these, these areas only have three or 4000 deaths, they have about one 10th of what happened in New York. So there seems to be something radically different. So while everybody's looking at the cases, look at what's happening with the deaths as well, because the deaths are not rising, like they were in March, in April. And there's something different happening with the virus right now that it doesn't seem to have the same virulence and the same impact on mortality.’

‘So there's two things that I'd really like to just follow up on. So the first is you said, it see, it has more the pattern of a seasonal infection than a pandemic. Does that mean that the explanation for why it's come down so much in Europe is that it's summer, basically. And we shouldn't take from that, that it's gone for good. It may very well later be back in the winter?’

‘Well, we've just, we were involved at the moment, one of the things we're doing at the moment is a review of transmission dynamics looking at these particular issues, and we've just put up an update actually looking at this particular issue. What it looks like is the stability of the virus is far less. When the temperature goes up, but particularly humidity seems to be important. The lower the humidity, actually, the more stable the viruses in the atmosphere, and on surfaces. So when we compare to other countries, what we did see in the Northern Hemisphere when the conditions were right, rapid spread, transmission and impact on deaths. Now it's interesting to see what happens as we move into the southern hemisphere. They tend to have outbreaks now at this point. Their January in effect is happening right now. So that's why we're seeing down below in places like Australia suddenly having outbreaks that are making the viruses reappearing. And that probably is to do with the stability of the viruses, more so on surfaces, than actually in the air. The second aspect of the seasonal effect is that we are a more outside, more ventilation, which also may have an impact to say our viral load is reduced at this time of year. And that's also important then, on potential virulence.’

‘But does that, does that mean that you're not persuaded by theories of greater immunity levels explaining the decrease? Because, you know, there's always this optimistic idea that maybe through other kinds of non detectable immunity actually we've, we're slowing the spread and the decrease seen across the northern hemisphere is is explained by immunity levels. You don't you don't buy that?’

‘Well, no I think there is quite an interest in lots of points we're now coming to. So first thing is that we come through March and April is to say, Pete, there is a group of people who are more susceptible at that time of year. So for instance, your immune system isn't as strong. That's the vitamin D argument. But number two is you may have had other coinfections, you may have just had an infection. So your lymphocytes are not primed. You're not ready to fight off another infection. So they're interesting aspects. The third aspect is to say, one of the issues we also saw, if you look at the UK data over the last five years, we tend to see a very bad winter. So in 2017, 18, we had 50,000 excess deaths that year. Followed by good winters. So if I go back to 2019, in fact, we had about 15,000 less deaths in over 85 year olds than what we expect. Actually, so trended into this year, we had a, a, what, a bigger susceptible population in the very elderly. And you might find in the the cities and the countries that did badly, that there’s a larger susceptible population coming into each year. So I think that's one aspect to why the virulence is less. The second is a seasonal aspect. And then third is a combination of the treatments getting better, which is a combination of doing some things right. And stopping other things that might be iatrogenic. [Ed: relating to illness caused by medical examination or treatment.]

‘Let me go over to Tom there. So you've been listening to this. What, what's your sense of why the results seem to be getting better over time, at least when you compare numbers of cases to numbers of deaths?’

‘Well, I would say is that what we're seeing in Europe at the moment is a Singapore-like transmission. The transmission that they had in Singapore in February March where they had a low grade, constant transmission. Amongst workers in dormitories, people who were working age, that means anything between 20 and 50, with very few deaths, and a number of cases. In Italy at the moment, we've got about a 200 case, an average of 200 cases a day, mostly imported, and deaths are below two a day. And there's less than 75 people in intensive care. Whereas in March, April, it was over 7,000. So it is a definite downward trend. Does then enter the role of asymptomatic. And that is completely, still completely unclear. People who have no symptoms or who have eventually developed symptoms, so called presymptomatics, that's also got to be understood. And as we move into the winter, we have to I think, the most efficient thing is to have a societal debate as to what we're going to do with these influenza like illnesses. All of them, not just Corona.’

‘So erm, that, that kind of level of transmission you talked about seeing in Italy and and now in the UK, we're round about, I think it's 500, more than 200 a day, but still very much down on what it was. The key question really, and I'm keen what both of you think of this is, is that a sustainable situation? Or are we getting literally a summer holiday from the, this virus and that it's likely to surge up again, we'll see some kind of second wave when the season changes? There's a difficulty because we don't quite understand what will happen once the winter period’s over. When we start to recirculate there'll be competition with other acute respiratory infections that might change the dynamics of the virus. As it goes through more people, you might expect to see mutations, but it seems to be more stable than some of the other Coronaviruses. The SARS-CoV-1. We're not sure what happened to that virus. Diit d actually mutate to the point where it became asymptomatic, carried on circulating? So there are so many imponderables here. That actually I think what we have to have is more the debate about how we gonna manage the risks. And how are we going to manage living with this virus. And I think the problem is the policy is not being clear. What should we be doing to try and inform the decisions we make? For instance, in terms of what's the impact of locking down, and these are important questions to now answer. Many people might say we should have locked down earlier. But actually, as I said, 50% of care homes developed outbreaks during the lockdown period. So there are issues within the transmission of this virus that are not clear and require for in a way to try and understand what, how did we manage to transmit it in so many places, when we were all supposed to be at home?’

‘Well, surely the, the answer to that one is that the people who were explicitly not included in the lockdown were key workers such as care home workers. So the only people who were not protected were the people who were coming into contact with the most vulnerable group.’

‘Yeah. And so these are the issues. So if you want to go forward, you've got to have a real debate about how do you stop doing this? So it's not just an evidence approach. It's a societal approach. So what you're describing is, how do you manage to seed it into care homes? Well, there are two ways. One is you discharge patients in there. Or the second is you have a care worker who may be low paid, doesn't get paid when they're not working, and is an agency one who moves across different care homes. So some of these people working five or six, keep coming and going. So what we need to do really efficiently now is understand in those countries like Hong Kong, where they had a deep, a clear strategy to protect care homes. And if you look at Germany, that seems to be some of their benefits. Lower death in these setting. Because you may be testing them every week. You may be having strategies where you pay for individuals to stay in the home. You may actually say this is a bubble of people who will go into isolation. And really what we're talking about is about an eight week period. If you look at the period, if you did it over eight weeks, you'd reduce about 80% of the outbreaks in care homes. So you need a different strategy right there. And if you did that, you get rid of potentially up to half the deaths. And then suddenly, you've got a different infection you can lock out, and then you might not go into lockdown, because that's a very blunt tool. What we need to do is have a debate about what are the intelligent mitigation strategies that actually that can keep society functioning while we keep those that are the most frail and elderly and the most vulnerable shielded in effect.’

‘If I, if I can just, just widen the debate a little bit, that's what I meant when we have to, we need to have a societal debate about what we're going to do with influenza like illness. With these acute respiratory infections, because everybody thinks it's influenza. And in fact, influenza is a very, very small, on average, chunk of the pie. There are several coronaviruses, which circulate every winter, there are several dozen other viruses that we're aware of that circulate every winter and then there's X number of unknown viruses like COVID-19, like SARS-CoV-2 was up until December that we know nothing about. So we have to have a clear idea as a society what we're gonna do. If somebody coughs, so we're going to go into complete lockdown? Is that what we, is that a way forward? If that's what society wants, that's fine.’

‘I guess what you're saying is, let's make more kind of surgical interventions in areas where we can be more confident that it's going to make a difference, and try and sort of roll back some of the kind of universal policies. Is that a fair?’

‘Let me just, let me just make an example. Our ancestors had fever hospitals, they had lazarettes, they had quarantine stations. Some of them are still around. So instead of binding everybody into NHS hospitals, possibly infectious, possibly non infectious, everybody together, how about separating them, which is one of the first things that you learn in medical school? Separating the potential infections from those who are not infectious. So say strokes and somebody’s had a car accident, because the consequence of not separation and the consequence of poor architecture like we’ve got at the moment are what we have seen. The transformation of hospitals into plague pits. Into, into infectious, infectious foci for the whole population. These are the sort of fundamental interventions that we should be looking at based on the experience of these last few months’

‘Which might have been a good use for those nightingale hospitals that we built and then didn’t use otherwise’

‘I would have to look at the surroundings of that and the structure’

‘One of the, one of the good points you just mentioned. The nightingale hospital. I think, I think what people will say is when you know nothing about Coronavirus, well, how can you have evidence? But actually one of the keys is to watch the evidence and the data as it emerges. And if you've been watching the acceleration of the, of the admissions into hospital, and the acceleration of the deaths, one of the things we watch is the rate of change. In effect, you know, you're going to get to 70 miles an hour and when you first go on the motorway you go very fast, don't you? And as you get near to the top, your acceleration slows. And that was one of the things we were watching. We watched the data very clearly. And about April the 11th, 12, we said we'd hit the peak. Now the problem with not following the evidence and following the model is, is that's exactly where we’d be building Nightingale hospitals. And losing focus of, we should have been looking at where the most vulnerable are while we've got this acceleration is slowing. We need to focus on care homes, and we lost sight of that. So that's one important aspect. The second aspect then about the intermediate care hospitals is the nightingale is a wrong structure. What you require is, if people go back we'll know, when people who are slightly probably a bit older than yourself Freddie will remember fever hospitals in the UK. That they were here till about 1980s, 90s. They've been about 100 years in existence. They were on single floors. They had isolation within isolation. They had staff who were trained. And they did not have lift shafts opened down. And that isolation within isolation said you could put a patient in there, you could see them. But actually everybody was protected from each other. And the argument to that is it prevents nosocomial infection. People going into hospital and catching it because as Tom said, these are infectious foci signs. And it looks like about at least 20% of people potentially got the infection while they were in hospital.’

‘Let me try to kind of zoom out and get some sort of a concrete sense. Is it a proportionate response to the threat? And is it right to say that we now face a new normal, where pretty much all aspects of life must be different in order to mitigate this threat? Or do you think we should be headed back towards an old normal?’

‘So, whether the benefits of carrying on with the current strategy are outweighed by the harms? And to be honest we, I think we are right there now at that point. And the the issue is what are you going to do from a behavior? So we need to instill’

‘What do you mean by that, Dr Heneghan? I mean, because the strategy at the moment is to be relieving, taking away restrictions, gradually keeping high testing and doing what the Prime Minister calls a whack a mole strategy when we see local flare ups.’

‘Yeah, so I give a local flare up. So for instance, I give you the number. One of the problems I have is in people being clear about, you're going to lock down again, at what level of infection are you going to lock down? The reason we went into lockdown was for health services, if they're becoming overwhelmed. And remember, in 2017, 18, they became overwhelmed. 50,000 excess deaths, and nobody said we're going to lock down society at that point in time. So this is a real debate about at what level. So it's in the winter we will hit epidemic levels of acute respiratory infections again. 40 per 10,000. 8 to tenfold higher than where we are now. At that point, what are we going to do? And we need to be start to be very clear in our understanding of these infections, the consequences and our decision making. And at the moment I'm finding it's so unclear.’

‘I think the the argument that has essentially won is the kind of suppression strategy. And you know, you get experts like Devi Sridhar, who is on television the whole time in the UK, who literally say, zero cases, is the only tolerable state. And anything up to that means we have to carry on with these massive interventions. That is now, it seems to me, that when the argument that has won, do you support that?’

‘So, when it comes to suppression, there's only one real, it's only the virus that will have a determination in that. Whatever we do next, unless you take a policy like New Zealand, which is gonna say, we've suppressed the virus to zero, and then we're gonna lock down the country forever, you're going to have a problem with any strategy that defines suppression. Because what we've seen with this virus is it now’s transmitted to the southern hemisphere. In the last 2003 outbreak, by now in July, it was in very small pockets in the hospitals in places like Toronto, and they managed to eradicate it in the middle of July by isolating and quarantine all staff, and patients. And in doing that, that's suppressed it. But this virus is so out there now, I cannot see a strategy that makes sense to me right now, that suppression should be the viable option. The strategy right now should be, we have to learn how to live with this virus.’

‘And part of that is just sort of readjusting the way we think about it, then, you know if you're, if you're making the comparison with 17, 18 flu outbreak, you know, we basically need to think of it like we think of other flu style respiratory outbreaks and sort of only trigger major interventions when it crosses a certain threshold of hospitalizations that we actually think is really worrying. Is that, is that where we should begin, you think?’

‘It's important to recognize within the UK if you look at the RC GP surveillance centre data, which is incredibly important data, it's been running for 60 years. It gives consultation rates every week in about 4 million population. And that's why I can be very certain about where the numbers are in terms of each week. Here's a number of ILI - influenza like illness and acute respiratory infections. That data showed in the UK, in the two weeks before lockdown, when people were being encouraged to wash hands, and there was encouragement of social distancing, where we change our behavior, because we recognize a threat, led to a 50% reduction in acute respiratory infection. So actually quite a big difference was made in the two weeks before lockdown. What we're looking for is the one or two bits of society that we can change or alter, that give us that extra 20 30% reduction in the infection. That means then it's manageable, within the hospital setting. And as we learn more, we can manage the disease much more effectively.’

‘Erm, Tom, let me come back to you then. What do you think going on? What, why has this become such a hugely politicized and, you know, the only news story in the world and all of us are changing our whole lives in response to it?’

‘I am a survivor of four pandemics. Four official pandemics. And for the other three, the preceding three, I didn't even realize they were going on. Nothing changed. Perhaps, people died. Not so many in 2009. But a lot of people died in 57, 58. And a lot of people died in 68, 69. But none of the fabric of society was eroded by, like it has been. By the response that was mounted. What worries me most? I have to say that, is that some catastrophic mistakes were made at the beginning of this story. I won't go into them because I’ll probably scare the audience. What scares me, what scares me more than the mistakes’

‘Now they, I tell you they’ll be all over the comments saying what are those catastrophic mistakes? You need to, need to give us a clue’

‘Well, I have already given you one. Mixing potentially infectious people with non infectious people. The need to keep infectious people complete, potential infectious people completely separate. The infrastructure, not just the patients, has to be separate. When you're dealing with an unknown agent that, as this was, this was one of the, the obvious, the obvious catastrophic mistakes that were made. Do I see steps being taken at European level? Remember, I am talking from Italy so I have a Europe-wide perspective. Do I see steps being taken to learn from that mistakes, from that mistake, and change policies. Change the way we do things, change the way that healthcare is delivered? And most of all, do I see reception structures being set up? Just in case there is a resurgence, or even a very bad ILI season caused by viruses which are not SARS-Cov-2? And the answer is no.’

‘So your view is not really that people have overreacted or the governments have overreacted so much as they're putting the emphasis on the wrong kinds of interventions, these sort of’

‘If they've overreacted. I think that is in part it's understandable because the memory of past plagues has gone okay. And for instance, Spanish influenza is a, is a folk memory. And is only brought out to scare people. So, I think that some of the mistakes are understandable. What is not understandable is not having learned from them. Another example, kicking everybody out of hospital. Okay, so some of them went into care homes without testing and that's not the point. The point is you make space for infectious patients. Where? On the third floor ward. Third floor, which means that you have elevator shafts. We know that elevator shafts where thermals are conduits of, for all sorts of things, including microbes. Then, you shift them from the third floor to the first floor somewhere else inside the hospital complex. And the staff looking after these infectious patients mingle with other staff in the canteen. Here's another thing that is almost certainly was an accelerator. Why did we, why did we witness this explosive beginning of this epidemic, pandemic? Has anybody been investigated, investigating them? Well, a few people have asked the question. We've reviewed that the answers. We, it seems to be more to do with meteorology, of the presence already presence on the on the ground on the virus. But we're not sure. Should we not be putting huge amounts of resources into investigating this? So we make sure that we understand exactly what happened and we make sure it doesn't happen again, and we can minimize the risk of this happening again.’

‘I think what some, kind of, it's an important point what Tom makes, and this is a really important. What we've seen in terms of the transmission dynamics, I think with the first SARS outbreak in, in the Far East. They've done a bit better job on producing field studies on transmission. And so for instance, we just had a recent outbreak in in a farm in Malvern. One of the key things within each outbreak there should be an indepth investigation. Samples should be taken not just from the infected people, but from the toilets, from the bathrooms. Investigations. Were you in contact? Were you in close contact? Did you share drinks? What's the layout of the settings? And we've done that. Some parts of the world have done that and they provide really interesting information. So for instance, in some hospital settings in China, they found the virus was located most in the bathrooms, in the toilet. Probably an area that didn't get the attention for cleaning. Toilets have the potential when flushed to aerosolise SARS-Cov-2. Each hospital should do a sort of significant event analysis where they look into the infection and detail what went wrong. And this is important. The reason this doesn't happen is often because people want to find somebody to blame. And this is not just in hospitals. This is across the board politically. It's gonna be a real issue if people become defensive and don't accept we made misstakes, but we need to study in them. And we need a no blame culture because otherwise, as we've seen around the world, it's going to lock down and we're going to learn, we're not going to learn what we need to understand particularly about the transmission.’

‘You mentioned politics and let me kind of conclude this discussion with that because it has become very politicized and heated. And, you know, I mean, I, you do quite a lot of media and Carl, I’ve seen you quite a bit, but I would say you don't get invited on as much as those professors who are giving a scarier and more sort of, you know, second wave is about to hit, governments not doing enough kind of narrative. Do you think we tilt in the media towards bad news?’

‘We as individuals are part of the problem because sensationalism drives people to click on and read the information. So it's a sort of big circle if we create the problem because if we put the worst case scenario out there, we will go and have a look. So if you want a solution, you've got to get people to stop clicking on this sensationalist stuff. A lot of what the problem here is context. People are now aware that people on a daily basis die. And this morning I had an interview with the radio 4 and they said hundreds of people are dying still of COVID each week and I said, well look, on average, 1500 people die each day. In winter, it goes up to about 2000 a day, and in summer comes down to about 1200. That's a huge disparity. But nobody knows that context. They also don't know in under 50s, for instance, there are no excess deaths. And actually, one of the important issue is as we get aware of this information, we've got to come to terms with it.’

‘So you don't. I mean, you're not sort of framing it like this, but you don't think that you have a whole set of kind of opponents within the scientific community who are driving a much more simplistic narrative where the more government interventions, the better. The sooner they're done, the more virtuous and anything short of that is negligent. And that group is actually winning the day.’

‘Yeah, look, I, we've been here before. It's it's an issue when people consider that interventions will work because of the mechanisms, because they believe it works. I hear that a lot. I think I consider it might. But actually, that's the problem when you start to look at evidence. There are so many examples throughout history, where people believed interventions have worked. Forgetting equipoise that when you test an intervention, it's equally likely to work and it's equally likely to potentially harm you. And that's why we need the clinical trials to try and determine what works compared to what doesn't. I do think there's a narrative where people want to come on and say with certainty, this is what's going to happen. And it's actually seems to me a very simple argument. Yeah, next winter, it's going to be worse again. It's much harder to sit back and go, do you know what? I've been looking at this for 15, 20 years. And I am still unsure about what's going to happen. What we're going to do is keep following the data. And one of the examples I give to people is, is I thought I'd say the data is a bit like the weather. I can tell you for about the next three or five days, what's going to happen. And potentially they can tell you about two weeks into the future, but what you do is keep updating the evidence and the information to reduce the uncertainty. And when we do that, we do come to a clear understanding that I can be more confident of saying, here's some evidence, it's high quality, and here's the size of the effect. And that's an important aspect. If you actually understand what I'm saying is you would then say, well, if I'm going to take this intervention, can you quantify for me exactly how much benefit I will derive?’

‘Final quiz question for both. Infection fatality rate, it's become this kind of hobbyhorse for everybody. Everybody picks different numbers. Having reviewed the evidence up to now, what's your best guess for the IFR will be, will have been revealed to be in, let's say two years from now?’

‘Okay, so there are two things and I can't do this quickly. But the big thing about the infection fatality ratio, it matters who you infect, because there is such a huge gradient in terms of the mortality by age… but if you [look at] everybody, it's very difficult because if you predominantly infect the elderly, you're looking at a population based fatality of about one in 50. If you did children, you'd be about one in 2 million, one in 3 million. So by the time you got out there and give it to everybody, we’ll be down about where we will be when we’ve seen the swine flu. Down about the .1 to.3%, much lower than what we think. Because at the moment, what we're seeing is the case fatality.’

‘Tom, Tom, would you, would you agree with that? If we gonna come back to you after two years and look at the numbers, do you think that sounds about right?’

‘Could you give me a number I can play for the National Lottery please?’

‘We did naught point one to naught point three is what will the World Health Organization might say but’

‘Okay, okay, I'll write that down. I'll play to the National Lottery now here in Italy and see what, what comes up.’

‘But no view you don't have a view?’

‘I have a, I just I just follow the facts. I don't I don't like to forecast the future because with respiratory viruses, as I've said before, you can't do that. If you look at the whole narrative, that whole narrative was distorted at the very early beginning by the obsession with influenza, which is just one agent. In fact, they’re two agents and nothing else existed. Well, we know different now.’

‘Well, Tom and Carl, thank you both very, very much for giving us that time. I've covered a lot of ground there, and lots of food for thought. So thank you for that... ‘That was Carl Hannigan and Tom Jefferson joining us from Oxford and Rome, respectively, and covering a whole lot of ground about what the current state of the pandemic is, and some really important thoughts for us to consider going forward. Thanks for joining’

‘Flatten the curve’ suddenly becoming ‘squash the curve’ is a great example of the ‘myth’ of the slippery slope
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