Free Friday: On the Frontline, Lockdowns and Herd Immunity

Free Friday: On the Frontline, Lockdowns and Herd Immunity
March 20, 2020 Daniel Rhodes
In Free, Free Friday

 

Best posts of the week, as chosen by Chris Rowland and Daniel Rhodes:

1 – Martin gives his thoughts on UK government’s approach:

I’m not an epidemiologist, but I am a scientist and I do work in a field that touches on viruses. I’m starting to think the UK government might actually be the only one making logical decisions*. There is a degree of panic at the moment that is effecting peoples judgement. Scientists are people too, we’re just as guilty of panic and the herd mentality as everyone else.

By the numbers this is expected to be ten times worse than a bad flu season (where ~30k can die in past UK years, they are projecting 300k for coronavirus). As for flu, coronavirus ticks the boxes of a) using the young where it’s non-lethal and even asymptomatic to spread easily, b) being deadly in the over 65s with poor immune function or poor health.

No one bats an eye lid at the flu. If we had a historically epically bad flu season, x3-4 as deadly, no one will suggest shutting countries down like in China and Italy**. At a guess, I would say coronavirus is in fact no worse than the flu. It’s just that no one in the population has any immunity to it, so every contact has the potential to spread it so a much higher number of people will get infected.

This is not going away. The lock everything down and try and wipe it out will never ever work. And by that we are talking about a Wuhan level approach of everyone, globally stay in their home for months unless you in in a critical role***. It’s in every country and it’s highly virulent. It’s impossible to contain now. Logically there are two approaches.

**The one everyone is suggesting and calling the least risky. Shut it down, stop the spread, cross your fingers and hope a vaccine comes soon. Yet this risk is based on the assumption that there will be a vaccine that will work? Like we have with the flu and the common cold? This approach is enormously risky. Best case scenario is a vaccine comes out in 18months. However there’s a whole range of what ifs. The vaccine could be partially effective, it could be rushed and have side effects in a small percentage of the population. This would be terrible, as it would add more fuel to the anti-vaccine movement. There’s the issue of, while you wait for a vaccine, every time you lift the quarantine the virus will bounce back and you’ll need another quarantine. If you lock down a country every time you get to a few 100k cases, and you have 60-70 million, are you just cyclically going to keep doing it? What if a vaccine takes 3-4 years***?

*Just like the flu, coronavirus is most deadly in the over 65s. If you are under 40, the death rate is 0.2%. Which likely means people with immune disorders or severe co-morbidities. In these circumstances, why go the route of Italy and mass quarantine everyone? Is it not more logical to isolate the over 60s and those with health problems and let it infect the young and the healthy? This sounds like it might be the UK approach, and is by far the most logical. People are starting to mock the herd immunity angle now, but it’s completely logical. Let the healthy 75% of the population <50 get exposed to it and isolate the vulnerable quarter. That they have announced this, and that they are waiting to bring it in due to fatigue makes sense. I’ve started to hear people say already they are bored of coronavirus, despite this being just the beginning.

*** There is the law of unintended consequences. People can see the number of coronavirus deaths and morally find it easy to weigh that as an outrageous thing to allow to happen. However the Italian/Wuhan/Spain route of lock everything down, close all but essential businesses over a long and drawn out period will be economically catastrophic. Millions will lose their jobs, poverty will skyrocket, homelessness will increase. The economy will collapse and the health service budget will be impacted. You may end up killing more people in the long run than you saved.

This is why pandemics were so feared. They are impossible to contain, all you can do is damage limitation and the lesser of evils is going to be the only option. The government is in an impossible position, trying to herd its citizens to not do damage to themselves. I’m on the underground every day and 90% people are still openly coughing without covering their mouth. People can and will blame the government, but when citizens show disregard for the health of others with basic things like that, what can they do?

2 – Mädchenkliop in reply to the above:

Martin Mac, I’ve always taken note of your ruthlessly independent viewpoint – normally on the football! – and it’s good to hear you pipe up on this topic.  There’s not many people that could convince me this government might be doing something right and what you’ve said I find pretty compelling. Not least, because it’s evident from own experience that the number of knock on effects of lockdown or just organisations closing down is proving a crisis in itself. My wife works for a Cancer support centre which is having to close it’s doors and it’s obvious that the impact of isolation will be devastating and there is almost a complete absence of contingency plans to deal with it.

What I would say though is that there are 2 strands to this situation and the way any government goes about dealing with it. 1. The long term strategy to survive the crisis and come out the other side in the best possible shape; and 2. the competence and political will of the government to look after its population. There is an equation where the first can be pursued at the expense of the latter, whereas I don’t think this necessarily needs to be the case.

As with everything else this government does, it’s the feeble effort that they are making to protect the vulnerable – to create a culture where the young and healthy are educated to try and help those at risk rather than leaving them to figure it out for themselves. And of course, massively investing in and expanding the health services and support networks which they’ve done so much to run down in the previous decade. I don’t really see that they are taking a responsible attitude towards the inevitable issue of the health service being swamped. They may be listening to the advice of experts but I think they should also be showing public recognition of how desperate the situation is in terms infrastructure to deal with the crisis. They could do this by massive war style energetic mobilisation of health services and public information.

Although it’s a really valid point, it’s not just the sight of other countries having lock down that’s causing panic – it’s the vagueness of the information available and the fact that we all know if we try to call 111 we’re going to get no answer or an Answer Machine that’s sending everyone nuts.

3 – Ding questioning the above take in 1:

Martin, I find quite a few of your points somewhat strange:

(1) Why compare Covid-19 to the common flu? While the mortality rate can’t be determined for sure yet, the best guess is that it is somewhere between 20 and 30 times higher than the flu. Even a flu season that is 3 or 4 times more deadly than usual (as you had suggested), pales in comparison with that.

Of course your assessment that Covid is no worse than the flu may well be borne out, but, as in matters of life and death, wouldn’t it be better to err on the side of caution?

(2) Another key difference between the diseases is that there is a vaccine for the common flu, which may explain why folks in general are not as vexed by it.

(3) It seems like a red herring to suggest that having stronger measures in the UK is akin or will lead to having a Wuhan scale lockdown worldwide: the main advice is to slow the spread by testing extensively, doing contact tracing and discouraging large scale events and unnecessary travel. Countries that have done so early on – Hong Kong, Singapore, Taiwan, Japan – appear to have gotten infections under control without extensive shutdowns of the economy; those that have had to do Wuhan scale quarantines – China, Italy, Spain – are the ones that only belatedly took action, allowing the infections to overwhelm their health system. Which trajectory do you think the UK is on?

If enough countries proactively addressed the disease early on, it is quite likely there will be much less need of Wuhan style quarantines. The latter may appear to be economically devastating, but it goes without saying that so would a situation where hundreds of thousands of people die, there is panic in streets, social trust evaporates, and the authority of governments collapses. In fact, the latter scenario is apocalyptic.

(4) I find it rather asymmetrical that one side is dismissing the quarantine strategy because of longer term hypotheticals such as (a) a vaccine might take too long to develop or may never work or (b) there will be a second, deadlier wave of infections after quarantine.

It is asymmetrical because the current approach – letting the virus take its course – is itself premised on hypotheticals, but ones that are far more immediate and questionable. Such as (a) you can successfully adjust the rate of infection when it suits you, (b) that vulnerable segments of the population can be neatly separated from more resilient segments, (c) the NHS stands ready to cope with the upcoming spike in cases, (d) that mortality and infection rates won’t increase as the system becomes overwhelmed.

Again, wouldn’t it be better to err on the side of caution on such serious matters?

(5) I find it very strange that a lot of defenders of the government’s strategy are arguing that quarantines will never work because folks won’t accept it after a while, but then imply that a strategy that – as far as I can tell – involves somehow quarantining vulnerable segments of the population, will nevertheless be accepted by those folks who find themselves under lockdown. Which is it then?

(6) The argument that this is a once in a hundred years problem tends to overlook the fact that some countries have coped with it better. What differentiates the East Asian countries is not just the SARS experience (though MERS and Ebola have also flared up in recently years so it’s not like pandemic preparedness is a novel concept), but that governments are willing to be proactive and premise policymaking on what they see as best practices.

It’s somewhat understandable that the UK did not catch on as quickly as the East Asian countries – China is further away and Britain didn’t have the lesson of SARS embedded – but what about Italy? There is concrete example near to home but the government’s response is essentially to say that that won’t happen on its shores?

Essentially, the government is implying that Italy’s mistake is actually to impose quarantine at this point. That the situation would have been more manageable if only the Italians had kept going like nothing’s amiss.

Does that seem somewhat askew?

4 – Mekokrasum on the experiences of dealing with the disease first hand:

Just posting this to remind us that this pandemic was coming…

https://www.warnerbros.com/movies/contagion/

FYI – I am officially a COVID-19 doctor. We have many patients in my hospital. I diagnosed one patient last weekend who has subsequently died. We don’t have enough of the PPE to stop ourselves from getting infected. It is a worry but we will try to keep as safe as possible. At the moment, I will not be looking after very unwell patients who need ventilation. That is a whole other story. The lack of adequate ventilators and the paucity of trained ICU staff is the next big elephant that the UK government will simply not be able to deal with. If I do get sick then I will try to keep people updated.

The population need to double down on isolation and social distancing. This is a very serious situation. I have seen people being too lax about it inside and outside of the hospital. Going by the figures revealed above we will have a lot of extra mortality which is already evident in London. The lockdown of the London transport system is vital to reduce the mass spreading!

You may be aware that Germany did already have a large proportion of the necessary reagents for the RT-PCR tests to be performed and validated. Due to its substantial MedTech industry it was well ahead with the coronavirus testing and the capability was widespread before Italy had their surge. The background level of disease was much higher than anyone expected in Europe but the Germans knew this so were therefore able to start isolation and contact tracing earlier. Sadly, our government figured things out a bit too late but is now more aware of the situation. We can only live in hope.

PLEASE, PLEASE Wash your hands regularly and thoroughly. Cough sensibly and throw away the tissues immediately, then wash your hands. Try to avoid scratching and rubbing your face, then before eating wash your hands. Work from home as much as possible. No gatherings in pubs, cafés, restaurants and bars. Walk outdoors in parks and woodland, try to get out in open spaces but please avoid congregating anywhere. Good luck people, stay safe!

5 – Cvt123 with a sobering but superb analysis and breakdown:

I have a rather sobering post on the state of the coronavirus based on some number crunching I have been doing. This all started when a friend and I were discussing the current state of Italy as the situation seems completely and utterly out of control. I decided to try to see how the situation mirrors or does not mirror what happened in Hubei province by aligning the number of cases and deaths to the same point in time.

Key dates

Hubei went into lockdown on 23 January. At this stage, there had been 444 reported cases and 17 deaths. This ‘day 1’ for my time series analysis. On 27th February, Italy reported 655 cases and 17 deaths. This is my ‘day 1’ for Italy as the number of reported deaths are the same (coincidentally) as the Hubei day 1. I locked onto the number of deaths rather than reported cases, mainly as the reported cases is a function of the rate at which testing happens (see here). The other key date, is that 11 days later, on 9th March, Italy went into lockdown, when there were ‘only’ 366 deaths. This is a key inflexion point as you will see…

Evolution of the number of cases

This chart shows the evolution of reported cases by day for Hubei (blue) and Italy (green) and Italy post lockdown (green dashes) when you align as above. It *seems* that the number of cases are much lower until recently in spite of the population being roughly. My thesis is that Italy has not been testing as much as Hubei (until recently) which causes a natural under-reporting. Which leads me to the point…

Evolution of the number of deaths

This chart  is the same but on the number of deaths rather than cases. You can see that Italy and Hubei rate of deaths were about the same until day eleven, when Italy went into lockdown (coincidentally). Given that the incubation is about 7-10 days and the population size / dynamics were somewhat similar, we should not have seen any material impact on the virus in the early days of the lockdown.

Day on day growth rates

This final chart shows the day on day growth rates for Hubei and Italy once lockdown has happened. Each dot is a day on day growth rate and the straight line is a the best fit curve for a logarithmic relationship (for Hubei, R^2 was about 0.72). What struck me is how similar the curves are, even though Italy is only ten or so days into their lockdown.

The difference in ‘height’ might be due to population density or noisy data… who knows. Regardless, this data would suggest that a lockdown needs a 45 or so days to get the increase in deaths to zero. I suspect that governments are going to go through a 15 day ‘quiet’ period before lifting any lockdown…

Implications

If I just extrapolate the Italy situation based on the China growth rates, it would seem that the final numbers for Italy will be in the region of 25K, which is heartbreaking…. Other learnings are:

It does however, suggest that unless you put a country (or community) under some rigorous social distancing regime, then this virus is just going to spread (we know that)
once a lockdown is in place, then the evolution is pretty consistent so don’t trust number of cases unless a sufficient proportion of the population are being tested.

What about the UK? Well… on 13 March we reported 10 deaths and 14 March it increased to 21, which is probably the best date as our ‘day 1’. 5 days later, this increased to 144 days, increasing by 6.85x. Both Italy and Hubei started with 17 and after the same interval, Hubei reached 125 deaths (7.35x) and Italy was on 79 deaths (4.65). Basically worse than Italy but not as bad as Hubei, but the law of small numbers is a consideration here…

I know this has said before, but where we end up in terms of fatalities is going to be a simple function of how many deaths have been reported when a serious social distancing regime is put in place.

I know many here are categorized in the ‘vulnerable’ group and my post is not here to alarm or distress. I wanted to share this data in the hope that it may change their views and perspectives to change their living habits if they live in a country that is not enforcing serious social distancing measures.

6 – Di Wei gives his view on the arguments behind different approaches to the virus:

I’m a Singaporean living in the UK and would like to share my two cents on the UK government’s strategy.

1) The debate seems to be about empiricist vs theorist. We know social distancing works is from empirical studies of previous epidemics. For instance, we can compare US cities that implemented social distance vs those that did not during the 1918 flu. Of course, COVID-19 is different so we build models to account for differences. Models require assumptions, some may not have sufficient empirical backing. So modellers need to decide how we weigh historical empirical evidence vs modelling assumptions. The problem is that the UK modellers have not made their model open to other scientist for peer review. If the UK modellers are right then opening their model will create a massive public good, if they are mistaken then only other scientist with the technical know-how can tell.

2) Another issue is, what is our default position. In situations like pandemics, where the risks of massive deaths is not insignificant, we may want to default on being cautious. Say the probability that the UK modellers are right is high, and a small probability they are wrong. But there is a catastrophe if they are wrong. A small probability multiplied by a big negative effect can still be a massive negative, in expectation. Our strategy needs to be robust to errors right?

3) I think the deepest argument against is a humanistic one. I have a few friends working in the public health sector, in Singapore, who are furious with the UK’s strategy. They feel that the UK is undermining their efforts, and justify it by pointing to the fact that the UK accounts for top 5 (nations) of imported cases to Singapore. At a time where humans should band together, the UK has adopted a strategy contrary to the WHO’s recommendations and may frustrate the efforts of other countries. At the end of the day, even if we develop herd immunity in the UK, it may be at the expense of exporting many cases to other countries. Maybe this is being too idealistic, but I think pandemics can only be truly overcome with global human cooperation.

Articles published since last Friday, with excerpts:

Monday March 16th:

Which Players Make Liverpool Perform Better?by Andrew Beasley.

The obvious thing to notice is that every player has shifted closer to the top right corner, which is the direction we want them to head in. Let’s look at a few key players from left to right.

I was surprised to see Joe Gomez at the bottom of the chart, but let’s put his figures into context: the Reds were still performing at close to +1 on expected goals difference and over one on actual, so it’s hardly a disastrous record.

We then have a cluster around the marker for the whole team, and unsurprisingly these are the men who played the most minutes. You’re unlikely to stray far from the team average if you barely miss any games, after all.

Tuesday March 17th:

Covid-19 – A Selection of TTT Subscribers’ Wisdom

I don’t know about you, but I’ve been checking the Johns Hopkins tracker as if it was BBC Football page. So far, Covid-19 is ahead, and like Liverpool throughout 2019/20, likely to extend its lead. Although maybe like Liverpool, it will also be denied victory right at the last moment.

(The ever-excellent John Oliver sums up how most of us Reds are feeling.)

As ever on TTT, the debate about almost anything behind our paywall is enlightened. We have a number of scientists, academics, PhDs and medical doctors, some of whom have been sharing their wisdom (and front-line experience), and we also have some people with the virus who are in isolation.

So, we thought we’d share just a few of the 1,000+ comments on the issue in a free piece, to help spread some of that wisdom and some of our concerns.

Thursday March 19th: 

How Liverpool Became a Bastion Of Sustainability by James McGee

The Deloitte money league released its latest report in early 2020.

This showed that Liverpool were making progress but other than that it was largely a case of as you were. Manchester United were the richest English club again, Barcelona and Real Madrid were first and second globally as they continue to be allowed to dominate their immediate spheres through a legacy of heavily biased TV deals and political support amongst other things. The top teams have either been cemented in place by Champions League money which is destroying competition in leagues across the continent (Juventus, Bayern…) or through benefactor money (How they can claim Man City’s revenue is £538m when it is in effect limitless).

But, amongst all this there was one significant nugget: Liverpool’s revenue (£533m) and the rate at which it was growing – up £80m a year. Now that rate needs to be put into context, as the current commercial climate also means that Manchester United were able to grow their revenue £30m year on year despite being terrible. Also much of what Liverpool brought in was due to success in tournaments which can fluctuate wildly annually. However, this did not count transfer fees and as we know if you can sustain the unsustainable revenue from tournament success for long enough, it can translate itself into something more concrete as commercial deals grow eg Liverpool’s recent kit deal, and a quality squad is built.

Why does all this matter? Well it means that for once Liverpool may be in a fair fight at a Premier League and Champions League level. For the entire existence of those two tournaments Liverpool have only been able to compete by spending the most money for about one year – when Souness was manager and dragging the team down with signings like Paul Stewart and Torben Piechnik. For the rest of the time Liverpool were not only trying to play catch up, but in many instances failing to do so as the revenue gap grew and grew.

 

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