The Wry Observer’s Covid-19 update (156)

Happy Official Birthday, Your Majesty.

The Birthday Honours List contains knighthoods for the leaders of the RECOVERY trial which, according to “The Times” discovered the benefit of steroids. It did not. The best that one can argue is proof of concept, in that the treatment of cytokine storms due to other things turned out to be the right treatment for the cytokine storm which is Covid-19. As I have said before, the fact that the virus was new did not mean that what it caused was new. I have suggested before that the trial did not time the intervention correctly. I tried to check this, but the link on the RECOVERY website to the trial protocol has been deactivated.

Meanwhile the positive test rate is “soaring”, although the hospitalisation rate is not. This may well be because the infections are now predominantly in the under-30s, who are much less likely to get severely unwell – and those admitted are almost entirely those who have not been fully vaccinated. Does this “soaring” justify the postponement of lockdown lifting? There are reasonable scientific arguments that suggest not, and certainly there are disagreements over the interpretation of statistics (yet again, confusion between absolute and relative risk is clouding the picture). See https://lockdownsceptics.org/2021/06/12/phe-briefing-claims-indian-variant-is-64-more-infectious-but-dig-down-and-the-finding-falls-apart/ for an analysis of the claim that the delta variant is 64% more infectious, and ask whether, even if true, this matters if getting infected is not a serious matter any more.

And anyway although yesterday’s positive tests number was just over 8000, today it’s just under. Will it go up, or down? Is the high number due to surge testing in higher-risk areas? It would be nice to have a daily breakdown by region that you did not have to dig for.

The Wry Observer’s Covid-19 update (112)

Back under house arrest.  At least (at last?) the streets are more or less empty, and we have seen but two people today who might have been tourists.  Furthermore the little flurry of correspondence about stupid bureaucracy appears to have borne fruit, as Hancock announced that a number of the silly modules are to be removed from the preconditions to become a vaccinator.

Maybe at last someone has been listening to me (and others).  But it’s a small practical issue, not a wider and essential management one.

Right at the beginning I was tapping a lot of material from the Ourworldindata website, but sidelined it when the gov.uk website became usable.  I should not have done.  I posted a query to the Lockdown Sceptics website, which had mentioned the question of absolute numbers of “cases” rather than the percentage of tests carried out that were positive, and said I couldn’t find any comparative data for Europe, and was kindly pointed me back to Ourworldindata.  Visit the site and you can add or remove as many countries as you wish.  Obviously there are differences in the populations tested but here is today’s comparison for the big countries of Europe.  I threw in South Africa because of the variant there that is supposed to have landed in the UK.

Make of it what you will.  My interpretation is that the European nations are not greatly different, while South Africa shows a quite different peak pattern.  This was previously noted (in absolute numbers) for Brazil and probably represents two things; August is Winter in the Southern hemisphere, and because both countries are significantly warmer, so this might affect the pattern.  But the bottom line is that the UK is not particularly out of step with the EU, whatever hysteria has been raised.  Undoubtedly the hospitals are coming under pressure, but we will never know how under pressure they might have been with ordinary flu, given the time of year and not least because official flu statistics suggest that levels of that are quite low.  So maybe one has simply replaced the other.  There are rather a lot of people in ventilated beds but I am still unable to find out whether they are being properly investigated and given steroids at the right time or at all.  A case on the news yesterday also worried me; told to isolate at home, she died.  With a pulse oximeter to assess hypoxia, likely to be happy, perhaps she could have received earlier intervention…

To play with the figures and pick other countries go to https://ourworldindata.org/grapher/positive-rate-daily-smoothed?tab=chart&time=earliest..latest&country=SWE~GBR~FRA~DEU~ITA~ESP~ZAF~BEL.

And just a thought (not mine); lockdowns are all very well, but quarantines are better, and not the same.

The Wry Observer’s Covid-19 update (155)

D-Day +1 (or at any rate its anniversary). There has been an invasion of Rye by foreign tourists over the last two weeks, judging by the different languages to be heard – French, Italian, Spanish, various Eastern European ones. And our churchwarden says that the leaflets in Japanese for the tower of St Mary’s Church (amazing views, see the clock and bells, only £4, most languages catered for, Rye has an amazing collection of multilingual residents and their friends) have been flying out. But I simply cannot believe that our Japanese visitors are all UK residents down from London for the day. It seems rather unlikely, and if they are not I am wondering how, given the hysteria over travel, they are getting in.

And on the subject of unlikely, the evidence, circumstantial though it may be, is pointing rather firmly towards the source of the pandemic being a laboratory leak. I have previously written that this question is a political one, but the evidence is now scientific, in that respected genetics people are suggesting that the probability of the amino-acid spike protein sequence of SARS-CoV-2 being a natural mutation is vanishingly small. Likewise the explanation for the taking-down of the Wuhan Institute’s viral database is rather weak, not least as it was done two months before things blew up. If I were presenting evidence to the Director of Public Prosecutions, or at any rate his office, I think the lawyers there might agree there is a case to answer. There are several articles detailing the case for the prosecution; for one, see https://lockdownsceptics.org/the-lab-leak-theory-who-suppressed-it-who-uncovered-it-and-what-should-we-do-about-it/. Unless evidence appears that categorically refutes the hypothesis, the suspicion will linger, and it is tempting to presume that of all explanations have their inconsistencies, then the one that is true is the least unlikely (which is not the same as the most likely).

Jamie Metzl, who knows a bit about genome editing, has dissected this most elegantly (short version in “The Sunday Times yesterday, long version on his website at https://jamiemetzl.com/origins-of-sars-cov-2/). To spare you a web jump I have copied the main hypothetical sequence below.

“• In 2012, six miners working in a bat-infested copper mine in southern China (Yunnan province) were infected with a bat coronavirus. All of them developed symptoms exactly like COVID-19 symptoms. Three of them died.
• Viral samples taken from the Yunnan miner were taken to the Wuhan Institute of Virology, the only level 4 biosecurity lab in China that was also studying bat coronaviruses.
• The WIV carried out gain of function research, almost certainly on these and a range of related and other samples (which is different than genetically engineering the viruses). Chimeric viruses were likely developed in this process. There has never been a full and public accounting for what viruses are in the WIV sample set and database, and key elements of the database have been taken off line or deleted.
• Given the close relationship of the Chinese Peoples’ Liberation Army (PLA) in the development and construction of the Wuhan Institute of Virology, it is fair to assume a connection between the PLA and the WIV.
• In late 2019 the SARS-CoV-2 virus appeared in Wuhan. The closest known relative of this virus is the RaTG13 virus sampled from the Yunnan mine where the miners had been infected. (RaTG13 is almost certainly not the backbone virus for SARS-CoV-2.)
• The genetic similarity between the RaTG13 virus and SARS-CoV-2 suggest that SARS-CoV-2 or a closely related backbone virus could have been sampled from the Mojiang mine and brought to the WIV (which is why the disappeared WIV databases and lab records are so critical).
• It is also plausible that SARS-CoV-2 could have been among the viruses held in or derived from a different virus in the WIV repository.
• In the earliest known stage of the outbreak, the virus was already very well-adapted to human cells.
• In the critical first weeks after the outbreak, Wuhan authorities worked aggressively to silence the whistleblowers and destroy evidence that could prove incriminating.
• When Beijing authorities got involved a bit later, they likely faced a choice of implicating the Wuhan authorities, and, in effect, taking blame for what was quickly emerging as a major global problem, or turning into the curve and going all in for the coverup. I believe they likely chose the second option.
• The Chinese government then massively lobbied the WHO to prevent the WHO from declaring COVID-19 as an international emergency and prevented WHO investigators from entering China for nearly a month.
• In late January 2020, PLA Major General Chen Wei was put in charge of containment efforts in Wuhan. This role included supervision of the WIV, which had previously been considered a civilian institution. General Chen is China’s top biological weapons expert. Allegations that the PLA was conducting covert dual civilian-military research on bat coronaviruses at WIV have not been proven.
• The Chinese authorities have gone to great lengths to destroy evidence and silence anyone in China who might be in a position to provide evidence on the origins of COVID-19.
• Although nothing can be fully conclusive in light of Chinese obfuscation, the continued absence of any meaningful evidence of a zoonotic chain of transmission and mutation in the wild and the accretion of other evidence is pointing increasingly, in my view, toward an accidental lab leak as the most likely origin of COVID-19. Given the extent to which China would benefit from discovering evidence of a transmission in the wild, we can assume Chinese authorities are doing all they can to find this kind of evidence without success. This failure would explain why Chinese officials have recently begun, with little credible evidence, asserting that the outbreak started outside of China.
• In light of all of this, only a full and unrestricted international forensic investigation into the origins of the pandemic, with complete access to all samples, lab records, scientists, health officials, etc. will suffice.
• Ensuring the most thorough and highest quality investigation exploring all possible hypothesis is and should be in all of our interest, including that of the Chinese government and people.”

So should the letter of refutation, organised by someone with an undeclared conflict of interest and published in “The Lancet” last year (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30418-9/fulltext#%20), be retracted? I think it should and have written to request this.

Meanwhile despite fears that the Delta variant is more transmissible (40% more so, according to one report) the Bolton spike seems to have peaked; there are no more patients in hospital and no rise in deaths. We might argue about why, but I still cannot see any particular reason to panic, not least as the “experts” have predicted doom and gloom before, and it has never been as bad as they thought. Roll on June 21st. Fingers crossed.

An editorial in the BMJ calls once again for an inquiry to start now. I responded:

“I am not so much concerned about the public having a voice as I am about professionals outside the system having one. Having followed a number of Twitter threads and blog comments it is clear that many of the public are simply not informed enough to make informed decisions; the strange concerns that have been aired over the risks of coronavirus vaccinations are a case in point. However, the “ruling cabals” have successfully stifled any contrarian professional comments or suggestions even when these have been based on facts from research and, indeed, have turned out to be correct. There should be some forum for informed scientific debate.

“The Science” can change – witness the growing, if circumstantial evidence that the original outbreak in Wuhan was due to a laboratory leak, and the realisation that the letter in “The Lancet” last year which refuted the suggestion has been undermined both by scientific analysis and by the realisation that there were undeclared conflicts of interest (the latter alone being grounds to request retraction). Witness also the disagreements within official bodies, with individual SAGE members offering different perspectives in the media (or as one might put it airing internal disagreements over policy in public). What is also bizarre, in my opinion, is that scientific advice continues to be offered (and thereafter followed) by people whose predictions and modelling have been called into question or even discredited.

The government is accused of dithering. If, in a clinical situation with an acutely ill patient, where you haven’t a clue what’s going on, is it not reasonable to dither? That said, the fact remains that decisions over the acute management of very sick Covid patients appears to have been in the hands of epidemiologists, infectious disease specialists and non-medical scientists rather than acute care physicians who might- just – have seen something like it before and do know what to do. Any inquiry must ask whether the government was getting its advice from the right experts.

But now is not the time. The situation continues to evolve, with conflicting statements on what deaths were actually due to the coronavirus (from, not with); on the true figures for excess mortality; on the issue of whether lockdowns truly coincided with the waning of infection; on whether Test and Trace worked; on whether border controls worked; with no clear picture, as yet, on how vaccination will both halt spread and prevent serious disease that results in hospitalisation and death; with absolutely no idea what effect a release from lockdown may have; on the cost-benefit analysis of medical priority over economic shutdown. So what point is there in an inquiry now? We have enough evidence to make judgements on some specific aspects, such as PPE supply. We have evidence of unnecessary delays in introducing treatment for severe disease. We have insufficient for almost everything else. An inquiry now will distract all from getting the pandemic under control, not least because we need to fully understand inter-national differences.”

Meanwhile despite fears that the Delta variant is more transmissible (40% more so, according to one report), the Bolton spike seems to have peaked; there are no more patients in hospital and no rise in deaths. We might argue about why, but I still cannot see any particular reason to panic, not least as the “experts” have predicted doom and gloom before, and it has never been as bad as they thought. Roll on June 21st. Fingers crossed.

The Wry Observer’s Covid-19 update (154)

I have sent in two Rapid Responses to the BMJ, both directed at articles calling for an inquiry immediately.  One (an editorial) referred rather dramatically to a “maelstrom of avoidable harm”.  Was there?  And, given all the uncertainties of medicine, was it avoidable?  And of so, would it have been avoided if the measures we are told we should have employed had been employed?  I think not.

Martin McKee wrote a Personal View “What went wrong in the UK’s Covid-19 response?” (BMJ 2021; 373: n1309).  I wrote

“I have to disagree with Martin McKee on the question of timing of an inquiry.  It is far too early.  On the ground the situation changes daily.  The dust must settle before any serious inquiry can possibly come to robust conclusions.  Just today we have different members of the SAGE committee promulgating different views on whether the current lockdown should end as announced, or be prolonged.  Quite apart from the problem in public perception and confidence when members of the official advisory committee appear to be pulling in different directions there remain many unanswered questions – not the least of which is whether lockdowns actually work.  Tracking the figures against the timing of lockdowns raises serious doubts as to their relevance to the progression of the pandemic.  Likewise there have been scare stories about the Kent, Brazilian and South African variants and their infectivity, now being repeated with the Indian variant (or whatever Greek letter it has now been allocated.

My present perception is that the “tens of thousands of unnecessary deaths” would not have been altered by lockdowns, because they occurred as a result of failures (which were in many ways understandable) to appreciate infectivity, potential severity and the role of nosocomial transmission.  Tens of thousands of deaths might have been prevented by the rapid deployment of proper measures to treat Covid-19; as I have said in several previous responses, the proven treatment was available, given the cause of severity being an induced cytokine storm, and did not require trialling.  I recommended steroids and interleukin antagonists at the end of April 2021.  The trials caused a serious delay.  In any event, given the fact that lockdowns were nothing of the sort (essential workers, transport personnel, healthcare workers etc were not locked down) the best one could have hoped for was a modest reduction in transmission, because one way and another all thee “loose” folk had the potential to transmit the virus.  And a travel lockdown would not have worked either; it would have sneaked in somehow, especially as the major influx to the UK was not from Wuhan but from residents returning from European holidays.  It was a while before that became clear.

We are still waiting to see if there is a hospital admission spike as a result of the latest Indian variant.  We still do not know the best vaccine strategy, nor exactly how effective they are at preventing either infection or severe disease.  We do not know whether lifting restrictions might result in another surge, and will not know until it is done.  I have seen no official protocol for Covid-19 aggressive therapy.  Indeed, there is even doubt as to where the virus came from.

We should be honest and perhaps recall how, as clinicians, we have seen patients where we did not know what was going on, even on occasion with the benefit of hindsight.  At the outset I for one was convinced that SARS-CoV-2 was going to be a flu-like virus.  There was panic, which turned out to be unnecessary, over SARS itself.  So to make decisions on what went wrong in this pandemic, given all of these uncertainties, is a mistake.  There is no urgency.  More haste, less speed.”

Kamran Abbasi wrote an online Editorial “Covid-19: Cummings, Johnson, Hancock, and a maelstrom of avoidable harm” (BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1404)

So I responded:

“I was unimpressed by the Cummings revelations and think that we should avoid going overboard with our criticisms-in-hindsight.  Most clinicians will have encountered situations where they do not know what to do; many will have made the wrong decisions at the outset and only get to grips with that when they employ that almost infallible instrument, the retrospectoscope.

Was the harm avoidable?  Possibly, but it was not unreasonable to start by assuming the SARS-CoV-2 virus might be like flu.  Was the government’s advice team accurate? Certainly not, as is now clear; the SAGE modelling was way off beam.  Is its advice good now?  No; separate members are pulling in different directions.  There is little evidence, in retrospect, that lockdowns change the course of disease.  Their timing, and that of passing peaks, do not coincide.  They are anyway incomplete for numerous reasons.  Travel restrictions would not have stopped viral imports, as it was not realised for several weeks that it was not, largely, coming from Wuhan but coming from several European countries.  Once the risk of severe disease was understood it was reasonable to empty hospitals, but it was not appreciated that nosocomial transmission would thereby transmit it to care homes.  Testing was not, at first, widely available.  I fail to see how any of this is the government’s fault, not least as you cannot test for something that didn’t exist before.  Indeed the speed with which testing was introduced seems quite remarkable and the development of a vaccine even more so.

I would point out that I tried on numerous occasions to engage with the DoH and ministers, without any result.  In particular I recommended in April 2020 that steroids and interleukin blockers should be immediately deployed for severe Covid-19.  This was an evidence-based recommendation.  That they were not was, in my view, a failure of “The Science” both to listen to outside advice and, indeed, to be scientific.  What point was there in doing time-consuming trials when the underlying cause of severe Covid-19 was the triggering of a known syndrome for which treatment was already well-established?  It is the scientists who should be held to account for this; the government only did what its committees wrongly advised.  I have pointed out before that it is all very well having experts, but you have to have the right experts.  When dealing with a clinical syndrome you require experienced clinicians, not statisticians and epidemiologists who have not been at the sharp end.  How many of them, for instance, have treated a cytokine storm syndrome, or even read the definitive textbook?  Any “maelstrom of avoidable harm” is, in my view, due more to this failure of process that anything else; if people get infected, but don’t get sick, it does not signify. Furthermore, as a member of the SAGE committee has admitted, outside advice was consigned directly, and apparently usually unread, to the waste paper basket or spam folder.  There should have been an army of experienced vetting staff to actually read stuff and submit sensible suggestions.  That is what Mr Cummings should have set up.

Lastly it is far from the time to have an inquiry.  Every day there are further uncertainties which may change both the progress of the pandemic and its impacts.  As an example, look at variant Delta (or the Indian variant).  There are currently hysterical calls to postpone the lifting of lockdown because it is “rampant”, the dominant strain, more infectious, etc etc.  Does that matter?  If its appearance does not result in a surge in hospital admissions and deaths, then no it does not.  Whether that is because it is infecting a younger age group which is less at risk, and/or because vaccination is keeping infections down is irrelevant to action.  These calls for delay are being made before we actually know the answer.  Isn’t the medical watchword watch, wait and see?  After all the Kent variant seems not to have been as bad as at one stage was predicted.  Other initial concerns seem to have dissipated; transmission from surfaces is not a major issue; outdoor transmission is very unusual so masks are probably unnecessary.  While the ground under our feet is in constant motion we should avoid relying on evidence, because that evidence may change.  The time for an inquiry is when the pandemic is over.  That said, if you study the responses to previous pandemics, you find that no-one really learns lessons, or if they do they are forgotten in the amnesia of institutional memory loss which depends on experience.”

Has the Indian, now called Delata variant, resulted in a surge of hospital admissions yet?  You would think so by the hysteria over delaying lockdown or not.  But not yet!

The Wry Observer’s Covid-19 update (153)

Rye is bathed in sunshine, and the New Normal has emerged.

Actually it looks no different from the old normal; the streets thronged with tourists, many speaking in foreign tongues (though the Japanese couple to whom on Friday I offered a church tower leaflet in Japanese – we go to extraordinary lengths – said they were from London). No masks, and except for the noise it’s rather nice. The seagulls like it, too, as there are plenty of snacks to snatch from unwary promenaders.

“The Sunday Times” today has an excellent piece by Matthew Syed titled “Scientists make mistakes. That’s fine, but they shouldn’t deny them”. The analysis of all the Cummings stuff makes it apparent that there were some bits of truth in his seven hour marathon, although even that may be a matter of interpretation. However my principle is that the longer it takes to cook up a denial, the less tenuous it is. The failure to test hospital patients discharged back to care homes is what it hangs on. I suggested a little while back that perhaps care home testing had been slow off the mark (on 16^th April last year). But to be fair the whole issue of nosocomial transmission was even then still as clear as mud. When I read what I wrote at the beginning I realise how little I knew, as an informed outsider, so I could not blame informed insiders for coming to the same wrong conclusions. Unfortunately such revelations rely on hindsight.

I think that the question of whether a lockdown should have been instituted earlier is much more difficult, as the evidence for it at the time was not great (especially is we were dealing with a flu-like illness) and is even less good now, when we have the opportunity to look at timing and compare lockers with non-lockers.

That said there is still a vacuum on the treatment front. No-one, in all the excitement and hype over where it started (more in a mo), how transmissible it might be, how sick people might get, whether all these variants really matter, whether vaccination really reduces risk of infection and severity, whether vaccination should be compulsory, whether lockdowns work or not etc etc, no-one has said anything about treating severe Covid-19. The suggestion I made 13 months ago that it was a cytokine storm syndrome appears, very slowly, to have become accepted, but there is still a lack of focus on its management with steroids and immune modulators. Forget the virus, I say again. Concentrate on what the virus does to the immune system, both in tests to watch its development and in therapy. Then, even if people get admitted, they won’t die.

The papers are also full of the growing belief that the virus suddenly appeared because of a laboratory leak. In deciding this one should employ good scientific practice, and say that if you are presented with several possibilities, all of which have fault, you should not consider the best but the least bad, and you should focus on the least improbable. Forget Mr Hancock and whether he dissembled, and decide whether the evidence, both scientific and political, stacks up. Which brings me back to Matthew Syed’s point; scientists (and politicians) should not deny their mistakes. If it is clear that the answers to questions are being withheld, it information is concealed, if previously available data is suddenly inaccessible, it is, in my opinion, quite reasonable to smell a rat, and not a pangolin. It would appear that the Chinese authorities will admit nothing and will not allow a proper analysis. On that basis the strident defence of the Wuhan lab in “The Lancet” might seem an error of judgement, and regrettably it won’t be that journal’s first. Such publications undermine scientific legitimacy. Remember Wakefield’s notorious measles vaccine paper?

Not many deaths reported today, and no surge in hospital admissions either. Surge testing in the hotspots may well account for the increase in positive tests. If the Indian variant is really bad another week should tell us – but all the signs point to the unvaccinated being the at-risk group now, and that group is steadily shrinking.

The Wry Observer’s Covid-19 update (152)

Dominic Cummings has spoken. From what I can gather it was a mixture of personal recrimination, unscientific distortion and spilling of private beans. Most unedifying. However he claims that a failure to lock down caused thousands of needless deaths.

I wrote a response to a “Medscape” report as follows:

Cummings’ exposition bears all the hallmarks of the use of a retrospectoscope – normally 100% accurate, but in this case I think the lens is cracked.

He suggests that thousands of deaths were needless, but attributes them to a failure to lock down and close borders in a timely fashion. However the evidence continues to stack up for infection spikes and troughs being independent from lockdowns – go to the Ourworldindata site and look at the comparative positivity rates of tests between the UK (locked down) and Sweden (no lockdown). There is no difference (there is in the numbers, but not their timing). He has quoted the success of Far Eastern countries in keeping deaths low, conveniently forgetting that these countries have been exposed over years to several other coronaviruses, which may well have conferred partial immunity. And if he is so sure that rigid lockdowns were a Good Thing, why did he break the first one?

However I think that thousands of deaths were indeed needless, but for a different reason. Severe Covid-19 is simply a cytokine storm syndrome. By the end of April 2020 this was abundantly clear. Treatment for severe CSS was already well-established, but on the spurious basis that the coronavirus was a novel virus the government insisted on clinical trials (of steroids and interleukin blockers) which were proven to work in other CSS scenarios. Had these therapies been instituted at the outset I have no doubt that their use would have saved more lives. The sad fact is that government, and its advisers, chose to ignore this evidence and several communications explaining the rationale (including from me in early May 2020). Indeed Professor Neil Ferguson is on record as writing that unsolicited emails were being automatically sent to spam folders! The committees contained the wrong experts; you do not plan clinical management using epidemiologists and public health people, let alone statisticians, politicians and special advisers. You use clinicians who actually treat the conditions. I wonder how many of the “experts” had actually read the definitive textbook on cytokine storm syndrome, published before the pandemic, in which tocilizumab is referenced 12 times. I hazard a guess. None of them..

The government also contributed to the early spread in care homes by getting patients discharged back there from hospital without testing; we now know that perhaps 30% of cases were hospital-acquired. You cannot blame the Health Secretary for that, if the advice from his committees was to do this. And in further mitigation I would argue that the original perceived need to clear beds outweighed other considerations because, at first, both the infectivity and the severity of possible consequences were underestimated. I certainly did until April.

The analysis of what went wrong, and what went right, should be left to an independent inquiry which takes advice from the right experts. I still think it’s too early to hold it, and having read numerous books and articles analysing the show so far most of them have failed to tell the whole truth, because the jigsaw is still missing too many pieces.

Cummings now says his flight to Barnard Castle was because of security concerns. That’s been a long time coming out. His original excuse was equally limp but I would have thought that anyone thinking of threatening him (and I cannot think who would be bothering to contemplate such a thing) would have taken about five seconds to discover he had fled, and to where. And I would also have thought that if he had mentioned this to the protection people then he would have been well guarded, so it’s not an excuse I can easily grasp. His excoriation of the Health Secretary might have some basis in fact over the lack of testing hospital discharge patients, but most of the stuff about underestimating the severity of SARS-CoV-2 is perfectly understandable. I reckon I was one of the first to twig what Covid-19 really was, and it took me until the end of April. Up to then I thought it was no more than bad flu, like most of the government and many of its advisers. We were wrong. Medicine is not an exact science, and I don’t believe that you can always make the right decision in the heat of the moment, especially if the advice you are getting is conflicted.

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The Dominic Cummings show at the Health Select Committee will intrigue, I think, but only if his stash of material to be released truly supports his case, and the evidence so far is that it does not.  He appears obsessed with the success of lockdowns, as I described last time, and that the scientific advice was to go for herd immunity, which meant letting people catch the virus.  But of course there are two ways of achieving herd immunity – to do that, or to vaccinate.  If you look at the spikes of infections in different places it appears to make no difference whether you are locked down or not – although the spike may be lower where the has been an effort to limit social contact – hardly surprising, but as I said before, unless it is total (which is impossible) the best it can do is help a bit.

So the bottom line is – whatever you do, until enough of the population is immune one way or the other, people will acquire the virus, whether from a delivery driver, a care worker, a hospital patient if you are in for something else, a fellow resident of a care home etc.  Transmission is inevitable unless you isolate everyone, and you cannot do that.  PPE may reduce transmission but will not stop it.

Now if SARS-CoV-2 just gave you a snuffly nose and a cough no-one would worry about it.  The problem is that it can (not will, but can) give you a very nasty illness.  So you will inevitably have hospital admissions among the non-immune.  Thus, while prevention is good, cure is essential and it has taken far too long to develop the right treatment regimes for severe disease.  This is due partly to the wrong focus – on using drugs to try and kill the virus, when the severe manifestations are nothing to do with the virus itself, but what it triggers in the body’s immune system.  All the panic over vaccine side-effects appears to be down to the vaccine provoking a similar immune response to the disease itself, though rather milder and in some ways more specific.  But now the right treatments have been developed.  If they are used extensively, and timed correctly, those unfortunates who get Covid-19 will stand a much better chance of survival.

I cannot be bothered over the minutiae of decision-making on the place of herd immunity.  It is an unassailable concept.  What matters is how you achieve it.  Some ways may be more acceptable than others, but from a scientific point of view letting SARS-CoV-2 rip is a way.  But there are others. If you have been reading my blogs from the beginning you will recall what I said in my very first one in February 2020; but you may not, so here it is again:

Before vaccination was available mothers used to have German measles parties; a farmer from South Africa whom I knew told me that if a cow got foot and mouth disease they would stick a handkerchief up its nose and then stick that up all the other cow’s noses so they all got it. Herd immunity if you like. If lots of people are exposed to a bug, the level of population immunity rises (and the converse also – the drop in measles vaccinations has resulted in an upsurge of cases). So letting people get COV-19 may not be that bad. Maybe.

Of course the “preferred” way of dealing with a foot and mouth outbreak is to slaughter all the affected cattle and stop all movement of livestock from infected farms.  I cannot envisage slaughtering the population of Bolton because of the appearance of the Indian variant.  But from a scientific point of view it is a viable solution. But if we don’t do it for humans, is wholesale extermination of animals actually necessary?  Perhaps there could be a balance between containment and the promotion of immunity.  Foot and mouth disease does not exist in the UK, but would it really matter if it did, and all the cattle were immune either from acquisition or from vaccination?  An interesting question.

Of course the Indian variant uptick may not matter at all.  Firstly it seems, at least at present, to be getting the younger age group, who are much less likely to develop Covid-19. Second, it may never get the older age group because they have already been vaccinated.  So the only interesting question for me is whether there is a significant increase in hospital admissions.  Another week and we will know for certain, but there isn’t much right now.  Perhaps the new local lockdowns (which none of the councils concerned were warned about) are just panic (again). I do not believe that thousands of deaths would have been prevented by an earlier lockdown, not least if up to a third of patients acquired SARS-CoV-2 in hospital, and a large number more had it dumped on them when the hospitals emptied their beds of care home residents and returned then to closed environments there to infect staff and other residents.  Indeed I think that in due course the two biggest errors of management will be judged to be the decanting of hospital patients and the failure of early development of treatment for severe disease.  That said, it is clear that the severity in vulnerable groups (the elderly, obese, diabetic, those with concomitant medical conditions that made then fragile at the outset) should have led to a targeted protection approach.  Likewise at-risk healthcare workers – at risk either because of a predisposition as above, or because they were genetically vulnerable – should have been kept away from infected patients.

The Wry Observer’s Covid-19 update (150)

Dominic Cummings has released a string of tweets prior to giving evidence to the Commons Select Committee.  Much of what he says is not backed up by real science, and I have to say that a series of tweets, with usual abbrvs, is a strange mode of expression.  He seems to be a hardline lockdown enthusiast, which is odd given his trip last year to Barnard Castle against the rules.  He does not seem to realise that nothing short of total, complete isolation of everyone, with prohibition of entry to anyone from abroad, will completely stop transmission.  Neither does he appear to understand that such a lockdown is impossible.  If you stop everyone from going out who will deliver goods? Who will maintain utilities? Who will care for the sick?  How will you import stuff if you block cross-Channel lorries and air freight?

This is apart from the evidence that lockdowns do not seem to coincide with falls in incidence – or that death and hospitalisation rates appear unrelated to whether a locality, state or nation has locked down.  The exception is where borders have been tightly closed, as in the Antipodes, but they have been able to maintain everything important self-sufficiently.  Most of the world can neither seal borders nor live without imports.

Thus the evidence is that lockdowns as they can be implemented cannot and will not work except in exceptional circumstances.  This is why we must concentrate on measures that mitigate the serious effects of SARS-CoV-2 infection, in other words the development of Covid-19 and its effective treatment if it does develop.  It’s a year since I sent my guidelines in to government, without either acknowledgement or evidence of implementation (OK, they have been partly implemented, but with an unnecessary delay).  Who was responsible for the DoH and SAGE committee ignoring the alternative science, as Mr Cummings suggests now was a mistake?  And ignoring me? I have my own thoughts on this.  Mr Cummings should also recall the treatises on government, especially David Owen’s book “In Sickness and in Power” and remember that hubris is followed by nemesis.  He should also think about Black Swans. You cannot ignore unimpeachable data that counters the hypothesis; you have to concede that the hypothesis is wrong.  And if he wants his grapes not to be sour I recommend a trip to one of our excellent local vineyards – Chapel Down or Gusbourne.

As for the Indian variant it seems to be no more resistant to current vaccines than other variants.  What will be the next variant to cause panic?  I don’t have any experience running sweepstakes but wonder if the big betting companies ought to open a book.  Mexico? 100-1? Nigeria? 40-1?  Seriously though the positive-test-as-a-percentage-of-total-test graph is interesting.  I have added India for the first time.  Could the worst there actually be over?  And the UK is still at the bottom.

The Wry Observer’s Covid-19 update (149)

The last five days have been a roller-coaster ride, during which the April showers have come late, but we have got more of the allotment planted, and the cucumber frames are up. The garden is well and the tomatoes are in.

There has been more panic nationwide. One might say here we go again. The Indian variant is now the bone of contention – is it really more infectious, is it more likely to progress to Covid-19, are the vaccines going to fail to work? Why Bolton? (I would guess a high Indian subcontinent population seeded by returning relatives). We have, of course, been here before with the Kent variant, the South African variant and the Brazilian variant. The panic stems from the overwhelming of the Indian health services, and does not account for the vast difference in vaccination levels between Western countries and the less developed and more socially crowded countries that are less well off. I dare not make too many predictions but I suspect the current ghost train noises may be a storm in a teacup, to mix metaphors. Another two weeks and we will see whether indoor re-opening has caused a jump in “cases”. And if these “cases” don’t translate to hospital admissions and deaths then all is well.

I have finished Jamie Walden’s book “The Cult of Covid”, and rather like my letters to my MP events have changed since writing. I had a ministerial reply at the weekend to a letter I wrote last November. I suppose you might argue that if you leave something contentious for long enough the steam goes out of it, but while Walden’s book is worth reading (though much of it repeats the various demolitions of the effect of lockdowns and masks that have been raised by others) it does not cover the third wave (sic) of January 2021, nor the effects of vaccination. This reinforces my argument that an inquiry should wait until all the information is in. Nonetheless it also illustrates another of the major failings of commentators – that they have not discussed the acute management of Covid-19 in any detail and looked at the mitigating effects of successful countering of cytokine storms. As I have said many times, getting SARS-CoV-2 does not matter if it isn’t going to make you very unwell. It certainly appears that vaccination prevents both transmissions, and progression if you do get the virus, but many serious clinicians are still relying on clinical trial data to assess things like ivermectin and tocilizumab. Some of these trials are simply not adequate. Put some of them into a meta-analysis and they look better. But I repeat – we know that Covid-19 is a cytokine storm, established treatments for other cytokine storm syndromes are well-tired – so we should use them. And there’s fluvoxamine, a serotonin reuptake inhibitor used for OCD. It appears to suppress cytokine production in mice and a small trial in Covid-19 is reported at https://jamanetwork.com/journals/jama/fullarticle/2773108. It seems to have slipped under the radar, as it was published in November 2020. Another cheap and cheerful possibility?

There is also some evidence to dismiss the “Long Covid” concept. A recent study found no difference in typical symptoms between those who had Covid-19 and those who did not. So maybe it’s no different from any other postviral syndrome. See https://www.medrxiv.org/content/10.1101/2021.05.11.21257037v1.full

It does seem at present as if SARS-CoV-2 news is a bit less prominent than of late.  That may be a good sign.  Fingers crossed.  Mind you, the evidence that it all started from a laboratory leak in Wuhan is appallingly convincing…

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There’s a good piece on the demographics of Covid-19 at https://quillette.com/2021/05/10/the-geography-of-covid-19/.  It suggests that overcrowding leads to trouble, which is not entirely surprising, but rather supports the concept of lockdowns making things worse, because the affected are confined with the non-affected in  closed environment.

Sebastian Rushworth has taken a careful look at ivermectin. His blog is worth a visit (https://sebastianrushworth.com/2021/05/09/update-on-ivermectin-for-covid-19/). I responded as follows:

“I have made the point before that if there is evidence – any evidence – that definitively shows benefit of a preparation, especially if the rationale for use is solid, then in an emergency situation it ought to be brought into use without conducting clinical trials.  This is especially true if the preparation has minimal risks.  As an example – Covid-19 is a cytokine storm; we know that other cytokine storm conditions respond to steroids and interleukin antagonists; so use it in Covid-19.  But no.  Clinical trials were done, which despite being fairly rapid caused nonetheless a significant delay in introduction.  They proved what was already obvious.

I have yet to see that there are any major issues, risk-wise, with ivermectin.  It is very cheap.  Even if the effect were marginal (which I doubt now) the potential benefit of use outweighs the risk, and the cost is magnitudes smaller than tocilizumab.  In the context of the waste of money in the UK on the test and trace program expenditure is peanuts.  That there appear to have been deliberate attempts to stop the use of ivermectin is a matter that will need discussing at a public enquiry, when it happens.”

Which it will. The PM announced that it would start next year.  There has been quite a lot of comment on this, but it is all directed at the epidemiological aspects, and none, it appears, at the medical issues of treating severe disease.  I shall have my say, then, in due course.  By then there will be more information on the age issue, care home problems, nosocomial transmission, risk factors and so on. Meanwhile deaths fall, the country is opening up, we will have to see whether vaccination has spiked the next spike.  It will be great to go to a restaurant again!