Everyone in the UK - please share this widely, this and other posts that explain what is happening in the UK. We are no longer trying to contain COVID-19 in the UK, only to slow down its spread. Also, we no longer try to keep track of who in our society has the virus, as people with mild symptoms are not tested to see if they have COVID-19. This would be good advice for influenza which is a very different disease. Sadly the Netherlands have also joined us in declaring a similar policy. I hope both countries soon realize how important it is to contain this virus.

skip to Yes this virus can be stopped

First if you are in the UK you may be unaware of what the WHO themselves say. They say this with every recent press briefing.

WHO continues to recommend that isolating, testing and treating every suspected case, and tracing every contact, must be the backbone of the response in every country. This is the best hope of preventing widespread community transmission.WHO Director-General's opening remarks at the media briefing on COVID-19 - 18 March 2020

Their advice is based on a major WHO-China study led by Dr Aylward and Dr Liung with 25 experts, 13 from outside China and 12 from China. This team spent 9 days researching what the Chinese did and then laid down specific recommendations for both China and the world based on what worked and what didn’t work in China.

In more detail it involves isolating and testing every suspected case, quarantining every confirmed case, tracing every contact, isolating contacts for 14 days from the time of possible infection, and testing contacts during those 14 days to see if they become cases. Many countries are following this advice with success.

When the WHO declared COVID-19 a pandemic, Dr Tedros, Director General of the WHO said:

We are convinced that, although this is the first coronavirus to be labeled as pandemic proportion, at the same time we believe it will be the first also to be able to be contained or controlled.

Transcript for WHO Emergencies COVID-19 Press Conference, 11th March 2020

In another press briefing he said::

"Several countries have demonstrated that this virus can be suppressed and controlled. The challenge for many countries who are now dealing with large clusters or community transmission is not whether they can do the same; it's whether they will."

Virtual press conference on COVID-19–11March 2020

He also said:

"If anything is going to hurt the world, it’s a moral decay. And not taking the death of the elderly or the senior citizens as a serious issue is one of the moral decays."

WHO Emergencies Coronavirus Press Conference 09 March 2020

The WHO were responsible for overseeing the eradication of smallpox, also eradicating malaria from many countries and near eradication of polio. They have stopped many outbreaks of Ebola including one in the Congo that has been successfully stopped with no new cases now for a month. They respond to 200 or more epidemics every year. These people are absolute experts on this topic.

Meanwhile the UK experts use models of 'flu to make their recommendations, which are based on their experience of dealing with influenza outbreaks. It turns out that influenza and COVID-19 are different in their transmission dynamics as we’ll see. That may be why the recommendations are so different from each other.

The WHO never publicly say that a government's approach is mistaken but I imagine they are likely having strong words with them in private.

The WHO are to be respected and listened to. I recommend following their press briefings to have the best understanding of the developing situation for COVID19

I have embedded the video of the WHO press briefing on 16th March here, with my summary of opening remarks and official transcript

• WHO (Mar 16): Test Test Test & ISOLATE All Cases Of COVID-19, However Mild, Until 14 Days After Patients Recover

For the latest WHO press briefings go to

Press briefings

See also my

• Where to go for reliable sources on the Coronavirus COVID19

This is another article I'm writing to support people we help in the Facebook Doomsday Debunked group, that find us because they get scared, sometimes to the point of feeling suicidal about it, by such stories.

Please share with friends if it helps you - they may be panicking too.

I wrote this not to alarm people but to  try to put pressure on our government to change, and not a week from now, not even a few days from now but right away.

YES THIS VIRUS CAN BE STOPPED

skip to You don't need to find everyone

The good news is that China contained it and many other countries are already containing it. We can too. We can stop it,and must.

On the 18th March, China had its first 24 hours with no new cases infected within China. They had 34 new infections from patients who returned from other countries, 21 of those in Bejing. March 19: Daily briefing on novel coronavirus cases in China

This is the clearest indication yet that COVID-19 can be completely stopped by case finding, contact tracing, quarantine and isolation of the contacts. The Chinese economy is gradually returning to normal, transport resuming even in Hubei province, restaurants opening, businesses restarting, schools opening.

YOU DON'T NEED TO FIND EVERYONE

skip to You can protect yourself and others from COVID-19

Suppose each new person on average infects 2 more for simplicity.

Then 100 cases infect 200 then 400, 800 and now you have a total of 1500 cases already. It doesn't take much longer to reach tens of thousands. If you have a doubling time every 3 days then it's a ten-fold increase roughly every ten days.

If you can break three quarters of those chains of transmission with contact tracing and isolation the outcome is very different.

This time, 100 cases infect 50 (3/4 of 200) which then infact 25 (3/4 of the 100 cases 50 would infect) which infect 13, 6, 3, 2, 1 and then it is over.

It will be over at around 200 cases.

YOU CAN PROTECT YOURSELF AND OTHERS FROM COVID-19

skip to Contact tracing has to be methodical and thorough

Do you do these four things?

1. Wash hands thoroughly
2. Stay 1-2 meters from anyone coughing.
3. Wash your hands before you touch your eyes, nose or mouth [try to get out of the habit of touching your face in the day]
4. Cough or sneeze into your elbow OR cough or sneeze into a tissue and put it into a bin immediately.

Do this as thoroughly as the experts, and you can say:

"I don't have COVID-19 - I am very low risk".

Dr Bruce Aylward said that immediately after he returned from Wuhan. He knew he was safe because he did those things.

These simple instructions save lives. They are not hard to do if you make them into a habit. More details here:

• How To Protect Yourself From COVID-19 - And Help Stop The Spread - If Everyone Did This The Epidemic Would Soon Stop

In theory if everyone did that rigorously it should stop pretty quickly. But in practice it's hard to get everyone or even a majority to do that.

It is the same for physical distancing - if literally nobody had the discipline to stay at least 1-2 meters away from everyone else, of course it would be over soon, within 14 days. But in practice that's also difficult to achieve.

Those are both measures that you can't force everyone to do if they are not diagnosed as having COVID-19.

However it is legally possible to enforce quarantine in a free country for someone who is a known risk such as a COVID-19 patient or a close contact.

Not only is it much easier to enforce. :They also are likely to take it much more seriously if they know they have the disease, or that the person they need to distance themselves from does.

So, by far more important is case finding with lots of diagnostic tests, quarantine, contact tracing and isolating contacts. It depends how rigorously and thoroughly they do that. South Korea and Wuhan got it well under control within a month of doing that, peaked within a fortnight of doing that.

So, on a personal level then the hygiene and social distancing can save your life and others and everyone who does this is helping to break transmisison chains in our society. On a society level, this is also important but we need a significant number to adopt it. The government and the media here can help, to stress to everyone its importance and necessity, in every way they can.

Then case finding is of the utmost importance - testing all suspect cases, quarantining, contact traeing and isolating contacts. It depends how rigorously and thoroughly they do that. South Korea and Wuhan got it well under control within a month of doing that, and it peaked within a fortnight of doing that.

The combination of case finding, contact tracing, an element of physical distancing and personal proteciton through hand hygiene etc is very powerful as a way to stop this epidemic.

The number of new cases with onset of symptoms peaks almost immeidately, within a few days - but you don't know that until you have the diagnosis, up to a fortnight later as they have to recognize that it is potentially COVID-19 and then get tested. You can see this strikingly with China in Wuhan, with the effect of the lock down. It would be the same with any new measures.

In China, if you look at the date of onset of symptoms, then it peaked on the 25th of January, only 3 days after the Wuhan city shutdown on the 25th January

However if you look at the date of diagnosis, it seemed to peak 9 days late on the 5th February.

It would be the same for any measure that radically changes the transmission dynamics.

For instance if the UK were to immediately do widespread testing, and quarantine all those cases and isolate their contacts, the onset of symptoms would peak almost immediately, but we would not know that for maybe as much as a week or more as we wait for the new cases to be diagnosed.

According to the models based on 'flu transmission dynamics this shouldn't work. Singapore is especially striking as they are controlling their outbreak mainly with this case finding and contact tracing. South Korea is similar, it didn't use much of the more traditional physical distancing measures. How can that work? We will see later in the section: Expert projections in the UK use adaptations of influenza models and later.

CONTACT TRACING HAS TO BE METHODICAL AND THOROUGH

skip to Concerns for spread of COVID-19 from Europe to populations with endemic aids or malnourished children

The Chinese did that very thoroughly and methodically. They also did it in Singapore, and South Korea. With Italy I am not sure how thoroughly they are doing it - it is the most important part of the whole thing. It seems some areas are doing it more thoroughly than others. It is not the same as just isolating everyone in the same building. This virus is not airborne and others in the building are not at risk unless they are close or prolonged contacts with the patient with COVID-19.

It means that e.g. if they were staying over with a friend for a couple of nights - you phone up that friend and get them to self isolate, if they had an evening out with another friend you contact them and so on. It is straightforward stuff. Anyone can do it. Civil servants or volunteers can do it. You can re-use civil servants from other branches of government or local community organizations. You don't need to have any experience as health workers to do this.

But you have to be organized and methodical and thorough about it. This is not so hard with a dozen cases, but it gets much harder as it scales up unless you have good tools to track them all.

This process has to be very organized to keep track of, say, 100,000 contacts. Not just find them all, also to keep in touch with them all and get them tested as needed and retested. This was something the Chinese did with large databases and software and the West can learn from them how they achieved the co-ordination to get it working. Countries should be looking into how to do this before their outbreak starts.

CONCERNS FOR SPREAD OF COVID-19 FROM EUROPE TO POPULATIONS WITH ENDEMIC AIDS OR MALNOURISHED CHILDREN

skip to What about a second wave?

Dr Tedros, director general of the WHO said much more in his speech on Monday 16th March reported as “test test test”.

He said that we all have a duty to stop this virus. He is especially concerned about what happens if it spreads to countries with people weakened by AIDS or with malnourished children or refugee camps.

Any country that doesn’t stop it becomes a source for it spreading more easily to those countries. Healthy children fight it off easily but the effects on malnourished children or young kids infected with AIDS are unknown. The WHO have previous experience of how devastating a respiratory disease can be for malnourished children in refugee camps.

We may well soon see scenes of malnourished children dying of this as well as people with their immune systems weakened with AIDS in countries where there is no possibility of getting ventilators for them all. We can prevent much of this future suffering for many people by acting promptly to slow down, and stop it in the UK.

As the virus moves to low-income countries, we're deeply concerned about the impact it could have among populations with high HIV prevalence, or among malnourished children.

WHO Director-General's opening remarks at the media briefing on COVID-19 - 16 March 2020

The WHO is acting to reinforce the ability of sub Saharan African countries to identify this virus rapidly, and stop it with diagnostic tests, personal protective equipment and training for their health workers. They have taken advantage of their existing response systems for other outbreaks, isolation wards for Ebola and anything they had available to prepare for the expected stress on their health systems of this virus if it gets there. Most sub Saharan African countries have been preparing for this disease with the greatest urgency for weeks now. It is a striking contrast to Europe.

Yet, despite all the African countries' efforts to prepare for this virus and the hundreds of millions of dollars in international donations to help them get ready, these countries are likely to struggle to contain this disease if it gets to them in large numbers.

This disease can easily get to sub Saharan Africa from the UK, which has strong historical ties with many African countries. South Africa already has a travel ban with the UK to try to stop us infecting them.

Previously UK residents didn’t even need a visa to travel to South Africa.

Now all UK residents require a visa to travel to South Africa, and the visa will automatically be declined, as for the other countries that the WHO classify as high risk including Iran, Italy, Germany and China.

Coronavirus: SA to enforce US, UK and China travel bans from Wednesday

WHAT ABOUT A SECOND WAVE?

vskip to Feelings strong in the UK about our approach

China remain on alert for COVID-19. They have kept the bed capacity and the ventilators to deal with new cases if they arise. China have got the time from onset of symptoms to first detection of COVID-19 in a patient down to 3 days. This is through educating the public on symptoms for potential COVID-19, asking them to get tested as soon as they experience those symptoms, and developing the testing capacity to support this testing.

If China notices the beginning of a "second wave", it can nip it in the bud before it starts. They have shown their capability to do this, without lockdowns, mainly through rigorous contact tracing.

Outside of Hubei province the only provinces with more than 1000 confirmed cases are Guangdong, Henan, Zhejiang, and Hunan. Eight of their provinces have contained it at less than 100 cases.

China has a population significantly larger than Europe. Each province is the equivalent of a European country.

With these precautions, there seems no reason why a second wave should surge even as far as 1000 cases, most likely not even as far as 100, just through rigorous case finding, contact tracing, quarantine and isolation.

If the world had followed the Chinese example back in January and put alert systems in place like the Chinese alert system for their populations too, we would never have had any of these major outbreaks in Italy, Iran, or anywhere else. Like the Chinese we would have nipped them in the bud before they could start. That has been the main lesson the WHO has learnt. You have to act promptly, and aggressively to stop this virus. Every delay, even of a few days, makes it a longer and more difficult task to stop it.

The wisest countries have been preparing for this since January and already have systems like that in place to stop it. The UK should have done this over a month ago.

But it is not too late. Many countries have shown it is possible to slow down, and eventually stop this virus even once you have extensive community spread.

See also my

• Many Countries Are Stopping COVID-19 - Containing Cases Is The Key - Every Day Of Delay Makes It Harder For Countries & The World

WHAT IS THE UK DOING?

skip to What is the UK doing?

The UK have abandoned the approach of the WHO. They no longer test anyone for COVID-19 unless their condition is already serious enough to need hospital treatment.

The UK no longer screen people who enter the country from Italy, Iran, Spain, Germany or any of the other countries with known COVID-19 populations.

The UK no longer follow up the contacts of known cases of COVID-19.

FEELINGS STRONG IN THE UK ABOUT OUR APPROACH

skip to Expert projections in the UK use adaptations of influenza models

Here is one MP showing how feelings are strong already about the risk for our health workers and old people with this policy:

"Without good leadership people in this country will start to panic"

Labour's Dr Rosena Allin-Khan asks "where is the testing for medics?"

Boris Johnson: "We are proceeding in accordance with the best scientific advice... that is how you save lives"https://t.co/0v0cGWtvjM pic.twitter.com/zN0xaPzozh

— BBC Politics (@BBCPolitics) March 18, 2020

Here Boris Johnson responds that he is acting on the best scientific advice.

I think he may well be unaware of the details of what the WHO are saying - politicians are not expert on science. They are often not especially scientifically literate, and rely on their advisors for that. Boris Johnson has a degree in the classics, ancient literature and classical philosophy.

By “best scientific advice” here he means the advice of his chief medical officer Dr Whitty.

Of course Boris Johnson, and Dr Whitty too for that matter, want to slow it down. If they thought they could stop it this would be their top priority.

Yet the WHO say it can be stopped and this is where it gets strange. Why is this not more widely reported here?

Even most politicians here seem unaware of what is going on. For instance Jeremy Corbyn would surely criticise Boris Johnson on this point if he knew about it, but he doesn't mention it.

Scientists of course can and do come up with different ideas about how to tackle a pandemic. However, why don’t they make it clear to the British public that what they say differs from what the WHO say?

I think that our advisors should be up front about how different their policy is from what the WHO advise. If Dr Whitty was to do this, he would need to say something like this:

“The WHO have said that this disease can be stopped and that it is not a question of whether we can any more but if we will.

The WHO recommend that the backbone of our response should be case finding, quarantine, contact tracing and isolation.

However as chief medical officer for England I have looked at the situation and my best expert opinion is that this is not a suitable policy for the UK to adopt for reasons x y z and so the UK policy is …”

That then would show a great deal of scientific integrity.

Our politicians then could also discuss whether this is the path we should follow. So could the general public. In my experience, for the most part the ordinary people in the UK have no idea there is anything here to discuss.

It is okay for experts to disagree, if they have good reasons to do so. However, they should tell us all upfront what is going on.

They should not only make it clear that they are following a different path from the WHO. They should say in detail what they think is wrong with the WHO's analysis and advice, or why they think it can’t be applied to the UK situation.

They should also explain clearly to the British Public that in the opinion of the WHO this course of action endangers other countries with weaker health care that we may infect with our outbreak.

Then they should explain to us clearly what they are doing to reduce or eliminate the risk to other countries from exported cases from the UK. Or if they don’t think this is a risk they should explain this to us too and say why their assessment differs from the WHO, so that we can decide for ourselves whether our country should follow their advice, or the WHO.

I live in the UK and nobody is doing any of this in the UK.

I think many politicians here don’t even know there is anything to discuss here. At least, nobody is challenging Boris Johnson on this basis or mentioning it, on the BBC. This doesn’t seem to be discussed even in the Guardian, a widely read left wing paper here which is usually critical of the more right wing conservative government,.

EXPERT PROJECTIONS IN THE UK USE ADAPTATIONS OF INFLUENZA MODELS

skip to Some of the differences between 'flu and COVID-19 not modeled here

The experts in the UK are doing projections which they create with simple adaptations of models they previously developed for influenza. They change none of the assumptions in the models about how influenza is transmitted.

You may have seen this graph reproduced from one of these papers, the one which leads our Government to predict a second surge if we don’t let it spread a bit now:

However the authors of this paper say in the paper itself that their model was designed to model influenza originally. It is largely unchanged with minor modifications. Influenza is a completely different virus from COVID-19. Both viruses do infect the respiratory tract - but they behave in very different ways.

We modified an individual-based simulation model developed to support pandemic influenza planning to explore scenarios for COVID-19 in GB. The basic structure of the model remains as previously published. In brief,individuals reside in areas defined by high-resolution population density data. Contacts with other individuals in the population are made within the household, at school, in the workplace and in the wider community.

Paper Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand

Popular exposition here: 3 charts that helped change coronavirus policy in the UK and US

This, is the model which the UK government say has lead to them modifying some of their ideas - but they are still nowhere near the WHO approach and nowhere near contain. It is no wonder because this model is not even able to model the spread of COVID-19 as we will see.

SOME OF THE DIFFERENCES BETWEEN 'flu AND COVID-19 NOT MODELED HERE

skip to Striking example of contact tracing to find every case in Singapore - total population of 5 million as large as Scotland

The main difference is that 'flu spreads easily randomly in the community, also amongst large groups of people, and in schools. It also has symptomless spreaders, which makes contact tracing impossible.

Meanwhile COVID-19 spreads mainly through prolonged or very close contact e.g. families visiting each other or in hospitals, prisons, old people's homes and some religious situations. These people know each other, or the organizers of the events know them all.

This is why COVID-19 spreads mainly through easily traceable close contacts - a method that wouldn't work for 'flu .

I will go into more detail soon but first, let’s look at a very striking example. If you are used to 'flu modeling, this observational data may seem impossible.

STRIKING EXAMPLE OF CONTACT TRACING TO FIND EVERY CASE IN SINGAPORE - TOTAL POPULATION OF 5 MILLION AS LARGE AS SCOTLAND

skip to: How can other countries do contact tracing?

You can how this works for Singapore. Here it is especially striking. Singapore is a country as large as Scotland in its population yet the total number of cases of COVID-19 has remained in the low hundreds. It is now growing mainly through cases imported from other countries, and contacts of those cases. Singapore can't stop its cases increasing slowly for as long as other countries are sources unless it imposes travel bans which it doesn't want to do. But it is under control with the number of imported cases it has at present.

It also has relatively few cases, which you can explore yourself in a publicly available contact tree.

This is the situation as of 20th March

Of the 40 new cases on the 20th March,

• none are imported from China
• 30 are directly imported from other countries
• 4 are in traced contacts from ones who previously arrived from other countries,
• 3 are locally transmitted without a traced previous contact, and
• 3 are contacts from local transmission.

COVID-19 cases in Singapore

Most of the local cases trace back to seven gatherings or functions

• Private diner fuction at Safra, Jurong
• Grace assembly of God church
• Seletar Aerospce heights construction site.
• The Life church and missions, Singapore
• Yong Thai Hang medical products shop
• Grand Hyatt Singapore
• Wizilearn technoologies.

As of 20th March, of those 385 cases only 49 were diectly infected within Singapore in some other way

All the others came via contact tracing from those six gatheringss, imported from overseas, or contacts of previously traced cases

This is how it started:

What we know about the locally transmitted coronavirus cases in Singapore

If there was large scale local spreading in Singapore, and this was causing serious illness or killing people, they would have reported to the clinics or hospitals and we should have come across some of those cases by now.

Here is just a small part of their big chart.

Explore it here, and notice how many are closely related:

• COVID-19 cases in Singapore

You couldn’t do that with 'flu . If any of those people had passed it on to someone in a bus, coach, plane, train, waiting in a queue or something, it would be impossible to do this contact tracing.

Also notice that most of the cases are end points in this graph, which means they don’t infect anyone. This virus spreads by just a few people of the many already infected spreading the virus to many. Then just one or two of those spread to many again, and so it goes on, on and on.

We know this graph is complete, apart possibly from symptomless non spreaders, because they test everyone in Singapore for COVID-19 that presents with fever or respiratory symptoms in a population of over 5 million and these are the only cases they found. If there were significant numbers of symptomless spreaders, they would be seeding other small clusters of cases throughout Singapore by now.

COVID-19 in Singapore shows there can't be a hidden population of symptomless superspreaders

Singapore can't stop its cases increasing slowly for as long as other countries are sources unless it imposes travel bans which it doesn't want to do. It can keep the imported cases well under control at current levels of imported cases however.

Hong Kong and China have also done a fair bit of testing in fever clinics too, and so has South Korea.

South Korea is using the same method for over 8,000 cases. The WHO said that these are still nearly all in a few well defined huge clusters.

This is what makes it so different from 'flu .

HOW CAN OTHER COUNTRIES DO CONTACT TRACING?

skip to: Need to be able to scale up

Contact tracing is something that any volunteer or civil servant can do.

It does not mean that you isolate everyone else in the same building or place of work or school.

It means that you ask the case about their movements over the last few days and who they were in close contact with.

E.g. if they were staying over with a friend for a couple of nights - you phone up that friend and get them to self isolate, if they had an evening out with another friend you contact them, if they had a family gathering, you contact all the family, if they kissed someone at a party, you contact them, and so on.

It is straightforward stuff. Anyone can do it. Civil servants or volunteers can do it. You can re-use civil servants from other branches of government or local community organizations. You don't need to have any experience as health workers to do this.

But you have to be organized and methodical and thorough about it.

NEED TO BE ABLE TO SCALE UP TO KEEP TRACK OF ALL OF TENS OR HUNDREDS OF THOUSANDS OF CONTACTS

skip to Imperial college london’s model assumes only a third of the transmission chains can be stopped by quarantine and isolation

This is not so hard with a dozen cases, but the experience of China is that it gets much harder as it scales up unless you have good tools to track them all.

This is much like the way it is not so hard to host a small website with a thousand or even ten thousand visits a day. But if you get tens of millions or even billions of visits a day, you need serious levels of technological expertise to keep it running (Facebook has over a billion active users a day)

There is no hard limit. It would be possible to trace as many as millions of contacts if you put enough effort into it.

However, th is process has to be very organized to keep track of, say, 100,000 contacts.

You not only need to find them all, and ask them to self isolate. You also have to keep in touch with them all and then need to find a way to get them all tested as needed and retested.

This was something the Chinese did with large databases and software. The West can learn from them how they achieved the co-ordination to get it working.

Countries should be looking into how to do this before their outbreak starts, or from their very first few cases.

Instead, sadly, many countries keep track of the first few contacts, but when it starts to get hard to keep track of them all, they give up.

In the UK where I live, we have stopped doing case finding altogether for mild cases. The main issue here is not the number of diagnostic tests. It is a challenge but there are machines you can get that have a throughput of thousands of diagnostic tests per day per machine, so this is certainly not an unsurmountable problem.

The main issue is to keep up with contact tracing once you have thousands, or tens of thousands of known cases.

The UK gave up on this on the 13th March at less than 1000 total cases.

The Chinese continued all the way through to tens of thousands of active cases and half a million contacts traced at the peak of its epidemic.

We know that the UK has large numbers of undetected mild cases.

To get back on track, we need to do rapid case finding now, as many as we can find. Then we must trace their contacts.

We can expect to have thousands of cases by now. So we can expect to have tens of thousands of contacts to trace.

So, yes this is going to be a big challenge. We should already be working on the software and the administration to be able to follow all these tens of thousands of cases, and get them repeatedly retested for COVID-19.

We can do this. We can afford to do it as a country. We have the ingenuity and technical expertise to do this. Our software developers are up to the job, or they can import software from other countries.

This should be our absolute top priority right now, to ensure thorough and accurate contact tracing. We have to find all the cases too, but without the contact tracing then it will not be possible to keep it under control.

You have to do the contact tracing to get all the contacts of known cases to self isolate.

If you don’t do that, people who don’t know they are contacts of a known case can infect others from 2 days before onset of symptoms, through the first days of symptoms as well, until they realize they might have COVID-19 and get tested. Some contacts with very mild symptoms may not guess they ever had COVID-19 if you haven't contact traced them first.

IMPERIAL COLLEGE LONDON’S MODEL ASSUMES ONLY A THIRD OF THE TRANSMISSION CHAINS CAN BE STOPPED BY QUARANTINE AND ISOLATION

skip to Example of Veneto in Italy

Much of my information about COVID-19 for this section comes from this report:

Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)

The study I am looking at is this one, which is the one that lead the UK government to revise its policy recently, to try to keep transmisison low for the next year or year and a half using extreme physical distancing measures (but not using community case finding, quarantine or contact tracing).:

• Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand

Summary of this section:

The imperial college study is not closely modeled on covid-19. For instance they assume that a third of the transmission is done randomly in the community. For COVID-19 then that percentage should be close to 0%. They assume a third have such minimal symptoms that they don't know to self isolate - for COVID-19 that number is very low and for contacts who are being traced you can make it zero by doing daily tests to see if they have it. They assume that a third is in schools and workplaces. For COVID-19 about 80% of the transmission is in households, which doesn't leave enough of a percentage for a third to be in schools and workplaces, and some of that remaining 20% is in prisons, hospitals, care homes, and certain types of religious gatherings. Transmissions in the work place are likely to be through very close contacts. You almost never get transmision, say, in a supermarket, in the streets, transport etc.

Because of all these differences in their model, they find that it is impossible to stop it by quarantine methods, or by isolating individuals. They don't model contact tracing but it is pretty clear it wouldn't work for their disease either.

However, theirs is a hypothetical disease based on 'flu , adjusted to match the growth dynamics of COVID-19. The differences between their disease andt COVID-19 are so great I don't think this model should be used to guide policy planning. I don't see how this model can match the data for Singapore or South Korea.

In the Imperial College London model:

• One third of transmission occurs in schools and workplaces.
• One third of transmission occurs randomly in the community (depending on distance between people in the community)
• One third occurs in the household

Here is where they say this:

We modified an individual-based simulation model developed to support pandemic influenza planning to explore scenarios for COVID-19 in GB

With the parameterization above, approximately one third of transmission occurs in the household, one third in schools and workplaces and the remaining third in the community. These contact patterns reproduce those reported in social mixing surveys

...

Transmission events occur through contacts made between susceptible and infectious individualsin either the household, workplace, school or randomly in the community, with the latter depending on spatial distance between contacts.

Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand

According to the big WHO-China joint report however

• 78%-85% of transmission in Guandong and Sichuan province was within families (secondary attack rate 3-10%) - and this is typical of China.
• As we saw from Singapore,, transmission randomly in the community doesn’t seem to be a significant factor.
• I can't find information about the amount of transmission in the workplace, but it can't be as much as a third, given that there is only 22% left after you take account of transmission within households.
• Infections in schools were not a factor in Wuhan as the schools were closed for the Chinese New Year holiday, and the school holiday was extended during the lockdown. However they found no example of a child infecting an adult. The WHO in the press briefings when ask about this say that they don't know if infection in schools is a factor in other outbreaks. So this can't yet be ansered.

• On the other hand there is a significant amount of spreading in hospitals, prisons care homes - and since the report also in some religious gatherings (South Korea and Iran)
  - this is not modeled by them.

This assumption of random transmission in the community might be one of the main reason for the difference in approach of the UK Government and the World Health Organization.

There may be some genuine community transmission of COVID-19 between random people who are unconnected. However there is so little of this that none has yet been detected in Singapore which is our country with the best data on the topic.

Also short distance airborne transmission is possible for influenza viruses particularly in crowded enclosed spaces.

• Seasonal influenza and influenza A(H1N1)

But COVID-19 can't do that. See:

• The coronavirus COVID-19 is NOT AIRBORNE

That figure, therefore, should be close to 0%. You don't have to break every transmission chain to end an epidemic, just enough to reduce the numbers enough so that fewer are infected with each step of the transmisison.

The difference between a third of it being community transmission, and close to 0% may seem minor, but if you are using contact tracing to stop an epidemic, this difference may be highly significant for projections and recommendations.

In the Imperial College model also

• One third of cases are sufficiently asymptomatic that they will not know to self-isolate (if required to by policy)

Here is where they say these things:

We assume that symptomatic individuals are 50% more infectious than asymptomatic individual

We therefore assume that two-thirds of cases are sufficiently symptomatic to self-isolate (if required by policy) within 1 day of symptom onset, and a mean delay from onset of symptoms to hospitalisation of 5 days.

In the WHO - China report however,

• Asymptomatic spreading was rare and was not driving the spread

If a third of the cases were asymptomatic with 50% infectivity this would surely have been noticed in Singapore and elsewhere.

They have various other parameters that again don't seem to match known figures for COVID-19 but instead are based on previous experience with influenza.

• Incubation period 5.1 days
• Symptomatic cases are infectious from 12 hours before onset of symptoms to 7 days after onset of symptoms.
• Asymptomatic cases are infectious from 4.6 days after infection

According to the WHO

• Cases are infectious from 1–2 days before symptoms start through to 14 days after patients recover.

When stopping an epidemic you don’t need to stop all transmission chains. If e.g. R0 is 2 then it is enough to break more than half the chains. They assume 2.4 . If in their model more than 60% (e.g. 75%) of transmission chains were broken, it would eventually stop altogether.

There are two forms of transmission that seem to be driving the spread. There is prolonged contact and there is brief but close contact. In both cases the main thing is the people concerned know each other, so you can do the contact tracing.

They don’t model contact tracing and isolation of contacts, or isolation of individuals within a household, just quarantine of entire households.

This is why quarantine doesn't work by itself in their model, while in South Korea, Singapore, China etc, they are containing it with mainly quarantine and contact tracing.

The contact tracing is part of the solution to end this. The WHO recommends that everyone does contact tracing. If they want to investigate this in a model they should model contact tracing and see how effective it is. The countries that do comprehensive contact tracing have had most success in stopping the spread.

EXAMPLE OF VENETO IN ITALY

skip to Nerve wracking wait

The Italians have become acutely aware of the value of extensive testing and contact tracing for saving lives. Michele Zanini has shared a number of figures on twitter that bring this out strikingly.

Of all the provinces, Veneto is the one to adopt the WHO recommendations most rigorously. They did more tests than any other province per 100,000 people:

This has paid dividends. In this figure notice how low the cumulative number of deaths is for Veneto starting from the tenth death:

They also have far fewer health workers infected as a percentage of the total cases, 3% as compared to 13% for Lombardy:

Michele Zanini tweets that they routinely test caregivers and other workers with greatest exposure to the population:

They routinely testing all caregivers & other essential workers w/ greatest exposure to the population (e.g., supermarket cashiers & law enforcement). This might in part explain why there are 25x more caregivers infected in Lombardy vs. Veneto (Lombardy is 2x the pop)

These measures may be part of the reason of Veneto’s success in keeping the deaths down so low compared to other provinces.

With this experience from the front line in Italy, you can understand the reaction of the colleagues of Professor James Smith to our Governments announcement that it would stop quarantining and containment and stop testing and tracing contacts:

- Italian colleagues opinion is not translatable in polite way

Text on the image:

Devi Sridhar - Colleagues all think we are doing it wrong - Professor of global health, Edinburgh

Prof. Sunit K. Singh - Not ethical to make hunmans guinea pigs in name of "Herd Immunity" - Prof. and head of microbiology, BHU

James Smith - Italian colleagues opinion is not translatable in polite way - Vice principal and prof, Edin.

Martha - How do we learn about this disease and its transmission by only counting those in hospital? - BA (Hons). LLB. MSc.

[note for autistic readers -when Prof Singh talks about "human guinea pigs" it is hyperbole. He doesn't mean they are literally experimenting on us like guinea pigs. He means that the actions they are doing implementing an untested academic theory to deal with this outbreak, instead of the practical advice of the WHO, is like experimenting on guinea pigs in effect not in intention.]

• Experts Condemn UK's Response To COVID-19 - We Must Reverse This Now - Detect Mild Cases & Contain Swiftly To Save Lives

I do hope we reverse this change of direction soon, but the sooner the better!

NERVE WRACKING WAIT - CASES PER DAY SEEM TO RISE TO A DELAYED PEAK DAYS AFTER YOU IMPLEMENT STRICT MEASURES

skip to Why is COVID-19 so different from 'flu ?

If you put these rigorous quarantine and case finding measures in place, it can be nervewracking at the start. cases per day seems to continue to rise for a while.

The number of cases per day immediately peaks, only a day or two of delay as measued by onset of symptoms .However these are not detected cases yet. You only know about them muh later.

The numbers will seem to continue to cllimb after that because of cases that are already symptomatic but the patients just think it is a mild cold or 'flu , and it can take over a week from onset of symptoms to the case being diagnosed.

In China, if you look at the date of onset of symptoms, then it peaked on the 25th of January, only 3 days after the Wuhan city shutdown on the 25th January

However if you look at the date of diagnosis, it seemed to peak 9 days late on the 5th February.

If you train the population to go and get tested as soon as they feel even mild 'flu symptoms and you have the testing capacity then you can get that delay down to around 3 days, as China did towards the end of its outbreak. If we had reliable tests you could do yourself at home or some way to do it instantly as easily as taking a temperature then it could be less than that.

It looks pretty much like a symmetrical curve, though to a trained epidemologist it is wierdly skewed :). Anyway - that means that very roughly, the cumulative total is double the number at the peak.

E.g. if cases per day peaks at 3,500 in one of the states say, you can expect it to endup with maybe 7000 total. because in Wuhan it came down a bit differently from the way it went up, but as a ballpark figure

WHY IS COVID-19 SO DIFFERENT FROM 'flu ?

skip to Community spread is not driving the COVID-19 pandemic - unlike flu

First, there is no evidence of any airborne spread (as there was for SARS)

• The coronavirus COVID-19 is NOT AIRBORNE

COVID-19 spreads by the droplets we expel when we cough or sneeze, and the way they fall on surfaces. Some of these fall in other people’s noses, eyes or mouths, and others fall on surfaces which people then touch, then touch their noses, eyes or mouths and so infect themselves. It can’t infect us through the skin.

The details of how it infects us need to be studied more, but they can tell from the transmission chains that there are two situations where you typically get it in the real world.

• brief but very close contact,
• prolonged repeated contact with the virus.

This virus has an affinity for the lower respiratory tract and not much of an affinity for the upper respiratory tract so it has trouble entering the body originally and may require a very high viral load to get started.

Also short distance airborne transmission is possible for influenza viruses particularly in crowded enclosed spaces.

• Seasonal influenza and influenza A(H1N1)

But COVID-19 can't do that. See:

• The coronavirus COVID-19 is NOT AIRBORNE

Since it is such a different disease, different even from SARS, a model of spread designed for 'flu would not necessarily be expected to work unmodified for COVID-19.

COMMUNITY SPREAD IS NOT DRIVING THE COVID-19 PANDEMIC - UNLIKE FLU

skip to Duration of quarantine for COVID-19 as recommended by the WHO

This virus mainly spreads in places where people are in contact for a long time. It just doesn’t seem to happen that someone coughs on you a few times in a supermarket or on an underground train and then you have the disease.

I need to be careful here. The WHO and other experts are stressing that it is important to protect ourselves against community spread.

They are not saying it is okay to go around coughing on people if you have COVID-19 or that it is okay to let others cough on you or that it is okay to skip quarantine.

There may well be a small risk of community spread.

With even the minutest spread, for someone with COVID-19 even to go shopping is like playing russian roulette with someone else’s life.

But the community spread risk is very small for this disease, unlike for a 'flu outbreak. So small that you’re containment measures only need a small element of social distancing, for instance certain kinds of large groups.

South Korea and Singapore, also China outside of Hubei province didn’t need to do any lock downs.

This is the real data from the world:

Many Countries Are Stopping COVID-19 - Containing Cases Is The Key - Every Day Of Delay Makes It Harder For Countries & The World

COVID-19 is a new disease and could resurge. However there is little evidence yet that it will surge up again.

China has stopped it just about completely, and has had days with no native Chinese cases. They are restarting their economy, opening restaurants, restarting travel even in Hubei province.

There has been no second wave yet. The Chinese are prepared for one if it happens. They have kept bed space, ventilators etc to be able to stop it as they stopped the first one.

During the first wave, most provinces outside of Hubei had only a few hundred cases.

China can now detect a new COVID-19 case within 3 days of symptoms starting because of they way the public there now go to fever clinics to be tested as soon as they have a fever and because of a huge testing capacity.

So China is not going to have a second wave like the first one even if it does resurge. The rest of the world could do this too. We can stop it, from the experience of China this is clearly something that can be done with this virus. Then we can monitor with extensive testing of anyone with 'flu symptoms to see if there is a second wave. With testing in place, we can stop any such second wave as well before it happens.

Dr Bruce Aylward talks about the Chinese response and compares it to the UK response here. His main point is that as a new virus then there is room for different ways to try to tackle it but his advice for the UK would be they have to adapt rapidly if they find that their methods are not working as expected.

(click to watch on Youtube)

‘We’re all guinea pigs because it’s a new virus’ – WHO’s Dr Bruce Aylward

Note for autistic readers - by “guinea pigs” they don’t mean that it is an experiment on us by people who don’t care who lives or dies. It means that those concerned do care, but as it is a new virus then it is something we have to learn about from experience of what works and what doesn’t work.

What we know for sure from our experiences so far is that we do as the Chinese did, and as Singapore and South Korea are doing, we don't have to just flatten the curve. Those projections with a second wave don't take account of the unusual way that COVID-19 spreads and the way that it can be stopped by contact tracing unlike 'flu . They can’t model what happens in the real world with COVID-19 until they add modeling of contact tracing.

So we can handle this if needs be. But so far there is no evidence that COVID-19 will resurge like this.

Also COVID-19 could transfer to humans again from its original reservoir, perhaps in pangolins (not discovered yet). But if so, again, the Chinese will spot it within days now they know how to detect it, and handle the second wave in the same way they handled the first wave in provinces outside of Hubei province.

DURATION OF QUARANTINE FOR COVID-19 AS RECOMMENDED BY THE WHO

skip to UK’s guidelines - might they even increase the spread?

The WHO recommend that if you do have COVID-19 that you can self isolate at home but anyone who is caring for you has to use a mask and know how to use it properly They say that you are potentially infectious for up to 14 days after you feel completely better and should have no visitors until that time period is up.

Others in the same household as a confirmed case are treated like any other contact - they self isolate from each other and the suspect case for 14 days and then if they didn’t have it they are virus free.

You are also infectious for 1–2 days before you show symptoms. That is why they ask contacts to self isolate even when they have no symptoms once they are known to be contacts with a COVID-19 case. If you got them to isolate only once they have symptoms then it is too late).

Our NHS, in the UK, is recommending patients who may just have a cold, or 'flu , to self isolate for 7 days, or for 14 days if they are with others. Then if they need medical care while they have a cold or 'flu they should ring up and say they think they might have COVID-19

Coronavirus (COVID-19)

NHS - For COVID-19 (Suspected)

• Isolate for 7 days
• if in household all isolate for 14 days
• no need to use masks
• you can then leave - no need for test

WHO - test suspected cases

• If you have mild COVID-19, isolate until better
  (you are still infectious) and no visitors
• carers must use masks
• trace and isoalte all close contacts for 14 days

The image is from here: Novel Coronavirus SARS-CoV-2

They can’t both be right.

This is the NHS advice:

Stay at home if you have coronavirus symptoms

Stay at home if you have either:

• a high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
• a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)

Do not go to a GP surgery, pharmacy or hospital.

• Coronavirus (COVID-19)

This is the WHO advice:

Caring for infected people at home may put others in the same household at risk, so it’s critical that care-givers follow WHO’s guidance on how to provide care as safely as possible.

For example, both the patient and their care-giver should wear a medical mask when they are together in the same room.

The patient should sleep in a separate bedroom to others and use a different bathroom.

Assign one person to care for the patient, ideally someone who is in good health and has no underlying conditions.

The care-giver should wash their hands after any contact with the patient or their immediate environment.

People infected with COVID-19 can still infect others after they stop feeling sick, so these measures should continue for at least two weeks after symptoms disappear.

Visitors should not be allowed until the end of this period.

So, if you do have COVID-19 in its mild form and just got over it, you are actually, according to the WHO, still infectious for another two weeks. But in the UK, if you have some medical emergency (say, a broken ankle) after the original 7 days is up, you will go into a hospital and be treated by doctors and nurses who won’t take any precautions as they will believe you to be free of the virus.

The WHO advice is evidence based. It is based on data about how long the virus is infectious for based on transmission chains and case pairs. It is designed to completely stop any forward transmission of COVID-19 if you have it.

The NHS advice is based on a model from Imperial College london that models a hypothetical disease that is a minor modification of a flu model adjusted to match the figures for the numbers of COVID-19 victins. It is almost but not entirely unlike COVID-19.

The NHS advice is not designed to protect you or your others completely from COVID-19 but to reduce the speed at which it spreads to others. But it makes many assumptions that don’t match the COVID-19 disease (for instance about when it is most infectious) so I am not sure it even does that. How can you know it will help at all when it is based on a hypothetical disease that has few points of resemblance to the real disease?

It is almost funny if it weren’t so serious. How can the health advice for an entire nation be based on a hypothetical disease instead of the real one?

UK’S GUIDELINES - MIGHT THEY EVEN INCREASE THE SPREAD?

skip to The 'flu transmission model is therefore not obviously suitable for this disease

However the UK again has developed its own guidelines that differ from the WHO. Their objective is to just slow down the spread with minimum inconvenience. Meanwhile also since they are not testing any more, everyone in the UK with similar symptoms has to consider themselves to be a potential COVID-19 case (a fever / dry cough / with a fatigued feeling like a bus has hit you ./ breathing difficulties). (see NHS advice here and iBBC graphics shere )

The UK government tells people living alone should self isolate for 7 days.

For those in a household with others, they ask them to continue living with their household and isolate the entire household from the rest of the world for 14 days.

They can't enforce this, as the numbers involved are too large. Also, there is no proven risk to the community as the patients don't even know if they have the virus. They may well not stay in for the full 14 days. Then, even if they did, typically 14 days is not enough for COVID-19.

Bruce Aylward put it like this as interviewed by New Scientist:

“In some countries they’re not even testing them. They’re saying if you have a cough and high fever, stay at home,”

“But the problem then is that they don’t know that they have the disease, they haven’t had it confirmed. After a couple of days people get bored, go out for a walk and go shopping and get other people infected. If you know you’re infected you’re more likely to isolate yourself.”

“If those people are all out of hospital, most of your cases are at home, but not isolated. In China, they found that didn’t work. They had to get them isolated in hospitals or dormitories or stadiums. The main goal was to keep them from getting bored.”

This method might be more effective with 'flu . People with 'flu can infect others any time from 1 day before they develop symptoms to up to 7 days after onset of symptoms. Some people with weakened immune system or children may be able to infect others more than 7 days after the start of a 'flu infection, but this is rare.

• How 'flu Spreads

With the mild cases of COVID-19 then at 14 days they are likely over the sickness, but remember the WHO say they are still infectious for another 14 days after they have recovered, not 14 days from onset of symptoms.

Many with the mild symptoms take two weeks to recover from the symptoms. At that point they are symptom free but will be infectious for another two weeks after that.

Also, remember they don’t ask the household to self isolate from each other.

So, the government is asking them all to stay indoors in the same small volume of space for those two weeks. If the patient is COVID-19 positive, then the family are all sharing the same air and breathing in droplets from the COVID-19 patient, and touching surfaces the COVID-19 patient has touched.

This is is creating the prolonged contact which seems to be what this virus needs to spread.

This seems likely if anything to increase the amount of spread.

So now the first case is over their symptoms but still infectious for up to 14 days. The other members may be infected now but presymptomatic. At that point the entire household can now leave their house and do what they like and pass it on to others.

This delays the spread back to the community for 14 days, yes, but then at the end of that period you likely have increased the number of cases by prolonged contact.

If people right now are following those instructions, we can expect a surge of COVID-19 cases two weeks from now when they start to return to the community after their two weeks isolation.

I think it is possible that our government’s instructions are acting to increase rather than decrease the rate of spread of this virus, though not immediately, delayed by two weeks.

THE 'flu TRANSMISSION MODEL IS THEREFORE NOT OBVIOUSLY SUITABLE FOR THIS DISEASE

skip to On a personal level, risk of transmission in the community is low

This is why a model of transmission for 'flu is not at all obviously suitable for this disease. It has to take account of its unusual transmission dynamics where the transmission is to people that the case already knows or to an event where typically they know each other.

This also makes the hospitals, prisons, old peoples homes etc top priority to protect because they are the places where people spend a lot of time in prolonged contact.

ON A PERSONAL LEVEL, RISK OF TRANSMISSION IN THE COMMUNITY IS LOW

skip to Protecting doctors, care homes, hospitals, surgeries and prisons

On a personal level your risk if you go out and about in the community, from this data is very low, and then by the hand hygiene, respiratory etiquette and not touching your face you can reduce it to the point you can be confident you didn’t get this virus.

You are far more likely to get it from someone visiting including a relative. You may also get it through close contact with a friend or colleague.

You can catch it in just one day, you don’t have to wait for weeks to get it. The German cases were acquired quickly and an early example in China was of one family that visited another family in Wuhan for a day and I think they all got it.

However you may also get it after prolonged contact.

PROTECTING DOCTORS, CARE HOMES, HOSPITALS, SURGERIES AND PRISONS

skip to Cannot protect health workers except by going back to contain phase

From the experience of other countries, those are the things they should focus on most of all.

Then there is the way they are doing almost nothing to protect care homes, hospitals, surgeries, and dentists from patients who may have undetected mild cases of COVID-19. Or prisons. These are not their center of attention.

They have even downgraded the level of protective equipment recommended to doctors working with known COVID 19 positive patients.

See my

• UK Must CONTAIN COVID-19 Right Now - We Can Stop It - Each Ten Days Delay Can Increase Cases Tenfold 1,000 To 10,000 Then 100,000

This is not a theoretical study, it is real life with real people’s lives at stake. These places have been involved in spreading and amplifying COVID-19.

As far as I know, ours is the only government that has policies that actively encourage community spread through doctors and care homes, again by this false analogy with 'flu and by reducing adequate protection even for known COVID-19 cases

CANNOT PROTECT HEALTH WORKERS EXCEPT BY GOING BACK TO CONTAIN PHASE

skip to My personal risk

What’s more we are not going to be able to protect our health workers unless we go back to the contain phase - or perhaps with very rapid testing in a few minutes.

The thing is you can only protect your doctors and nurses if you know that patients have COVID-19. If someone comes in with a broken ankle, and they are coughing and sneezing - do you get on full protective gear with face guard, or can you treat them without any special equipment?

There are tests under development that could detect it within half an hour, but that still is not enough for an emergency response.

• Oxford scientists develop new coronavirus test that provides results in just 30 minutes – TechCrunch

In a more urgent situation, if you are treating an accident or other life and death situation then you may have seconds to make this decision. What do emergency response teams do if they find someone who has been involved in a car accident, with no knowledge of whether or not they have COVID-19?

Public Health England have actually downgraded their protection even for doctors treating known COVID-19 patients.

COVID-19: infection prevention and control

As you can see, as of 17th March, doctors

• don’t have to wear eye protection in a general ward (doctors in Wuhan were infected with COVID-19 through the eyes)
• use an apron instead of a complete disposable gown even in high risk units, so that after leaving the ward and removing their aprons, they will be wandering around the hospital with COVID-19 infected scrubs.
• They don’t wear the high tech FFP3 respirators even in high risk units any more, only for intensive care.

All this equipment used to be worn by anyone entering a room where a COVID-19 patient is being isolated, even before definitive assessment of them as a possible case.

The guidelines were changed on the 6th March.

This is what it used to say:

The following PPE is to be worn by all persons entering the room where a patient is being isolated (either before definitive assessment, or once assessed as a possible case):

• long sleeved, fluid-repellent disposable gown – wearing scrubs underneath obviates problems with laundering of uniforms and other clothing
• gloves with long tight-fitting cuffs
• FFP3 respirator conforming to EN149 must be worn by all personnel in the room. Fit testing must be undertaken before using this equipment and a respirator should be fit-checked every time it is used
• eye protection, such as single use goggles or full-face visors, must be worn (note prescription glasses do not provide adequate protection)

The PPE described above must be worn at all times when in the patient’s room (see putting on and removing personal protective equipment)

COVID-19: infection prevention and control guidance

Meanwhile the WHO guideline are

Respirator or Facemask

• Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure (See Section 4).

Eye Protection

• Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
• Remove eye protection before leaving the patient room or care area.
• Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use.

Gloves

• Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated.
• Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.

Gowns

• Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.
• If there are shortages of gowns, they should be prioritized for: aerosol-generating procedures
• care activities where splashes and sprays are anticipated
• high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.

COVID-19: infection prevention and control guidance

So, basically our NHS has downgraded the COVID-19 guidelines for doctors and nurses to the WHO guidelines for countries with a shortage of personal protection equipment.

Coronavirus Disease 2019 (COVID-19)

However now that they are no longer even testing mild cases it has got worse than that.

There will be patients with COVID-19 treated in general hospital emergency rooms with staff that have no idea they have the virus and not taking any precautions at all.

We can’t shut down hospitals and stop treating people with a broken ankle in case they might have COVID-19. It is not practical to treat everyone in the UK as if they are a COVID-19 patient without testing them. It is not practical to test everyone who comes into accident / emergency either, as it takes several hours to do the test. Also right now, there is a shortage of tests and we couldn't do that.

We have to go back to containment. Also now that we have lost track of the virus we have to step up our diagnostics capability, and test everyone in the country with a fever, like the Chinese do.

Within a few days we could locate the majority of COVID-19 patients in the UK if we did what the Chinese did. The tests themselves cost $5 each for the WHO and more like $50 each in the US. It is expensive to do so many tests, but far less disruptive and expensive than what our government is doing.

MY PERSONAL RISK

skip to Why our government needs to be agile and respond rapidly if its measures don’t work

Many of those I help are concerned about my personal risk as I live in the UK and am 65 years old

I am keeping myself safe. I live by myself so there isn't much possibility of contamination if nobody visits me and I don't visit anyone else and don't travel. The UK is saying we should only do essential visits of each other, and my social life is largely online, so I am doing this too.

So the main way I could get COVID-19 is if I go shopping. When I do this, I am careful not to touch my face, wash my hands when I get back and clean all the surfaces I touched to get back into the house with soapy water. I also keep a distance from anyone who might be coughing or sneezing, in my case that is easy living half a mile outside of a remote village in Scotland on the Isle of Mull.

I think my main personal risk would be if I had a broken ankle or a bad toothache and needed care from a hospital or a dentist. The government here are not acting to make sure hospitals and dentists are protected from treating mild cases of COVID-19. Any hospital or dental surgery could have treated a mild case of COVID-19 before me, including mild cases that can infect others before they develop symptoms or for up to 14 days after symptoms cease.

So - I think we have to assume that any hospital or dentists surgery might have COVID-19 endemic to the facility - especially since this often happened in Wuhan in the early stages of their epidemic. This will be very unlikely to start with. As for Wuhan we could go some days before the first outbreak in a hospital, clinic or surgery - but it becomes more likely for as long as this policy continues.

So I am especially careful not to break an ankle or do anything risky like that and not eating sweet things so as not get a toothache. Those are probably wise things for others to do if you live in the UK.

Your personal risk is very small if you are under 40, only 1 or 2 in 1000 and less than that for younger people, and then your risk of getting it from a surgery or hospital here is surely very low too.

At my age, 65, I have a 3 % or so risk of dying if I get COVID-19 so have to take especial care.

WHY OUR GOVERNMENT NEEDS TO BE AGILE AND RESPOND RAPIDLY IF ITS MEASURES DON’T WORK

skip to Note i am not saying this will happen

All of our governments advice seems to be based on measures they know from experience help with 'flu rather than the new measures developed in China, Singapore, South Korea, Italy etc that work with COVID-19.

As Bruce Aylward said the most important thing here is to be agile, to be able to quickly respond and change direction if your methods are not working.

They need to get up to speed fast and change their ideas rapidly. It needs to be evidence based, based on evidence for COVID-19 rather than influenza.

There are signs of this already. Look at the deaths from COVID-19 in the UK doubling every 2 days. Usually it is every 3–4 days. Their measures may be making things worse.

With a doubling time of 2 days it would continue

200, 400, 800, 1600, 3200, 6400, 12800.

We could have 12,800 deaths by two weeks from now, at this rate, increasing 64 fold every fortnight. That’s more deaths than in the whole world right now.

If it doubles every three days this happens three weeks from now and if it doubles every four days, it happens four weeks from now.

NOTE I AM NOT SAYING THIS WILL HAPPEN

skip to Governments new measures are stronger but are they what is needed?

There is no way we go as far as that.

If we don’t stop this approach RIGHT NOW, it will soon be in a situation as difficult as Italy and if we do nothing for another 10 days it can easily begin to get as bad as WUHAN or worse.

GOVERNMENTS NEW MEASURES ARE STRONGER BUT ARE THEY WHAT IS NEEDED?

skip to Paradigm shifts and trained incapacity - why don’t the uk experts seem to see any of this?

The governments increase in testing to 25,000 a day by four weeks from now is a welcome step in the right direction. But there is far more they have to do.

First,

• Do they locate all the mild cases or only a fraction of them?
• Do they then isolate all the mild cases appropriately?
• Do they trace all their contacts and isolate them too?
• Do they do campaigns to educate our public about hand washing and other measures to keep themselves safe?
• Are they testing all suspected cases and are they doing surveillance of everyone with influenza like symptoms to catch COVID-19 cases in the community early?

Also for specific vulnerable populations:

• Do they provide adequate personal protection equipment, and training, to protect all our health workers who work with COVID-19 patients?
• Is adequate personal protection advice and equipment given to dentists, workers in care homes with COVID-19 patients, nurses and midwives, as well as frontline doctors?
• Are those who care for COVID-19 patients and contacts who self isolate at home given adequate instructions on how to keep themselves safe?
• Are they working to ensure that our overcrowded prisons with Victorian buildings are protected from COVID-19.
• Is COVID-19 testing going to be available for free, and without questions asked, to homeless people and illegal immigrants?

So far they are not doing any of these things, and every day counts.

They are doing many other radical things that would work for 'flu but for the most part are untested for COVID-19

Details here:

• UK Must CONTAIN COVID-19 Right Now - We Can Stop It - Each Ten Days Delay Can Increase Cases Tenfold 1,000 To 10,000 Then 100,000

We don’t really know the number of cases infected now until they do rapid and extensive testing. But if the cases are doubling only every 3 days instead of every 2 days, then that would be a ten fold increase every ten days. 1000 cases become 10,000 ten days later, then 100,000 then within a month, 1 million, more than ten times worse than the total cases for Wuhan.

We crossed 1000 cases on the 14th of march. That makes it the 24th when we may hit 10,000 cases and 3rd of April when we may hit 100,000 cases. If the government’s actions are actually accelerating spread due to using the wrong paradigm of 'flu instead of COVID-19 it may even happen faster.

PARADIGM SHIFTS AND TRAINED INCAPACITY - WHY DON’T THE UK EXPERTS SEEM TO SEE ANY OF THIS?

skip to We don't have the luxury of time to try a new strategy based on as yet unproven methods

I think myself it is an example of a paradigm shift as in Thomas Kuhn's "The Structure of Scientific Revolution".
Paradigm shift - Wikipedia

They are using the 'flu paradigm and everything else is checked according to how it fits that paradigm and they are discarding information and advice that doesn't fit it.

This can often seem puzzling to non experts because you are not invested in the old paradigm. You can't see things the way they do with their decades of experience working in great details with all the intricacies of transmission mechanisms of 'flu .

I think it is also related to Thorstein Veblen's idea of "trained incapacity". He has a rather unflattering analogy with chickens:

By trained incapacity he meant that state of affairs where one's very abilities can function as blindnesses. If we had conditioned chickens to interpret the sound of a bell as a food-signal, and if we now rang the bell to assemble them for punishment, their training would work against them. With their past education to guide them, they would respond in a way that would defeat their own interests.
Thorstein Veblen - Wikipedia

We are not talking about chickens and a simple conditioned response here of course. Our experts are erudite, highly educated, and very intelligent .

However paradigm shifts can be tricky for even the most intelligent. I have a special interest in the history of Maths.

Back in Sumerian times then they put a mouth picture over a number, meaning “part” to turn e.g. the number 5 into 1/5

So the Sumerians could notate any number, e.g. 5 and a single part as a result of any number of divisions e.g. 1/5.

However they had no way to notate, say, 3/5.

For instance they couldn’t notate 3/4. Instead they had to notate it as

History of Fractions

For centuries an entire civilization of people with the same genes as us, as intelligent as us, never invented the idea of a ratio.

You can do the same calculations with these methods, but they become increasingly hard to do, with many more steps as the calculations get more complicated.

Ratios would have made many calculations they had to do so much simpler for them, but the idea never occurred to them. Not even their equivalent of our best scientists or mathematicians were able to think of this idea. Put Albert Einstein back into Sumerian times, raised as an orphan there, and he wouldn’t think of it either.

That’s an example of a paradigm shift.

There are many others in maths. There was huge resistance in the middle ages to the introduction of negative numbers in equations.

Before negative numbers were accepted by mathematicians - then they had many different forms for the quadratic or the cubic. You always had to rearrange the equation to make sure all the coefficients are positive. As they went through the steps to solve the quadratic, they had to keep everything positive because they didn’t think negative numbers were valid numbers. This lead to many different techniques you had to learn to solve a quadratic and even more so for the cubic with this clumsy notation.

It took until the fifteenth century for negative numbers to take off in Europe.

As late as 1758 the British mathematician Francis Maseres wrote that negative numbers

"... darken the very whole doctrines of the equations and make dark of the things which are in their nature excessively obvious and simple" .

The History of Negative Numbers

Now we learn about negative numbers as children. Back then it was an advanced subject for their equivalent of university level maths with the experts arguing about whether it was valid to use them or not.

I hope this helps you have more sympathy for these experts. They are not stupid, or arrogant or unethical. Just facing a paradigm shift, and their vast experience of influenza has caused a “trained incapacity” that makes it really tough for them to change this paradigm. So they are discarding the evidence against their ideas over and over.

Their own erudition is the thing that is causing them problems.

They will come around eventually. I expect it to worsen over the weekend and by the end of next week it should be increasingly obvious that this approach is not working.

But we don’t have time for this; every doubling of cases makes it a longer and more difficult task to contain this and stop it - we must act promptly to stop it as fast as we can right now.

WE DON'T HAVE THE LUXURY OF TIME TO TRY A NEW STRATEGY BASED ON AS YET UNPROVEN METHODS

skip to So what do we do next?

This is a new disease and that everyone is "learning on the job". But this disease can increase in numbers rapidly. Governments need to be very agile to respond if the methods they are using don't work. Within days or hours. If it is a mistaken approach and we find out a week later, it could easily be nany times worse.

We already have methods that are proven to work.

Many of the Chinese provinces stopped it before it got anywhere e.g. there is only one case in Tibet. 21 provinces never had more than 100 cases and only 4 outside of Hubei had over 1000 cases, none reached 2000. These provinces are the size of European countries and the Chinese population is larger than that of Europe. Only Hubei province had cities in complete lock down.

We can do the same but aren't. We have to become more methodical and careful in the contact tracing, and quarantine and in personal hygiene instructions and we can stop this too. Lock downs and social distancing don't work by themselves with this virus. It has to involve the ordinary people following the simple instructions to keep themselves safe and it has to involve contact tracing to a rigour we are not used to.

Some countries are doing it, but we have to do this rapidly and fast - the reason China contained it at such low numbers is because of a rapid response over the entire country as soon as the seriousness of the situation in Wuhan became clear.

If you nip it in the bud at a few dozen or a few hundred cases it stops. If you do nothing for a few days or weeks, each day of delay makes it harder.

There may well be more than one way to deal with this. But this virus has the potential to escalate rapidly. We don't have the luxury of the time to try out radically new unproven approaches.

We need to use the methods already proven to work and learn from other country's mistakes and successes.

This is a serious disease for health care systems. For instance the UK has a maximum capacity of 30 artificial lungs for the entire country and only a 1000 or so ventilators Those are not enough to treat a major outbreak and also bear in mind that someone is already using most of those ventilators and COVID-19 patients typically need a ventilator or artificial lung for up to 6 weeks. They also need 2-3 health care workers to each patient to keep them alive under ventilators.

Meanwhile our health cares systems typically run at 95% of capacity. This is a major stress on any health care system. We can ramp up but have to do so very fast and don't have that ramp up built in already as a capability.

This is another reason to act promptly. Soon our health care in the UK will be struggling to cope with the disease.

SO WHAT DO WE DO NEXT?

skip to What do you think?

First you need to find the virus in your society, or else, as Dr Tedros put it, it is like trying to fight a fire blindfold. You also need to understand how this particular disease is being transmitted in your society.

Then to control it, your control methods have to respect the way the virus is transmitted in your society.

The methods used by China, Singapore and South Korea are proven - they work.

Many of the Chinese provinces stopped it before it got anywhere e.g. there is only one case in Tibet. 21 provinces never had more than 100 cases and only 4 outside of Hubei had over 1000 cases, none reached 2000. These provinces are the size of European countries and the Chinese population is larger than that of Europe. Only Hubei province had cities in complete lock down.

I am working on these as petitions for the UK government (as I am a UK citizen), so it gives an idea of the priorities. It is based on the priorities of the WHO:

Find and quarantine COVID-19 cases and isolate all their contacts

The World Health Organization recommend that countries test every suspected case of COVID19, and isolate and treat every confirmed case. It also recommends that they trace every contact and isolate those until they are free of the virus. We call on the UK government to do all these things.

Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said: "Several countries have demonstrated that this virus can be suppressed and controlled. The challenge for many countries ...is not whether they can do the same; it's whether they will. ." The UK is one of the few countries to stop contact tracing and quarantine. The world needs to join in solidarity to suppress and control this virus, both for ourselves and other countries that we may infect, especially with weaker health care systems.

Then another one:

Test everyone with influenza-like illness for COVID-19

The Government must test everyone with influenza-like illness for COVID19 as recommended by the WHO-China Joint Mission headed by Dr Aylward and Dr Liang and published on 25th February

Singapore, Hong Kong, South Korea and China have all shown the value of extensive testing for COVID19. When combined with quarantine, contact tracing, and contact isolation, this is a proven method to nip new clusters of infections in the bud, reduce the numbers of deaths and save the lives of frontline health workers. Dr Tedros said we can’t fight a fire blindfold. Now that we have lost sight of where the virus is in the population we need to test everyone with symptoms to find it again.

I did an earlier petition a week ago, as soon as the announcement was made that the UK would stop testing mild cases and quarantining them - but the moderators felt it wasn’t clear enough. It took a week for them to get to it:

• Petition: The UK government must immediately return to the contain phase for COVID-19

Similarly this petition is not likely to be approved before next week.

Still if this new one is approved, then a week from now would be crunch time, likely to be over a thousand deaths by then at the current rate of doubling every two days and that week would then see a build up to 18,000 by two weeks from now- that is if the doubling progression continues.

I very much hope that our government changes course before then, but if not then that would be a time when there are likely to be lots of protests and many trying to really put pressure on them to do something about what’s happening.

I am glad to see that at last the BBC is reporting how China, South Korea,and Singapore were able to stop their outbreaks:

Coronavirus: What could the West learn from Asia?

To answer a couple of the points they make there.

First, yes of course Europeans can follow orders of their government, it's not unique to Asian socieities.

Back in WWII residents in the UK blacked out their windows to prevent German bombers from seeing the houses from the air at night. They covered them with thick curtains and other materials so that the lights they had didn’t show outside of the houses. Just a few people not doing it would have made our cities easy targets.

This is how they did it in WWII, a big campaign with posters such as this:

WPA Blackout poster

Blackout (wartime) - Wikipedia

So no, you don’t have to be born in an Asian culture to be able to follow orders!

That is just an ethnic stereotype that some in the West have. It is not based on reality.

Of course most European countries are continuing to do the testing, case finding, quarantine, contact tracing and isolation through to many thousands of cases. So far only the UK and Netherlands have given up on this.

And yes you can enforce self isolation in a free country. Liike many countries, UK already has legally enforced self isolation - at least it did until this switch from the contain to the delay phase.

Italy also enforced lock down, with the military standing in as extra police to guard the locked cities and this also is permitted in a free country.

A free country can enforce self isolation when there is a clear danger to society of them leaving the self isolation. It can certainly do that for COVID-19.

It can't enforce quarantine on people who might well just have a cold or 'flu .

We need to TRY before giving up. Where is the legendary British "Fighting spirit"?

The UK were doing case finding and contact tracing until they decided to switch to the delay phase. So it is NOT impossible to do in a free country.

You don't have to have 100% success. If only a few people avoid the quarantine then you still are reducing the amount of transmission to the next round of casese and if you can reduce that by, say, 75% it will soon stop.

But at least some in the UK who read the BBC news may now be becoming aware of what the WHO has been saying all along, probably for the first time.

WHAT DO YOU THINK?

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Do comment with your thoughts on this.

Also please say if you spot any mistakes in this article however minor and I will fix them. Thanks!