This is one of the biggest differences between the UK policy and the WHO recommendations. The UK think that Covid19 is very infectious like flu, and only for a very short time and that if you have it then likely everyone in your house already has it or will get it soon.
But the data from China and now many other places is the opposite. Covid19 is mildly infectious for a long time. It can be infectious through to death if you die and up to two weeks after recovery if you recover.
If you catch it early, often nobody else has got it from the first case. This story is often in the news - couples where one has it and the other doesn’t. Prince Charles got it for instance, and his wife Camilla didn’t get it.
China found that if you isolated people from their families as soon as it is detected, this saves many lives. Family members often infect each other gradually over weeks.
In one province, 80% of their clusters were the result of leaving people to try to isolate at home, until they changed this policy.
You can isolate at home, separated from everyone else in your household, if you take great care and the home is suitable. However, the WHO advise this only as a last resort if there is nowhere else to isolate.
WHY YOU SHOULD WANT TO BE ISOLATED FROM YOUR FAMILY IF YOU GET THIS
So - if you start coughing, it might be just a mild thing for you, cough for a few weeks, slight temperature for a day or two. But a week or two weeks later or even a month later, you are over it but still coughing, and still infectious (it is infectious for a very long time).
Eventually your mum or dad or granny or grandpa or sister or brother starts coughing. It seems mild to them too and most of them are fine (4 in 5). But for 1 in 5, in their second week they start feeling breathless.
At that point they should contact medical help immediately. If they realize they need help they phone the NHS111, go to hospital and this is life saving. Some don’t and may die at home if they are unlucky.
Most who go to hospital recover, but if they continue to deterioriate, they might end up on a ventilator or even die. If on a ventilator they may be unconscious for several weeks of their life depending on machines for every breath they take, and take months to regain full use of their lungs so they are no longer breathless after activity.
For most it is mild but for 1 in 5 it is way worse than flu, for 1 in 20 they may need a ventilator and for 1 in 100 you die
Text (for those who don’t read English):
Simpsons - UK policy all stay at home
Day 1 Homer tests +ve
Day 10 Margo +ve
Day 15 Grampa +veDay 24 Grampa in hospital
Day 50 Grampa diesSimpsons - WHO advice Isolate mild cases
Day 1 Homer +ve COVID-19
Homer isolates to hotel in Springfield with other mild cases
Nobody dies.Nearly all other countries do this
I got the Simpsons screen grab here: The Color Yellow – Dead Homer Society
Do you want to risk your Mum, Dad, brother or sister, grampa or gramma getting this disease?
This is not flu.
The top priority as soon as you start to get your cough or fever, according to the WHO happens is to isolate you from the rest of the household.
It is what everyone should want to do if they had been educated properly about Covid-19.
This is not rocket science. It is basic public health.
Case finding, contact tracing and testing, and strict quarantine are the classic tools in public health to control infectious diseases. WHO says they have been painstakingly adopted in China, with a high percentage of identified close contacts completing medical observation. In Singapore, Vietnam, and South Korea meticulous contact tracing combined with clinical observation plus testing were vital in containing the disease ....
The reasons why tracing was stopped, against WHO recommendations, have not been published. It seems to be connected to a shift from “contain” to “delay” in the government’s action plan, when contact tracing was replaced rather than supplemented with other control measures.
CHINA SEPARATED THEM COMPLETELY FROM THEIR HOUSEHOLDS IN TEMPORARY WARDS
So - this is to protect the other family members and stop the spread. Those big wards of hundreds of beds - the normal wards without ventilators in China were to isolate mild cases. This was part of the key to their success. This is also the main thing that other countries often fail to do, especially early on in their outbreaks.
You can see from this image - these aren’t intensive care units. There is very little equipment in them. Just beds and privacy barriers. Minimal medical equipment - because they didjn’t need it. Image from the Xinhua News Agency - I got it from this story:
COVID-19 | Wuhan closes makeshift hospital as new cases in China drop sharply
This is a temporary ward set up in a Stadium in Wuhan for the mild cases another photo showing what it was like inside with close ups of the beds and some patients here: Nearly all of China's new coronavirus cases outside Wuhan from abroad
The main job of the nurses was to prevent them geting bored. These are mild cases, so they don’t feel that ill, just like flu. Some might not feel ill at all, presymptomatic, but tested positive and so have to be isolated from their families.
They would monitor them, regularly take temperature, also check in case they had breathlessness or some other symptom to go to the main hospital.
CHINA AND ITALY BOTH TRIED GETTING PATIENTS TO ISOLATE AT HOME - BUT THEY STARTED UP NEW CLUSTERS
China tried getting people to isolate at home, early on in their outbreak. It backfired badly.
According to Xiao Ning, a researcher from the Chinese Center for Disease Control and Prevention, in one province, 80% of the cluster infections came from people who were told to rest at home.
The same happened in Italy early on, they found growing evidence that if one person is told to stay at home they gradually infect the rest of their family.
So, Milan started to seize hotels for patients with mild symptoms.
Home isolation of mild COVID-19 cases is a mistake: China to Italy
UK NEEDS TO DO THIS, GET OUR MILD CASES OUT OF HOUSEHOLDS
We need to do this. In some cases they can be isolated in households but this needs them to be rigorous isolation, for instance, both patient and carer needs masks (the only situation where the WHO recommends masks for the general public) and they need to be scrupulous about hygiene and physical distancing - more about this below
If the ward space is available the WHO say it is far preferrable to keep the mild cases separated in a COVID-19 ward. You only isolate at home as a last resort if the health system is so overstretched you can’t even house them in stadiums or hotels or community centers.
If you do isolate at home, a clinician visits your home inspects it and asks you questions to check it is suitable, and they say you need to be monitored too. Typically someone will ring you every day to check how you are doing and make sure you haven’t developed any symptoms that mean you ned to come urgently to hospital.
But the UK isn’t listening to either China or Italy, and is making the same mistake again here. It’s not even testing the mild cases at home.
At least if it was a mistake in China and in Italy - surely it is a mistake here as well?
NEED LONGER ISOLATION PERIODS TOO
Prince Charles is out of isolation now - and according to the WHO he is still infectious (unless he gets two negative test results 24 hours apart).
Prince Charles & Camilla share a laugh - photo by Andy Gott
Text: Prince Charles got COVID-19
Camilla did not get COVID-19
But 7 days isolation is not enough (by WHO) so he could still be infectious and she could still get it (unless they did the -ve tests)
Of course I very much hope this doesn’t happen, but if he is indeed still infectious he could still give it to her. It is the same for Matt Hancock, our health secretary, out of isolation after 7 days. He also is still infectious unless he has had those two -ve tests, and I don’t think they do them.
This may seem surprising for flu - but it isn’t flu. SARS was infectious typically for three weeks. COVID-19 seems to be infectious for even longer.
IF YOU DON’T HAVE IT YET TWO WEEKS INTO THE LOCKDOWN YOU LIKELY DON’T HAVE IT IN YOUR HOUSEHOLD
If your family is locked away from anyone with COVID19 then you won't get it, not if you never see any other family that has it.
A lot of households will be in this situation - so for them this lockdown is working, it is reducing their risk of getting it.
As for getting it in a supermarket or the street - this is very rare for COVID-19 even without any precautions - again this is NOT flu.
To be super safe, keep to good hygiene, keep physical distance of anyone who is coughing, sneezing, laughing or talking to you, and wash your hands before you touch your eyes, nose or mouth. Then you are very protected from this virus.
How To Protect Yourself From COVID-19 - And Help Stop The Spread
BUT IF ONE OF YOU HAVE IT
But if one of your members already has it at the start of the lockdown, then as the lock down continues for weeks on end, it can spread to the others in your household.
After one person gets it, eventually over weeks, everyone in the family has it, like Granpa Simpson.
To stop that you need to be very careful about isolating the member(s) of the family who may have it. It might not be too late. If grampa or gramma doesn’t have the symptoms yet, you may be able to stop them getting it.
ISOLATION AT HOME
The UK government is advising people to isolate themselves from any vulnerable person in the house.
The Scottish branch of the NHS goes further than this. In Scotland ALL people who have COVID-19 like symptoms are advised to isolate themselves from EVERYONE ELSE in the household - to isolate from the rest of the household with separate cutlery etc.
But both of them fall way short of the advice of the WHO. Neither of them link to the WHO recommendations.
According to the WHO, patient and carer both should wear clinical masks if possible, and know how to use them. This is the one situation where the WHO say that members of the public should wear medical masks. They also should stay in a separate bedroom and use a separate bathroom
[obviously if you have only one bathroom you won’t be able to do that, but they can use it after everyone else and then wash it thoroughly, the best you can do given there is nowhere else for them to be in the UK]
The carer of course uses all the usual hygiene precautions and wash their hands thoroughly after contact e.g. after going into their bedroom.
Some countries have expanded their capacity by using stadiums and gyms to care for mild cases, with severe and critical cases cared for in hospitals.
Another option is for patients with mild disease to be isolated and cared for at home.
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.
WHO Director-General's opening remarks at the media briefing on COVID-19 - 16 March 2020
You can find the detailed advice here:
But this is how it should be done if we were doing it properly - you would have a health care worker who visits your house and assesses if the setting is suitable, and the patient and family are capable of adhering to the precautions.
In cases in which care is to be provided at home, if and where feasible, a trained Health Care Worker should conduct an assessment to verify whether the residential setting is suitable for providing care; the Health Care Worker must assess whether the patient and the family are capable of adhering to the precautions that will be recommended as part of home care isolation (e.g., hand hygiene, respiratory hygiene, environmental cleaning, limitations on movement around or from the house) and can address safety concerns
They would also keep monitoring your situation - someone would ring you up every day to check your condition, that it hasn’t got worse, and to see if you need any help or new advice.
CONTACT TRACING
Isolating people once they have symptoms finds most of them eventually, if they are educated as in China to report for testing and you have the tests available. But it still can take three days on average from start of symptoms to be tested.
Then, a few are infectious for a few days before you get symptoms and many are infectious early on when they just feel a bit unwell and tend not to realize it iw
This is why you do the contact tracing, and the quarantine. The quarantine is to catch the presymptomatic cases or the early ones with symptoms to cut transmission from them to anyone else as soon as possible.
Text: With contact tracing
Day 1: Barney has Covid-19. Doesn’t know. Homer gets itDay 3: Berney tested. Homer traced. Homer quarantined. Nobody else gets it.
The UK government did this through to 11th March but don’t do it any more.
E.g. when Boris Johnson got it, they should have quarantined almost the entire cabinet for 14 days as well as everyone in 10 Downing street that had close contact with him.
They would have had to continue via video conferencing.
Even now, if we test everyone in the UK with COVID-19 symptoms, isolate them all from everyone without COVID-19, and quarantine all their contacts, then we could soon start a slow unwinding of the lock down and the rest of us could gradually return to normal life.
Life is more difficult for those in isolation, but it protects everyone else. The mild cases get the right treatment, and the close attention they need.
The mild cases should want to do this because the people who are close to them are protected from them if they didn’t get it yet.
The country as a whole can slowly resume business.
PRECIOUS WINDOWS OF OPPORTUNITY NOW CLOSING - BUT NOT CLOSED YET
The WHO say that these precious windows of opportunity are closing around the world.
The window for containing the virus at the subnational and national level is closing in many countries. The infection numbers in Africa are relatively small now, but they are growing fast.
WHO Director-General's opening remarks at the Mission briefing on COVID-19 - 9 April 2020
But it’s still not too late to stop this. He says they are closing, not that they are closed.
Tens of millions of people in the UK don’t have COVID-19 and some areas have few cases.
These are the confirmed cases as of writing this. Since they don’t test mild cases at home, these figures probably should be multiplied by five as only 1 in 5 of COVID-19 cases need hospital treatment. For instance if it says 250 cases, the likely number is more like 1,250. and for 500 cases the likely number is 2,500.
This data also underreports because since people at home are not monitored some may be unaware of how serious it is when they get breathless and try to manage this at home, when intervention can save their life. Also those who die at home or in care homes are not currently tested for Covid-19 even if they had the symptoms.
You can look up the latest numbers here:
How many confirmed cases are there in your area?
ALTERNATIVE TO CONTACT TRACING
The alternative here is to test absoluely everyone. That is useful for clearing a hospital, say, once you discover an outbreak - keep testing until you find everyone including the presymptomatics and it will soon be over. That way you catch the presymptomatics most likely before they have infected anyone else too.
But it’s hard to keep up so many tests with our limited testing so far in the whole country.
The contact tracing is a way to greatly reduce the number of people to test and if you can, you keep retesting all the contacts, and if not, you test them only if they develop a fever. The Chinese kept retesting many of the contacts every day - they built up a vast testing capacity during the outbreak - and that’s how they found the presymptomatic cases.
The small provincial town of Voe Euganeo did do it by testing everyone, symptomatic or asymptomatic, and they got it down from 3% to 0.3% with it in 14 days and had no new cases after that. So if you can do this, if you have the testing capacity to do it, it can be very fast indeed.
It’s now being done in a small Italian village of Nerola with 77 cases, under lock down, and it will be interesting to see what happens to the cases there when they test everyone, symptomatic or asymptomatic, and isolate the cases (which of course they will do in Italy) and then track what happens next.
Text: Alternative to contact tracing. Test everyone. First done in hospitals. Then in Vo Euganeo. Now in Nerola.
To do this for a country the size of the UK we’d need millions of tests a day. Not impossible but big ramp up.
It is well practical to use this method for a hospital.
Smaller countries can try it too. Iceland is testing anyone who wants to be tested, with or without symptoms. I talk about this in my
LOCK DOWN PERFECT TIME TO DO THIS CASE FINDING - AND THAT’S HOW TO EXIT FROM LOCK DOWN
The WHO say case finding, isolation, teating the cases, contact tracing and quarantine is how to safely exit from a lockdown.
Also, a lockdown is a perfect opportunity to do this thing, which then has a huge effect in suppressing the virus.
This is the main thing the UK are not doing along with also not testing hospitals, care homes, prisons etc to find the virus and separate the people who have the virus away from the health care workers, patients, social workers, and other residents.
Don't do those things and our lockdowns have some effect but it is still there, even if the cases per day go down, and as soon as you release the lock down it flares up and it just delays the problem.
You also get more and more people getting sick in families during the lockdown and in hospitals, care homes etc.
On the other hand, if you do these things and you can end the lock down much faster and many fewer people die.
Many in the UK may not know what the WHO recommendations are, or may have forgotten them, so here is a brief summary, with links to the technical details of their recommendations:
Our real priorities for COVID19 according to the WHO
- Test all suspected cases for COVID19, isolate them while waiting for the test, and quarantine anyone who has it.
- Trace all contacts of confirmed cases from 2 days before onset of symptoms. Ask all contacts to isolate themselves until 14 days after the contact
- Test all contacts for COVID19 if they show any symptoms.
- Quarantine anyone who has it until 14 days after they get better.
- Physical distancing is a defensive measure. All it can do is to buy us time. We can’t win without going after the virus
This is how Dr Mike Ryan put it in the press conference on Monday 22nd March.
All that we get from movement restrictions and people staying at home and all of these measures; we buy some time, we take the heat out of the epidemic or the pandemic, we buy some time.
… one of the key ways we can move forward is a massive scale-up - in public health capacities to do case finding, isolation, quarantine of contacts and being able to go after the virus rather than the virus coming after us
There is a very, very precious window now in which we can prepare to do that.
Also
You can't win a football game only by defending. You have to attack as well.
Asking people to stay at home and other physical distancing measures are an important way of slowing down the spread of the virus and buying time – but they are defensive measures.
To win, we need to attack the virus with aggressive and targeted tactics – testing every suspected case, isolating and caring for every confirmed case, and tracing and quarantining every close contact.
THIS IS A WAY TO GET THROUGH THIS WITH FAR FEWER DEATHS
We will get over this one way or another but we will have far fewer deaths if we aggressively go after it in households like this.
The UK are not doing this because they are basing their policy decisions on a simulated flu virus.
See my
Text: UK stands resolute on COVID-19 but policy comes from table for a SIMULATED flu pandemic with almost no input from not real world data
For more about this see my:
Also my longer:
If the real virus was like their simulated virus the UK strategy would make some sense, and the strategy the WHO recommend wouldn’t work.
But we know that what the WHO recommends works, from China, Singapore, South Korea now Spain, and Italy - and we also know from the data that this real virus is not transmitting like their simulated flu.
Wth the real world disease contact tracing is the key to it all. This is what I keep writing all these articles about. To try to get someone in the UK to recognize this.
All this is not rocket science. It is just looking at what has worked for other countries and concluding, if it worked for China, South Korea, Singapore, Spain, Italy, it will work for us.
Mike Ryan put it like this:
In some senses transmission has been taken off the streets and pushed back into family units. Now we need to go and look in families to find those people who may be sick and remove them and isolate them in a safe and dignified manner so that's what I was saying previously; the transition from movement restrictions and shut-downs and stay-at-home orders can only be made if we have in place the means to be able to detect suspect cases, isolate confirmed cases, track contacts and follow up on the contacts' health at all times and then isolate any of those people who become sick themselves.
who-audio-emergencies-coronavirus-press-conference-full-30mar2020.pdf
It is SO frustrating. We are working so hard on it. We have done such huge things, made many sacrifices, closed down businesses, schools, universities, had the Queen’s speech to tell us all we will get through it. People are pulling together in remarkable ways to help each other and get through it.
We are doing everything except isolate the mild cases. Also this is not for any political reason. It’s not economics - the case finding and isolation woudl be much less costly.
The only reason we don’t do that is because of a bit of maths that is telling our government what to do instead of the real world data.
I trained as a mathematician - I have a good first class degree in maths. I know that maths like that is not the real world. It’s just maths. Whether it fits the real world depends entirely on whether the data that it is based on matches the real world data. And just looking at this - it doesn’t match. Not only in some detail. Just about every feature of this model does not match the real world data.
At least here in the UK we need to debate this. Why did our COVID19 response team stop using these standard health measures of case finding, isolation, contact tracing and quarantine?
What is their evidence base for ignoring the WHO recommendations?
They need to not just explain it to us. They need to hash it all out urgently in a debate with the top experts with direct knowledge of the experimental data.
I suggest they should explain all this in public to some of the 13 experts who visited Wuhan at the height of the outbreak in China such as Bruce Aylward.
Also to others - have a wide range of selected experts who have experience in fighting epidemics, who know about the real life characteristics of COVID-19. And they have to answer awkward questions from them about the evidence basis and how reliable and accurate their model is for guiding UK policy.
DETAILED ANSWER ABOUT EXITING FROM LOCK DOWNS BY MIKE RYAN
Good evening or good morning. I'm from BFM Radio Malaysia. My question is, many countries around the world have imposed lock-downs or some sort of restrictions on movement. I was wondering what WHO's guidance would be; what's the sweet spot, the kind of data that governments need to consider before lifting or relaxing some of these lock-downs? Thank you very much.
00:34:29
MR Thank you. It is a difficulty for governments right now because the lock-downs in many situations are proving effective in dampening the flames of the epidemic in those countries but those lock-downs are also causing great economic hardship and everybody especially in the developing world needs to get to a more sustainable way of managing this epidemic and controlling COVID-19 without continuing to damage economic and social life.
The transition strategy out of lock-down requires a calibrated, step-wise approach. It would be probably very inadvisable just to lift a complete lock-down, all of the measures because lock-downs are a general term that include closure of schools, closure of churches, stay-at-home orders, closure of workplaces. It's a mixture of different things and I think each government needs to break out, what does our lock-down actually constitute, what are the elements of our lock-down, where is that happening in the country, do we now understand the epidemiology of the disease in each area in which we have an element of lock-down or shut-down.
Then to chart the path out, you have to build strong public health capacity to take over from the lock-down. In other words the lock-down is pushing the disease down by putting people back in their homes, by separating communities. Once you raise the lock-down you have to have an alternative method to suppress the infection. The way to do that is active case finding, testing, isolation of cases, tracking of contacts, quarantining of contacts and strong community education and participation and ownership around normal physical distancing, hygiene and giving communities the power to control infection by in effect managing their own physical distance, managing their own capacities to support the response.
00:36:32
In that situation, if you've strong public health capacity, if you've got a community that's mobilised and empowered and if you've strengthened your health system then you're potentially in a position to start unlocking or unwinding the lock-down. The specific parameters you need to be looking at are on two sides.One is, it would be very inadvisable to lock down if the number of cases coming through the hospital is already at a level where your occupancy of beds is nearly at 100%. You need to be in a position where you now have free beds in your system so that you're managing and coping with the caseload and that means you have some absorption capacity left.
You need to look at things like the doubling rate; how many days does it take for the number of cases to double? You need to look at positivity rates; what proportion of all samples that we test are positive? You'll see in somewhere like Korea two to 6% of the samples they test are positive. Last week in New York 37% of tested samples were positive so you need to carefully look at what proportion of people you test are positive.
00:37:45
You need to look at the number of contacts that are generated per case and it goes on and on and WHO will be issuing guidance to countries that is a much more specific around the parameters they should be looking at. There are no absolutes here, there are no answers, there are no numbers that say if this number is this then you do that. That doesn't exist but what we can do is offer countries very specific measurements that they need to look at to chart the path out of lock-down.
That step-wise approach of unlocking somewhat and then waiting to see; I think you need to say, we will stop doing this element of the shut-down and then we will wait and we will look at the data and if that works we go to the next stage and the next stage. So a careful, calibrated, step-wise exit from lock-down with putting in place public health capacities, putting in place community capacity, building the capacity of the health system to cope should the disease bounce back up; that's the safe path out of lock-down.
We want to achieve it as quickly as possible and we want to avoid many countries going into that circumstance and we still have many countries around the world who are not in a locked-down situation. In fact their epidemiology would suggest they can avoid the worst of this and we need to support them to avoid them going into that situation.
The most damaging lock-downs are in many developing countries where people -as the DG has said many times -can live from hand to mouth, not from pay cheque to pay chequebut from day to day and we have to find adaptive solutions around lock-down and around disease control in vulnerable periurban populations living in poverty, in poor rural communities. We have to find alternative, adapted ways to manage lock-downs or slow-downs or shut-downs in those situations.
WHO Emergencies Press Conference on coronavirus disease outbreak - 6 April 2020
See also my
Also remember you can protect yourself.
How To Protect Yourself From COVID-19 - And Help Stop The Spread
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