covid-19 – Do panic?

As far as I can make out there is no current plan for containing the second wave in Victoria. The effective reproduction rate is clearly still above 1, two weeks after returning to stage 3 restrictions but no plans to lower it have been announced.

The continued exponential growth is not unexpected since cases in the second wave are driven by “community transmission” from sources that remain unknown after contact tracing and consequently cannot be isolated. The first wave was mainly seeded from overseas and was contained with only a low level of untraceable community transmission remaining. Contact tracing was able to keep up when contacts were restricted by stay at home orders. But with restrictions lifted while transmission continued it is much harder to suppress the second wave. It is likely to require stronger restrictions as well as take longer, but no such plans have been announced yet.

The Australian Medical Association called for stage 4 restrictions nearly a week ago:

https://mobile.abc.net.au/news/2020-07-17/coronavirus-australia-live-news-covid-19-victoria-nsw/12464550

Instead of a plan there were three announcements today:

  1. First, there was an announcement about a future announcement. There will soon be an announcement about paying people who cannot afford to stay away from work while waiting for test results so that they can afford to do so. Obviously necessary but there is no more reason to expect workers in precarious jobs to quickly change their responses as a result than there is to expect a governent to take such an obviously necessary measure less than 3 months after a pandemic begins.
  2. Second, instead of a plan there was announcement today that the government is concerned that 90% of people who get tested because of having symptoms are waiting 3 days from onset of symptoms and half of those tested are not remaining isolated while waiting for results.

That does drive transmissions since it is well established people are most infectious for the few days immediately before and after onset of symptoms. The successful response to that has been extensive health monitoring and testing with immediate isolation in separate facilities, as in China (including HK and Taiwan). No other response has been shown to work.

Nobody has ever claimed that mere speeches at press conferences could possibly have a major impact on the predictable and expected delay between symptom onset and testing nor on the likelihood of people isolating themselves when they have got tested as a result of appeals to do so rather than with an expectation that they actually have the disease.

  1. Third, instead of a plan there is an incoherent press release about face coverings (with an exception to encourage people breathing heavily as they run past others to continue doing so). This press release has not even been turned into an enforcable “direction” but has been accompanied by a $200 penalty for “failing to comply with a requirement in relation to a face covering”.

https://www.dhhs.vic.gov.au/face-masks-covid-19

https://www.legislation.vic.gov.au/as-made/statutory-rules/public-health-and-wellbeing-amendment-further-infringement-offences

Recommendations to use cloth face masks were accompanied by instructions on how to sew one yourself on 20 July:

Click to access Design%20and%20preparation%20of%20cloth%20masks%2010%20July.pdf

Actually organizing supplies of cloth masks, should be easy compared with supplies of effective PPE such as P2 or N95 disposable masks. Instead, national stockpiles of PPE are being released to hospitals and aged care facilities to cope with the inevitable supply chain difficulties resulting from panic buying by the public in response to a panic announcement that use of masks would be compulsory from midnite tonight.

Cloth maks are of course even less effective than the surgical masks that health and aged care workers have been stuck with. They simply don’t adequately prevent aerosol transmission in confined spaces. Recent evidence indicates such aerosol transmission is more significant than previously thought.

Being in the same room as a confirmed case for more than two hours already makes one a “close contact” subject to mandatory 14 days quarantine. That was true when aerosol transmission was considered less important. Confined spaces encourage droplet transmission both direct from face to face and via face to hand to surfaces to hands to faces. Cloth masks and ordinary surgical masks can both reduce droplet transmission and should have been made compulsory in all confined spaces long ago (with cloth masks as merely a “better than nothing” expedient while supplies of disposable surgical masks were ramped up).

But a serious response to evidence that aerosol transmission is more important than previously thought cannot involve either cloth masks or standard surgical masks. It would require very strict controls enforcing effective PPE both on public transport and in workplaces (including schools) since crowding people into both results in breathing each others aerosols in confined spaces. That is radically inconsistent with the national policy of opening up the economy instead of first eliminating community transmission. It would involve prohibiting the use of cloth masks or surgical masks and requiring the correct use of effective diisposable PPE (N95 or P2 masks or Positive Air Pressure Respirators).

Mandatory cloth masks have been openly introduced in both the UK and USA to to reassure people that it is safe to go to work and school and shopping when it isn’t.

The stated reason for following the catastrophically stupid UK and US policies here is in response to a Lancet article published:June 01, 2020:

“Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis”

https://doi.org/10.1016/S0140-6736(20)31142-9

That article did systematically review a large number of previous publications and confirmed the well known fact that PPE is essential in health care settings. It did not shed any light whatever on the public policy issue of whether mandatory cloth masks would have greater benefits in making people more situationally aware and increase compliance with physical distancing and hygiene measures or whether it would do more harm by tending to reassure people that it is safe to enter crowded public transport, workplaces and shops etc. In healthcare settings cloth masks are used only when supplies of proper PPE are unavailable.

It is inherenty difficult to be sure about the effects outside healthcare settings. The evidence actually available is confounded by the likelihood that people who do wear masks when they are not mandatory are more cautious generally and therefore less likely to give or receive infection. The UK government may find people are not as reasssured as they hope.

But the only serious medical advice is that WHEN you are unable to maintain physical distancing AND you don’t have effective PPE, a cloth mask is better than nothing. Presenting that as though using cloth masks can substitute for greater restriction of physical distancing is purely cynical.

The Lancet study had no relevant information about likely effects of mandatory use. In fact it listed only one paper that was actually about Covid-19 and was not about healthcare settings. All the rest were either about other coronaviruses or about healthcare settings. The relevant paper was:

“High transmissibility of COVID-19 near symptom onset”.

medRxiv 2020; published online March 19:

https://doi.org/10.1101/2020.03.18.20034561

The title accurately describes the content. That title is the most important fact about COVID-19 that distinguishes it from other pandemics.

The implications of that fact are starting to sink in.

A debate is now starting about whether to attempt Elimination instead of the obviously failed current strategy. (The term “Eradication” should be avoided as impossible until a global vaccine whereas Elimination might be possible with strict border controls for island countries like Australia and New Zealand).

If it does turn out that the current second wave in Victoria is entirely or even just largely from strains of the virus that were not in circulation before the ending of stage 3 restrictions that will be fairly conclusive evidence of the bankruptcy of current policies to “Adapt and Control” (and claim to “Suppress”).

It would imply that elimination was feasible in Victoria since the previously existing small levels of community transmission had been eliminated in Victoria just as in New Zealand, Western Australia, Tasmania etc. It would also imply that the “slow and careful lifting of restrictions” was in fact completely fragile since it had been able to rapidly produce a second wave.

Unfortunately advocates of an elimination strategy are not explaining clearly how hard it will be and what sort of measures are required.

Elimination first requires greatly prolonging restrictions for enough weeks and months after zero cases per day until there have been no new cases outside quarantine isolation for a month or so. Pretending that would be quick or avoiding the issue only helps opponents.

Pretending that Elimination would not be fragile and require major preparations against another epidemic is even more helpful to opponents. It is blindingly obvious that with the large majority of the population still fully susceptible to infection and an announcement that the virus is not circulating at all the conditions would be ideal for “normal” behaviour to resume and so for any new outbreak to become another epidemic exactly as before.

The following are necessary to prevent subsequent sporadic occasional clusters becoming outbreaks and then epidemics during the long period in which the overwhelming majority of the population remains susceptible because there is no vaccine:

  1. Tight quarantine isolation. That lesson has probably been learned although still not applied to “contacts” and people “waiting test results”. Absurdly, people considered likely to be infectious are still being encouraged to isolate at home and infect their households. I thought that idiocy was over when the AMA in Tasmania recommended medi-hotels and the Commonwealth Health Minister indicated being open to it. But it isn’t over. Police were used to confine infected people in “vertical cruise ships” to their cramped large households rather than escort them to safe quarantine accommodation.
  2. Massive continuous testing, especially for all workers in contact with the public (shops and schools as well as healthcare etc). That requires serious industrial effort to deploy test workers, equipment and supplies. Pooled tests can immediately expand the numbers by an order of magnitude without waiting for more equipment and supplies, but it still requires a major workforce for which there does not seem to be any current plan. More than an order of magnitude increase is required for continuous testing so large long term investments are necessary for capacity to produce equipment and supplies as well as to train staff. This should also be part of an effort to help other countries in a less fortunate situation.
  3. Rapid contact tracing. Basically not possible without mandatory use of tracking devices. Targets for manual contact tracing within 24 hours are not being achieved during stage 3 restrictions and could not possibly be achieved once restrictions are lifted following Elimination. It is unclear whether achieving those 24 hour targets would be sufficient to stop another outbreak anyway. Instant contact tracing is achievable only with mandatory tracing devices.

Manipulating people to “opt in” to trusting governments with mass surveillance was a cynical ploy rejected by a substantial majority. The tracking must be switched off whenever it is NOT a public health emergency and switched on only during sporadic outbreaks for the purpose of rapidly suppressing them.

6 thoughts on “covid-19 – Do panic?

  1. Arthur, I sent your article to OLO. The editor replied with the following, which you may like to respond to here. I can then forward your response to him, if you like.

    From Graham Young:
    “I only read up to the second paragraph but he is making a fool of himself at this stage of the article. The growth is not exponential and I suspect R0 is around 1, or less, given the extensive testing going on. Here is a graph https://www.bing.com/search?q=Coronavirus+trend+in+Victoria&tf=U2VydmljZT1HZW5lcmljQW5zd2VycyBTY2VuYXJpbz1Db3JI’vbmFWaXJ1c01MIFBvc2l0aW9uPVRPUCBSYW5raW5nRGF0YT1UcnVlIEZvcmNlUGxhY2U9VHJ1ZSBQYWlycz1zY246Q29yb25hVmlydXNNTDtjb3VudHJ5Q29kZTpBVVM7c3RhdGVDb2RlOlZJQztpbnRlbnQ6Q2hlY2tDb3JvbmFUcmVuZDthYm92ZW5ld3M6VHJ1ZTsgfA%3d%3d&hs=RJ4PCWd89D5xQlbA23g0bzYsY%2bzjmbfM1TQGLa7aCx8%3d&FORM=COVIDR

    “I’m no fan of the Andrews government, but this level of inaccuracy this early in an article doesn’t encourage me to read any further.

    “I don’t generally fact check articles, but in this case, with the stakes so high, unless you represent a political party or some sort of community group I’m going to be careful about what we publish”.

    Like

    • Thanks. Responded to in article. Graph bizarre and unintelligible when I looked but probably changes daily so I don’t know what he saw. I have given links from which he could look at the actual curves.

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  2. Hi Arthur, sent this to the OLO editor two days ago:

    “Just wondering whether you’d like to reconsider A’s article in light of today’s figures. If that’s not exponential, I don’t know what is.

    “Not sure if I sent you this by A, which he incorporated in his article, in response to you:

    “The current situation is that most public discussion is basically uninformed about epidemics and contact tracing.

    “See for example the comment on my last article:

    “The growth is not exponential and I suspect R0 is around 1, or less, given the extensive testing going on. Here is a graph” (linked to a search on Bing)

    “According to both the current Victorian guidelines (v23, July 10) and the National guidelines (SoNG 3.4) :

    “Estimates for the basic reproductive number (R0) of SARS-CoV-2 range from 2–4, with R0
    for confined settings, e.g. cruise ships, at the higher end of this range. Estimates of the
    effective reproductive number (Reff) vary from between settings and at different time points
    are dependent on a range of factors, including, public health interventions such as isolation,
    quarantine and physical distancing to limit close contact between people (5, 6).”

    “Reference to R0 instead of Reff indicates that the person making the comment could not possibly have an informed opinion as to whether the growth was exponential, even if they were looking at accurate current figures and were able to notice when the graph they are looking at is simply a Bing bungle.

    “Suffice to say that there were 0 new daily cases at the start of June, rising to a record of 459 before the end of July.

    “Technically that is an infinite rather than merely exponential increase. But a glance at the actual curves for the first and second waves in Victoria enables anybody with their eyes open to see that the second is already much larger and still growing faster than the “exponential” period of the first wave.

    “Many people have their eyes firmly shut. This does not prevent them from pontificating about what they “suspect” after looking up “trends” in Bing”.

    Like

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