Covid Plan B

1 May 2020

Simon Thornley

With much journalistic ink spilled over Covid-19 it is easy to forget that our policies of lockdown and social distancing are based on a belief about the lethality of the virus and its spread.  This belief comes from interpreting evidence. Currently, two main ideas predominate. Although the government has not stated it explicitly, their elimination policy now indicates that Covid-19 cases are contained, and that the virus can be put back in the box. This optimistic picture starkly contrasts with more convincing evidence from overseas that the virus is now well and truly out of the box, being now much more widespread than first thought. While this initially sounds terrible, it is instead good news, as it allows for a more relaxed stance toward the virus.

The government is now treating the disease in a similar fashion to how we have treated measles. Under this model, the vast majority of cases of infections have symptoms, the test is accurate, and we can contain the virus through contact tracing, quarantine and vaccination. This is a good model for infections that ‘declare themselves’ by causing unequivocal disease in cases and where vaccination is available.

The government has reused this model for Covid-19. Superficially, there is some justification, since community surveys of swab testing for coronavirus have all returned negative. The elimination strategy justifies harsh lockdowns which may be severe in the short term, but pay long term dividends. Under this model, the infection fatality proportion, that is the number of deaths divided by the number of people with infection, is (at the time of writing in NZ) 1.6%, well above seasonal flu (~0.1%), and justifies the ‘eliminate’ approach.

While this may sound attractive, several lines of evidence now indicate the virus often doesn’t ‘declare itself’ like measles, and is instead far more widespread than was initially thought. For example, in Iceland, a community survey of the population showed about 1% of the population tested positive for the virus from a nose swab, and about half showed no symptoms, despite the positive test results.

Information from antibody tests adds to the evidence that the virus has well and truly left the box and left its trail circulating in our bloodstream. After infection, the body mounts an immune response. After exposure, we produce antibodies as evidence that we have seen the virus. This blood test is quite different from the genetic nose swab that has so far dominated New Zealand’s ‘elimination’ thinking. The swab results only indicate the presence of the virus at the time the test was taken.

Antibodies give a contrasting picture from nose swab tests. Varying percentages of positive antibodies are reported, but the overwhelming picture is that many more people have recovered from the virus than has been appreciated. The percentage varies between 4% (Santa Clara, California) to 21% in New York city.

Why is this good news? Well, it indicates that exposure to the virus is about 50 to 85 times that observed from nose swab tests alone. In turn, this information dials back New Zealand fatality estimates to about 0.03% of all infected cases. This adjusted mortality rate is no greater than that for seasonal influenza. This is an important reality check on modelling figures which forecast carnage from Covid-19 equivalent to World War I deaths.

These antibody surveys are from overseas, and critics may argue that this does not apply to our New Zealand Covid-19 situation. Features of our Covid-19 cases, however, support the ‘out of the box’ idea. For example, in the recent measles outbreak, sourced from overseas, the majority of cases occurred in Auckland. For Covid-19, however, cases are much more dispersed around New Zealand, with 3% having no apparent link to overseas sources or other cases (44/1,461). In an effort to stamp the virus out, we will be hunting for needles in a very large haystack.

Since the disease is much more widespread than initially thought, then lockdowns are also unlikely to be effective at reducing spread. Recent evidence supports this idea. A comparison of US States showed that regions with social distancing were doing as well or even better on average for Covid-19 case or death rates than those that had a lockdown policy. Per capita cases and death rates were largely determined by a State’s population density – a factor New Zealand has on its side. While it is tempting to compare ourselves with New York, we have a population density more similar to Vermont, Arkansas, Oklahoma and Iowa. States with these population densities have death rates 95% lower than in New York, and are almost identical whether or not the State has locked down.

The government’s idea of a contained virus simply doesn’t gel with recent antibody surveys. The idea of elimination is scientifically unsound. The weight of evidence clearly illustrates that we are dealing with a virus that is more widespread and much less deadly than we feared. Evidence strongly supports us throwing off the lockdown shackles, safely returning to work and school, while doing our utmost to protect our most vulnerable in hospitals and rest homes.

29 April 2020

Gerhard Sundborn, Senior Lecturer Population and Pacific Health, The University of Auckland.

With Covid-19 bearing down on New Zealand, and fears of an overloaded health system and a death toll numbering many tens of thousands, the Government moved swiftly to implement a national lockdown. The magnitude of this threat is now being questioned by many epidemiologists and statisticians, here and internationally.

Although the lockdown was administered with the best intentions at heart, we at Plan B propose that the stringent five-week lockdown went further than necessary. Consequently, there are real questions to be asked about whether the benefits of the lockdown justify the negative social and health impacts. There is also doubt as to whether draconian measures such as lockdowns are any more effective than less severe measures such as social distancing.

Impact on Health Care Services

A clinician at a local hospital explained that they have been temporarily closed during level 4 and have been working out of a sister hospital nearby for acute patients only. When their hospital re-opens, to clear the accumulated backlog of surgical procedures and investigations it may take at least one to two years’ work including weekends to get back on track.

There are many reports of similar occurrences where hospitals around the country have reduced their provision of standard care and have been eerily quiet only operating at 50% of their usual capacity. The level to which life-saving and prolonging treatment and surgery has been either cancelled and delayed for many conditions including cancers, heart disease, diabetes, fertility, joint surgery and more need to be considered when weighing up whether the lockdown has been justified or has caused more pain, suffering and death than it has prevented and how much longer this can last.

In a recent communication the medical director for the Cancer Society feared that up to 400 cancer related deaths could be seen due to significant delays in diagnostic and treatment procedures resulting from the lockdown. Overseas evidence has shown that only half as many cancer diagnoses have been made during lockdown than normally expected.

Adding to this dilemma is the bizarre situation that many general practice clinics find themselves in where they may be forced out of business due to spiralling costs and falling revenue. One clinic explained that there are significant costs placed on GP practices in acquiring the right supplies in preparation for Covid-19 as well as a significant reduction in business from the lockdown. People have delayed seeking medical advice for less urgent ailments which has meant reduced income. People have also not sought treatment for more serious conditions for fear of becoming infected if they leave the safety of their ‘home-bubble’.

Short-term health and social harms

Domestic Violence – A surge in domestic violence as a result of lockdown procedures has occurred. In the UK, calls to helplines for domestic abuse increased by 25%, visits to their associated websites increased by 150% and cases of actual abuse soared. In China’s Hubei province during February domestic violence reports to police tripled. Regrettably, we (New Zealand) hold the title of having the highest rate of domestic violence in the developed world, meaning that we are not immune to this second ‘silent casualty’. Police statistics showed that just three days into lockdown (Sunday 29^th March) a 20% increase in reported cases of domestic violence. I am fearful to know what levels of domestic violence exist in our communities now – 5 weeks on. What do the victims – adults and children – go through and what impact will this have on their future? Added to this, some DHBs have reported rises in the number of drug and alcohol presentations to their Emergency Department and in cases of suicide.

Poverty – In the most recent Salvation Army Covid-19 Social Impact Report and Dashboard a number of measures are cause for concern, including the number of people and families that have become impoverished. The greatest increase was in the food security measure. In the third week of the lockdown, close to 6,000 food parcels were distributed. This is equivalent to what is usually distributed in one month.

Long-term health and social harms

Due to the impending economic downturn as a result of Covid-19, there are several negative health and social harms that are expected to continue over a number of years as a result of loss of jobs and higher poverty. The NZ treasury have predicted that unemployment rates could climb to twenty six percent.

At the individual level we expect increased:

• Use of primary and secondary care health services
• alcohol-related hospitalisation and death
• levels of chronic ill-health
• excess mortality from: circulatory disease; poor mental health; increased health harming behaviours; self-harm; and suicide

For families – studies have shown that following mass unemployment events there is likely to be increased:

• levels of divorce,
• conflict and domestic violence,
• unwanted pregnancy,
• levels of poorer spouse and child health,
• levels of financial hardship affecting parenting,
• strain of child mental health
• levels in lower educational attainment¹

For communities the experience of mass unemployment is likely to result in less social support networks and community participation, which add to a sense of grief, social isolation and a loss of community identity.

Level 2 Now

The negative implications from the lockdown on our lives as well as on the economy are causing damage that won’t be fully appreciated for years to come. This carnage is the result of business closures, job losses, rising unemployment and the stresses that go with it.

From a public health standpoint, we need to limit the social and health harms to our society, we need to move to ‘Level 2’ immediately. We will need to wrap stronger protection around hospitals as well as elderly care facilities and develop ways in which we can better support the elderly and people with underling health conditions who are living in homes with younger family members. These initiatives will need to be carefully thought out, developed and resourced appropriately. The vast majority of our population, including most working people, students and infants, face minimal risk from the virus and can safely resume normal life.

We need to get our society up and running again and open for business. Students need to be back at school and in tertiary education and all types of workplaces opened immediately.

The sooner the ‘lockdown’ can be lifted the more businesses and jobs that can be saved, the better us all. Unfortunately, the long-term impacts of the situation we find ourselves in will need to be worked off over many years and possibly decades by ourselves and our children and will shape our lives and society in ways that we are yet to fully appreciate.

25 April

Simon Thornley

The government is now cautiously opening schools, but many parents are reticent, fearing that their child will be exposed to the virus. Let’s take a look at we have learned about childrens’ risk of exposure to Covid-19 at school?

When thinking about the risk of death from Covid-19, it is important to appreciate that the risk is not the same for everyone. As our experience has made clear in the recent weeks, older people, living in resthomes are much higher risk of dying from the virus compared to all other groups. One’s risk of dying from the virus is about the same as our risk of dying that year given our age. This means that children of school age are extremely low risk for having severe complications from the virus.

In a systematic review of scientific studies relating to Covid-19 in children, the authors concluded that children had a much milder response to the virus than for adults. Of three children that required intensive care, all had severe underlying conditions. In one case-series in China, 90% of test-positive cases had no symptoms attributable to the virus. Of all children, infants are more likely to have severe complications.

One possible objection to returning to school is that adults could catch the infection from children. While this is possible, an analysis of cases from Shenzhen, China, shows that attack rates are higher in older adults and the majority of transmission occurs among household contacts. Modellers have concluded that school closures are unlikely to be an effective strategy for halting Covid-19. New Zealand has had a cluster of about 92 students at Marist College in Mount Albert, Auckland. The first identified case was a teacher and 12 students have subsequently tested positive. The majority of cases have been adults and at the time of writing, 79 cases had recovered.

In New Zealand, there is little evidence of risk from spread of infection in children. According to the Ministry of Health, at the time of writing, there were 18/344 or 5% of New Zealand’s active cases in people    under the age of 20 years. Overseas data shows that immunity to the virus is building in populations that have been tested. It is very sensible for the government to open schools. I believe that this will help build higher levels of immunity in children to act as barriers for the spread to elderly and those with pre-existing medical conditions. These people are the ones we really want to protect from the virus.

As a scientist I am trained to think critically, to evaluate evidence, and ask questions – lots and lots of questions. That’s my job. In March 2020 the World Health Organization predicted that 3.6% of those infected with COVID-19 would die. New Zealand’s own modelling predicted 80,000 Kiwis would die. These numbers seemed extraordinary to me. If they were accurate the impact of COVID-19 would be enormous. But, as I delved deeper, I began to question the accuracy of the predictions. At the time, the infection fatality rate was calculated as the number of COVID-19 deaths divided by the number of confirmed infections. As a scientist, that seemed overly simplistic. Surely many more people would have caught COVID-19 than had been officially tested? If correct, that would lower the predicted fatality rate dramatically. So I began to do what I’m trained to do: think critically, evaluate evidence and ask questions.

What I found was analysis and perspectives I had not been exposed to in New Zealand. John Ioannidis, Professor at Stanford University, and one of the world’s leading physician-scientists, was particularly vocal. The data collected on how many people had been infected (and used to model the fatality rate) were “utterly unreliable”. Not only was there no reliable evidence for “draconian countermeasures” like lockdowns, but if enacted, the measures would themselves lead to significant long-term social and health harm. His concerns were echoed by Sucharit Bhakdi (Professor Emeritus, Johannes Gutenberg-Universität Mainz, Germany) as well as many other eminent epidemiologists around the world. Why had I not heard these different arguments and perspectives in New Zealand? Where was the balanced debate?

On 31 March Dr Simon Thornley, an epidemiologist at the University of Auckland, published an article entitled “Do the consequences of this lockdown really match the threat?” His questions and concerns about the data resonated with me. It turned out I wasn’t alone. Simon received emails from across New Zealand with similar and related concerns. What impact would the lockdown have on mental health, rates of suicide, long-term unemployment, and poverty? What were the legal and ethical ramifications? The list of questions went on.

Last week our cross-disciplinary group of academics published COVID Plan B. Our aim is to get those different arguments and perspectives heard, expand debate and provide a pathway out of lockdown. We want to help New Zealand navigate its way through this pandemic in a way that mitigates its impact on all kiwis. But, while we have received considerable positive support from concerned members of the public, we have also received criticism because of our desire to widen the debate. We have been criticised, for example, for not focusing enough on the elderly or vulnerable. You may wish to read point’s 2 and 4 of Plan B to learn otherwise. To offer a different perspective is apparently now to be ‘contrarians’: people to be dismissed as outside the scientific consensus. I assume, by association, that Professor Ioannidis and those many eminent epidemiologist are also ‘contrarians’? As Michael Crichton (MD Harvard and author) says…“the work of science has nothing to do with consensus. Consensus is the business of politics… invoked only in situations where the science is not solid enough”. Some commentators and scientists have even suggested that we should remain silent and toe the line. This attempt to stifle debate and marginalise those who offer a different perspective on one of the most important issues of our time is deeply worrying and has more in common with political activism than science.

We must never stop interrogating and adapting our COVID-19 strategy. We should, at all times, be open to new analysis, different perspectives and vigorous debate, however uncomfortable that makes us. Different perspectives should be welcomed, not castigated. There can be few decisions in history that would not have benefitted from different perspectives and wider input. No one is well-served by groupthink. As Galileo said “In questions of science, the authority of a thousand is not worth the humble reasoning of a single individual.”

Dr Michael Jackson is a postdoctoral research at Victoria University of Wellington.