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by alloneword » Sat Apr 18, 2020 10:30 am
Professor Johan Giesecke, one of the world’s most senior epidemiologists, advisor to the Swedish Government (he hired Anders Tegnell who is currently directing Swedish strategy), the first Chief Scientist of the European Centre for Disease Prevention and Control, and an advisor to the director general of the WHO, lays out with typically Swedish bluntness why he thinks:
by alloneword » Sat Apr 18, 2020 12:07 pm
..scandalous... ..What was the government’s strategy for dealing with nursing homes? It has been, up until the last couple of days, to make things even worse... ..one thing that stands out is that complete and utter abject failure to grasp the impact of COVID on care homes.
The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. On Thursdays, while others have been clapping the NHS, I have been clapping for the unsung heroes of this epidemic. The care home staff.
by alloneword » Sat Apr 18, 2020 12:13 pm
These prevalence estimates represent a range between 48,000 and 81,000 people infected in Santa Clara County by early April, 50-85-fold more than the number of confirmed cases. Conclusions The population prevalence of SARS-CoV-2 antibodies in Santa Clara County implies that the infection is much more widespread than indicated by the number of confirmed cases.
by alloneword » Sun Apr 19, 2020 11:09 am
Main Findings - February 2020:
Critical Care Beds
• There were 4,122 adult critical care beds open and 3,342 occupied, giving an occupancy rate of 81.1%. This is lower than the occupancy rate observed last month, which was 83.0%, and lower than in February 2019 (81.5%).
by alloneword » Sun Apr 19, 2020 2:59 pm
The intensive care unit is not the best place for all Covid-19 patients
Moral outrage about limiting medical treatment in some coronavirus cases is misplaced
David Oliver April 18 2020
The writer is an NHS consultant physician, a former vice-president of the UK Royal College of Physicians, and national clinical director for Older People’s Services 2009-13.
The UK’s experience of the Covid-19 pandemic has thrown up some controversial stories about the limits of medical treatment for infected patients who become dangerously unwell.
But doctors have been discussing death and dying with patients and families long before this crisis — and finding out their own goals and wishes. We have not just reinvented advance care plans for those who may not be capable of making decisions later on. Nor is palliative care to help people die with dignity and comfort a new invention for the coronavirus era.
National Health Service clinicians have documented “Do Not Attempt Resuscitation” (DNACPR) decisions and “treatment escalation plans” (about the level of intervention we provide for people at high risk of deterioration, as described in the NHS End of Life Care strategy in 2010) for years. There have also been for several years Early Warning Scores and there is now a National Early Warning Score to spot signs of deterioration.
We have always had to choose carefully which patients are most likely to benefit from a spell on an intensive care unit, with or without intubation and mechanical ventilation. None of this is new. Yet it is only now generating moral outrage.
In actions widely reported a few days ago, it was considered insensitive that a GP surgery in South Wales wrote letters to patients in high-risk groups urging them to consider DNACPR and “don’t convey to hospital” instructions. It was seen as equally ham-fisted for the Brighton and Hove Clinical Commissioning group to have written to local care homes suggesting all residents should be put in those categories.
But let’s distinguish poor choice of language and a depersonalising style of communication from the general principles. For many years there has been a need for us to have more advanced care plans for people living with life-limiting, long-term conditions or age-related frailty. And when people do pitch up in acute hospital care without such plans, we also need to have more and better discussions at that point. These changes would help people who are dying to have more choice, control and better symptom relief when the time comes. Their families would also have a better experience of bereavement.
Forms such as Respect (Recommended Summary Plan for Emergency Care and Treatment), introduced four years ago, are now widely in use, allowing us to go beyond a “yes/no” decision on resuscitation if your heart stops: it encourages us to consider quality of life in recovery versus burden of the treatment.
Admission to the ICU is no guarantee of recovery for many patients, nor is ventilation. Many will not survive or will live with long-term effects. The experience can be very distressing, and can include sometimes terrifying delirium. Even so-called non-invasive ventilation such as continuous positive airway pressure (which is used as a step before intensive care for people with respiratory distress) can be claustrophobic and frightening, especially for frail or confused older people. The processes can also be disturbing for their families. So this is not a black and white case of “intensive treatment good; supportive care bad”.
Even for patients in hospital, cardiopulmonary resuscitation does not have anywhere near the survival rate depicted in popular medical television shows; in many cases, performing CPR amounts to a ritualistic and undignified medicalisation of natural death.
Good palliative care to relieve distress and provide dignity would often be better. Care home residents are often in poor health and often in their last year or two: 59 per cent are aged 85 or older, according to the ONS. They rarely do well if they undergo CPR, and conveyance to a busy, noisy acute hospital can be distressing and often leave them dying away from familiar surroundings and faces.
People with dementia, with learning or physical disabilities, or groups advocating for them, have raised understandable concerns that medics will somehow make “quality of life” assumptions or decisions and deny them treatment from which they might benefit. I realise that medicine has at times let such citizens down or discriminated against them, but I see no evidence or prospect of this approach being taken during the pandemic.
If we really do hit a peak of demand that overwhelms our much-expanded intensive care capacity, there may in extreme cases be hard choices to make between two patients who could both benefit from admission. We aren’t quite there yet. Open decisions and discussions about limits of treatment are what we should have been doing all along. We are now merely talking about them openly.
Once the pandemic is over, let’s hope this is our new, demystified normal.
by alloneword » Sun Apr 19, 2020 3:27 pm
by alloneword » Sun Apr 19, 2020 3:36 pm
"Our Santa Clara seroprevalence study is now out. It shows 50-85 times underestimated number of infections, therefore 50-85 times overestimated infection rate fatality. True infection rate fatality is in the ballpark of seasonal influenza."
To read the study, head here: https://www.medrxiv.org/content/10.1101 ... cYFxcVmU6w
by alloneword » Sun Apr 19, 2020 4:10 pm
by alloneword » Mon Apr 20, 2020 10:15 am
by alloneword » Tue Apr 21, 2020 5:37 am
Two weeks ago, I wrote about ‘the Swedish experiment’ in The Spectator. As the world went into lockdown, Sweden opted for a different approach to tackling coronavirus: cities, schools and restaurants have remained open. This was judged by critics to be utterly foolish: it would allow the virus to spread much faster than elsewhere, we were told, leading to tens of thousands of deaths. Hospitals would become like warzones. As Sweden was two weeks behind the UK on the epidemic curve, most British experts said we’d pay the price for our approach when we were at the peak. Come back in two weeks, I was told. Let's see what you're saying then. So here I am.
I'm happy to say that those fears haven’t materialised. But the pressure on Sweden to change tack hasn’t gone away. We haven't u-turned. We’re careful, staying inside a lot more. But schools and shops remain open. Unlike some countries on the continent, no one is asking for ‘our papers’ when we move around in cities. The police don’t stop us and ask why we are spending so much time outdoors: authorities rather encourage it. No one is prying in shopping baskets to make sure you only buy essentials.
The country’s Public Health Agency and the ‘state epidemiologist’, Anders Tegnell, have kept their cool and still don’t recommend a lockdown. They are getting criticised by scientific modellers but the agency is sticking to its own model of how the virus is expected to develop and what pressure hospitals will be under. The government still heeds the agency’s advice; no party in the opposition argues for a lockdown. Rather, opinion polls show that Swedes remain strongly in favour of the country’s liberal approach to the pandemic.
So why isn’t Sweden changing tack in the fight against the pandemic? ‘The evil that is in the world always comes of ignorance’, wrote Albert Camus in The Plague – a book that eerily depicts the suffering of the human condition when a disease sweeps through society. And lately, scientists and observers have ventured that explanation publicly: perhaps Sweden’s refusal to fall into line is because Tegnell and his team are a bunch of philistines?
A group of 22 scientists made that charge in an op-ed last week in Dagens Nyheter, appealing to the government to rein in supposedly ignorant officials at the Public Health Agency. Last week, a piece in the Daily Telegraph ran with the same theme and expanded it to include much of the national population: Swedes have willingly been duped by ignorant authorities and a chief epidemiologist who has been seduced by his own sudden fame. Our faith in government is so big, and our bandwidth for dissent is so small, that we even scold criticism of the government as ‘shameful betrayal of the national effort’. A journalist from French television that I talked to on Sunday admitted, somewhat sheepishly, that ‘it’s almost as if we want Sweden to fail because then we would know it is you and not us that there is something wrong with’.
There is a simpler explanation: Sweden is sticking to its policy because, on the whole, it is balanced and effectual. So far, the actual development is generally following the government’s prediction. On Monday, 1,580 people had died and tested positive for Covid-19. The number of daily deaths has remained pretty stable at about 75 for a while but is now on a declining path. A lot more people will die in the next weeks and months but our death toll is far away from the pessimistic and alarmist predictions suggesting 80 to 90,000 people would die before the summer.
There are also encouraging signs that the growth of reported infections is also slowing down – a development that holds for both Stockholm (by far the worst affected region) and the rest of the country. The estimate from the Public Health Agency is that 100,000 people will show up at a hospital and test positive for Covid-19: the current headcount, just south of 14,800, suggests we are broadly in line with that estimate – if not below it.
Perhaps more important is the situation at our hospitals and their intensive care wards. The main ambition of suppression policies, after all, has been to avoid hospitals getting overwhelmed by patients they cannot treat because of shortages of staff, equipment and intensive care beds. Modellers in Sweden that have followed an Imperial College type approach have suggested demand will peak at 8,000 to 9,000 patients in intensive care per day. But actual numbers are telling a very different story. Yes, the situation is stressful, but – mercifully – the growth in intensive care patients has slowed down remarkably and the number of patients currently in intensive care has flatlined.
We now have about 530 patients in intensive care in the country: our hospital capacity is twice as high at 1,100. Stockholm now averages about 220 critical care patients per day and its hospitals, far from being overwhelmed, have capacity for another 70. Stockholm also reports that it has several hundred inpatient care beds unoccupied and that people shouldn’t hesitate to seek hospital care if they feel sick. A new field ward has been set up in Stockholm for intensive and inpatient care and some predicted it would start getting patients two weeks ago. It hasn’t received any patients yet.
Sweden hasn’t declared 'victory' – far from it. It’s still early days in this pandemic and no one really knows yet how the virus will spread once restrictions are lifted and what excess mortality it will have caused when it’s all over. Sweden doesn’t know the size of its ‘iceberg’ – how many people that have had the virus with only mild or no symptoms. It will remain unclear for at least another couple of weeks if parts of Sweden (especially Stockholm) has developed some degree of herd immunity.
A recent test at Karolinska suggested that 11 per cent of people in Stockholm had developed antibodies against the virus. Professor Jan Albert, who has led these tests, says the rate is most likely higher – perhaps substantially higher. So far they have only tested a small sample of blood donors and they can only donate if they are healthy and free of symptoms. Albert thinks the actual situation isn’t far away from the ballpark suggested by professor Tom Britton in a study that was released this weekend: that between 25 and 40 per cent of the Stockholm population have had the virus and that the region will reach herd immunity in late May.
These results are hopeful, even if they are still informed estimates and not observed reality. Nor will they change Swedish policy anytime soon. In fact, all the uncertainties around the future of this pandemic are part of the motivation for Sweden opting for a liberal approach. We have to plan for strong social distancing measures to remain in place for a long time and they won’t work if they are harder than necessary.
Countries like Austria and Denmark are now beginning to ease their lockdown restrictions but the virus is still spreading in their countries, albeit at a slower rate than earlier. Once more of the restrictions have been lifted, they may soon have to be imposed again to control new outbreaks of the virus. No country in Europe has yet figured out how a policy of test, track and trace could be organized on a large scale. We don’t know when a vaccine will be ready. For the foreseeable future, the backbone of every country’s defence against the virus will have to be based on strong social distancing. Sweden’s authorities proposed a liberal approach based on individual responsibility because it can be tolerated for longer and it has the effect of ‘flattening the curve’.
There is also a broader case for it. Lockdown policies harm basic civil liberties: in Sweden these liberties are, with some exceptions, intact. Lockdown policies have huge consequences on public health. And they are profoundly damaging to the economy. Sweden is no exception: our economy has been falling like a stone in the past month. In the city where I live, Uppsala, bankruptcy notices are now put up on many shop windows and I hear every day about friends and acquaintances that have lost their jobs or their small firms. National production has also slipped because global trade has closed. Big industrial stalwarts like ABB and Sandvik are still producing but can’t ship their products to other countries. Carmakers like Volvo and Scania decided to close their factories at an early point in March because they couldn’t get parts and components from other countries.
So everyone was already set up for gloomy reading about the economic outlook when the government unveiled its new budget last week. Still, the experience was grim. In the main scenario, our national output will decline by 4 per cent this year, taking unemployment up to 9 per cent and the fiscal deficit to 3.8 per cent of the gross domestic product.
The only silver lining is that it could have been worse. We are pretty far away from the levels of economic decline predicted for most lockdown countries. In fact, the Swedish economic situation looks sensationally positive when compared to the ghastly reports and scenarios elsewhere. Cash turnover indicators, for instance, suggest that personal consumption in Denmark and Finland has dropped by 66 and 70 per cent respectively – compared to less than 30 per cent in Sweden. Unemployment benefit claims in Norway has shot through the roof and grown four times as fast as in Sweden. Fiscal deficits in the UK and the US are likely to be in the region of 12 to 15 per cent. Last week’s economic scenario from the OBR suggested that Britain’s GDP could drop by almost 13 per cent this year.
So yes: the economy has to be factored into a balanced pandemic response if it is going to last for longer than a few weeks more. No country can sustain suppression policies if they have catastrophic consequences for the economy. Many countries can borrow cash now to pay people that aren’t working and help businesses that are on the verge of bankruptcy. But that isn’t an unlimited option. Debt accumulated now will have to be repaid later. We can hope for a sharp economic recovery but chances are that it will be slow and that it will take years to rebuild national production. And we already know what that means: unemployment will remain high, people will be poorer and there will be less spending on benefits, welfare services and core state functions like the police. Sweden won’t be spared, but our economy will not be as ravaged as elsewhere.
So Sweden isn’t edging closer to a lockdown. Nor is team Tegnell panicking and fighting for its reputation. The vast majority of people think Sweden broadly opted for a balanced and effectual policy and current trends support that view. Everyone is upset about carelessness in nursing homes – that a very high share of our death toll is elderly nursing home residents – and that emergency plans were so poor and medical contingency stocks so small. People will be held to account. Some heads will roll. My guess is that it won’t be Tegnell’s.
by alloneword » Tue Apr 21, 2020 5:56 am
by alloneword » Tue Apr 21, 2020 7:04 am
I’m not saying that the claims in the above-linked paper are wrong. Maybe the test they are using really does have a 100% specificity rate and maybe the prevalence in Santa Clara county really was 4.2%. It’s possible. The problem with the paper is that (a) it doesn’t make this reasoning clear, and (b) their uncertainty statements are not consistent with the information they themselves present.
Let me put it another way. The fact that the authors keep saying that “50-85-fold” thing suggest to me that they sincerely believe that the specificity of their test is between 99.5% and 100%. They’re clinicians and medical testing experts; I’m not. Fine. But then they should make that assumption crystal clear. In the abstract of their paper.
by alloneword » Tue Apr 21, 2020 4:44 pm
by alloneword » Wed Apr 22, 2020 7:24 am
Professor Heneghan, who also works as a GP, told MailOnline: 'The peak of deaths occurred on April 8, and if you understand that then you work backwards to find the peak of infections. That would be 21 days before then, right before the point of lockdown.'
Professor Carl Heneghan, director of the centre for evidence-based medicine at Oxford University, told Radio 4’s Today programme: “In fact, the damaging effect now of lockdown is going to outweigh the damaging effect of coronavirus.”
by alloneword » Wed Apr 22, 2020 10:16 am
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