British Society for Immunology open letter to Government on SARS-CoV-2 response | Hacker News Reader

British Society for Immunology open letter to Government on SARS-CoV-2 response

immunology.org

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It’s fascinating (and depressing) to watch the difference in response between Asia and the West.

I’m an American living in Myanmar. Here’s what’s being done in my city all before there are any confirmed cases:

- Cancellation of large events.

- Free testing.

- TV notices encouraging social distancing and hand washing.

- Temperature checks and hand sanitizer dispensed at entrances of indoor crowded places like malls, grocery stores, large retail stores (not doing this really baffles me, since it’s so straightforward and practical).

- School closures.

- Travel and border restrictions.

These are simple tactics that every country should be utilizing. Yet when I talk to my friends in US and Europe, they report no temperature checks or hand sanitizer. My family member just flew through SFO and said there were no temperature checks or hand sanitizer being dispensed.

It’s sad and perplexing to me that common sense practical approaches to testing and spread control are not being utilized by many countries, and that closures have been reactive instead of proactive. It’s unfortunate that the UK is focused on actively ignoring practical efforts to control spread.

Italy is doing all of those things.

Now they are. The key point being made is that these measures were put in place "before there are any confirmed cases."

Can you share the city name?

I’m in Yangon. I’m sure these measures are less prevalent in much of the country due to lack of development (around half the population lacks electricity, to give you an idea). But that just calls more attention to how apathetic the US and UK response are considering they are very developed with vastly more resources and expertise.

Most of this is being done in the West, and Westerners aren't as inclined to comply with government instructions as a typical Asian country even before we get to the specifics of Myanmar's situation (decades of authoritarian government requiring people to comply with bans as arbitrary as 'no bicycles in the former capital, because reasons' and parts of the country already with travel restrictions for other reasons)

As European living in East-Asia, I'm also stunned by how lightly the various Western governments, and people living under them, have taken this virus issue. It's like everyone think it will not affect them (first not their country, then not them personally) so they don't need to do anything. At first I was angry at my government seeing they did absolutely nothing for two months, but when I hear how people still react to it ("it's just a flu!") I start to think they actually need to see the consequences to understand how bad the situation is. Then they will be ready for next time, but sadly at a high price in term of deaths.

Your Asia versus West comparison doesn't hold up, because these the countries in those groups are not doing the same things.

For example "Asia": Taiwan? or Thailand? Both have very different approaches.

"West": the US? Or Italy? Same again.

When I wrote this I was thinking of China, Singapore, South Korea, Myanmar vs. USA, UK, Netherlands since those are places where I have contacts. A few weeks ago I was told that flying into Amsterdam there were no temperature checks. Same with flying today around US. Singapore was doing that months ago...

> A few weeks ago I was told that flying into Amsterdam there were no temperature checks. Same with flying today around US. Singapore was doing that months ago...

I don't know who is handling this better, but Singapore also has people press on visibly filthy thumb scanners at immigration with no hand sanitiser to use afterwards (likewise other airports), bowls of candies for thousands of daily passengers to freely dip their sweaty hands into, and how do you rate this touchscreens in toilets, which seems like a terrible idea at any time.

You can add Sweden to the western list, probably as an extreme case. Some regions are not even testing for the virus except in really ill people and healthcare workers. One region says it’s still testing but that it will no longer publish the numbers. We’re still a week or two behind Italy, but my feeling is it could get ugly...

It's not just about the West vs Asia, the same urgent measures are being taken in Eastern and at least parts of Central Europe as well (slightly later, but IN Romania where I live, they started when we were at 25 confirmed cases, and the story is similar in nearby countries).

I think several rich countries keep believing that they are somehow exceptional and that they can get away with not doing something which will impact their economies. I would be amazed if we don't see another few Italies, unfortunately...

Interesting. Which city are you in? I used to spend a lot of time in Yangon in Myanmar, my wife's family are Burmese doctors who emigrated to the UK decades ago. We live in London at the moment. They also find the difference in approach between Asia and the UK puzzling.

I think the stark reality is, given how easily the virus spreads, you can play whack-a-mole with closures for potentially a very long time, but the virus will eventually spread and overwhelm the healthcare system.

I don't know how many ICU beds there are in Myanmar but I'm afraid it won't be nearly enough, just like everywhere else. I've been to a public hospital in Yangon once, and it was full to the brim with very long waiting times. Ended up just leaving before I come out with something worse I went in with. This was during a time without any pandemic.

I’m in Yangon. I had temperature checks and hand sanitizer when going to city mart (a grocery store) yesterday. Same when getting on a bus to Kalaw last week, at the events I’ve been to the last month, etc.

Makes sense as long as those temperature checks lead to something if you are showing an elevated temperature - rapid testing, and quarantine if you are positive. In China this process was like clockwork.

What are you doing in Yangon btw? Mind if I drop you an email?

I live here with my wife (who is from Myanmar). Yeah I don’t mind emails, inbox is always open :)

> I've been to a public hospital in Yangon once, and it was full to the brim with very long waiting times. Ended up just leaving before I come out with something worse I went in with.

Huh, I was down with severe food poisoning in Yangon in early 2016. A local associate of my friend brought me to the local hospital's A&E department, where I got an injection of some sort and diarrhoea medication. I was out of the hospital in probably 30 minutes.

I'm not in the position to assume that their hospitals can handle a severe outbreak, but their medical system wasn't that bad when I had the unfortunate chance to experience it.

Could have been timing, or the hospital. I've heard others have had good experiences also.

Still, I really don't think they have enough ventilators or intensive care capacity to cope with a coronavirus epidemic. 70% of the population live in rural areas where they don't even have hospitals

Nobody has enough ventilators.

Also, people in the West mostly underestimate the rest of the world and their capabilities. Once you show them that majority of the rest of the world does not live in caves they are bummed. It's ignorance.

> These are simple tactics that every country should be utilizing.

Although simple, they have a large socio-economic impact.

There're many of us who are privileged enough to not work for a short period of time, but a large number of people can't afford that.

Is it worthwhile to shut-down schools before any reported cases? What if we encouraged those who are most vulnerable to quarantine themselves while the healthy population develops herd immunity?

I think the heavy-handed response is partially based on the notion that the virus can be contained. It cannot. It will continue to spread, if not in your own country it will in others around the globe. Viruses don't respect borders.

If we assume a that the spread cannot be stopped, then a better approach could be to maximize herd immunity while minimizing overall deaths and severe cases?

Denmark is doing all of those same things as well. School closures, borders closed, all non-essential public staff sent home, everyone who can possibly work from home told to do so, most other people sent home with pay/compensation, officials telling us to practice social distancing and so on.

And yet some people insist on going to bars, shisha joints, private parties. It could easily turn messy.

Regrettably we imported a lot of our verified cases via Danes coming home from ski vacations in Austria and Italy, before we realized it was happening.

America is doing most of those things:

> Cancellation of large events.

Check

> Free testing.

Half-check: testing is free, but availability it totally inadequate.

> TV notices encouraging social distancing and hand washing.

Check. Not sure about "TV notices" but this advice is all over the media.

> Temperature checks ... at entrances of indoor crowded places like malls, grocery stores, large retail stores

US is not doing this.

> hand sanitizer dispensed at entrances of indoor crowded places like malls, grocery stores, large retail stores

Check. This is being done, but more by private initiative.

> School closures.

Half-check. These are happening, but it depends on the state.

> Travel and border restrictions.

Half check. Some restrictions are happening at the international border, but as far as I know, there are no formal internal travel restrictions.

This idea that the primary aim of the UK Government is herd immunity is plain wrong. The primary aim is to flatten the curve with specially timed interventions and any herd immunity is a by product of that. The aim is to flatten the curve so that the systems are able to cope better.

Herd immunity will be a by product in almost every western countries actions today. Ask them and if they are honest they will say the same that it's a long term effect but not the primary driver or the main aim.

The difficult non sound bite criticism is about the flattening of the curve based on their models which basically means they need to get both the timings and the interventions spot on for it to work correctly.

> This idea that the primary aim of the UK Government is herd immunity is plain wrong.

You can understand people's confusion when the government have said, repeatedly, that they aim to create herd immunity.

https://www.ft.com/content/38a81588-6508-11ea-b3f3-fe4680ea6...

> Britain’s chief scientific adviser stoked controversy on Friday when he said that about 40m people in the UK could need to catch the coronavirus to build up “herd immunity” and prevent the disease coming back in the future.

> Defending Prime Minister Boris Johnson’s decision not to follow other European countries by closing schools and banning mass gatherings, Patrick Vallance said it was the government’s aim to “reduce the peak of the epidemic, pull it down and broaden it” while protecting the elderly and vulnerable.

> But Sir Patrick told Sky News that experts estimated that about 60 per cent of the UK’s 66m population would have to contract coronavirus in order for society to build up immunity.

> “Communities will become immune to it and that’s going to be an important part of controlling this longer term,” he said. “About 60 per cent is the sort of figure you need to get herd immunity.”

You just need to be down with doublespeak. They say one thing, but you have to understand that they meant something entirely different. To think otherwise would be to think that our leaders are either dishonest or incompetent - and because they are our leaders they cannot be either dishonest nor incompetent.

Therefore, you must adjust your comprehension.

Honestly, if their intent is as GP says, I’ve not seen it communicated - I’d love a source other than goodthink.

None of those quotes say they aim to create herd immunity. They just say you won't get herd immunity until about 60% are infected. There's a difference.

The government has changed from "containment phase" and is now in their "delay phase", and that means they think millions of people will become infected.

Patrick Vallence:

> ‘So our aim is to tray and reduce their peak – broaden the peak – not to suppress it completely. Also, because the vast majority of people get a mild illness, to build up some degree of herd immunity as well.

https://metro.co.uk/2020/03/13/millions-brits-get-coronaviru...

Herd immunity is a direct aim of the current phase of the government plan -- it has to be, because they think that covid-19 will become a seasonal illness.

https://www.ft.com/content/0475f450-654f-11ea-a6cd-df28cc3c6...

> The prime minister and his scientific advisers hope to manage the epidemic by “flattening the curve” of infection and delaying the peak until the summer, when the National Health Service will face less seasonal pressure.

> Then — or so the theory goes — enough people will have acquired resistance to Covid-19 to avoid a second wave of disease next autumn or winter. Downing Street believes that other countries that have taken draconian action now will be vulnerable later in the year.

> Mr Johnson’s strategy depends on building up the so-called herd immunity. If a high enough proportion has become resistant through Covid-19 infection, the virus will not have enough new people to catch and the epidemic will not be able to sustain itself. It will burn out.

> They just say you won't get herd immunity until about 60% are infected

But even this is wrong, or at least, unsure. Herd immunity relies on low (or zero) re-infection. It works for diseases like measles, where the risk of re-infection (after either infection or immunisation) is effectively zero.

We don't yet know if re-infection with covids-19 is possible or not.

Health Secretary Matt Hancock reiterated this morning in his BBC interview that this is not the government's main aim.

It is is a fun buzzword that officials have mentioned and some people have since obsessed about. Which is unfortunate as it really distracts from the real issues so it would be great if we could move on.

> some people have since obsessed about

The burden is on the government to better unify the messaging in a time of extreme uncertainty.

Sure and I didn't say those obsessives were to blame. In fact, I'm going to say blaming anyone is a waste of our efforts right now.

Edit, maybe by 'burden' you didn't mean 'blame', exactly. It is part of the government's job to communicate properly and it seems they didn't get it right. But we can accept that and now be open to the explanations of what they really meant. So we can get on with what matters.

I understand that there is confusion and seek to address it. The quotes provided come from the press which are spinning this in an inaccurate way and leading to letters such as this.

This is a bit too cute by half, especially considering that leading UK politicians have themselves cited "herd immunity" as the reason to do what they're doing.

Your rephrasing sounds reasonable, but I'm not sure what it concretely means, particularly how it differs from every other country's approach. It's vague enough that you could pretty much say the same thing about everything from China's to Singapore's to the United States' approach.

> Matt Hancock insists 'herd immunity' not part of government's plan for tackling coronavirus

> Mr Hancock added: "Herd immunity is not a part of it. That is a scientific concept, not a goal or a strategy. Our goal is to protect life from this virus, our strategy is to protect the most vulnerable and protect the NHS through contain, delay, research and mitigate."

https://politicshome.com/news/uk/health-and-care/illnesstrea...

The amount of politicizing people are engaging is a bit sad. Especially when you take a wider view at how every country with the best doctors and scientists have dealt with it. Significant criticism has happened across party and ideological lines (Which you’d hope the healthcare bodies would be largely independent of and instead follows the best scientific advice). Even here in Canada where our prime minister’s wife got COVID-19 and are both in isolation, yet they’ve been even less aggressive than the policies the UK has already announced.

It’s obvious few countries and even WHO were well prepared for something of this scale and a ton of criticism today has the benefit of retrospect. Meanwhile aggressive policies, like the US closing borders and China locking up entire apartment buildings when one resident gets sick, also got immediate heavy push back, and globally has been far more the exception than the rule.

Even with better preparedness, which no doubt will be adopted after this event, there is still a difficult balance between scaling up restrictions on daily life without being accused of being “draconian” (which is how I remember the same UK press characterized Italy’s early moves). Especially politically, let alone scientifically.

We should be spending more effort on finding the right balance, which is still not obvious nor scientifically well established for countries with lower rates, even today. Those are the hard questions, political opportunism is easy and low effort.

I'm still left in entirely in the dark about what the UK's strategy actually is. As far as I can tell, it's "do less than other countries to avoid experiencing as much economic disruption." Which is fine (for the purposes of this discussion), but everyone defending the UK's policy should at least just own it.

The strategy of all countries is to flatten the curve to enable their respective health services to cope. My concern is that the U.K. is now proposing isolation for the over 70s “within weeks”: this demographic has been shown to be at serious risk as of now, when looking at the experiences of China, Italy and Spain. Further, in the UK, testing is only now being carried out on cases serious enough to hospitalize, so I do not understand how the UK government can have confidence in its data as to the spread of the virus.

As you say, the UK government's strategy is to isolate those most vulnerable first, exactly as is the main point of this letter. It's just a mater of timing. The letter isn't asking them to do anything they haven't already committed to doing.

On timing, the longer people are in isolation, the harder it is to maintain it. Vulnerable people might need to remain isolated for 3 to 4 months. Many of them will inevitably end up compromising their isolation during that time, so it's vital that the isolation period does not start earlier than it needs to. It's trading increased exposure risk now when the virus has a very low prevalence, for better isolation later when the virus is everywhere.

Yes - and moreover, the very old and frail living on their own are vulnerable to many things other than Covid. Having a neighbour check in on them every day, for example, might mean that if they have a fall then they are found before they die from injuries or lack of food or water.

There is very real risk in isolating these people for months that this type of protection is lost and costs more lives than it saves so there is a complex tradeoff involved.

It's even more complex then that.

Even if you do end up isolating the elderly, there will still be an increased influx of patients who will take up hospital beds.

At that point, the problem isn't just an elder person taking a fall, it literally affects anyone who contracts another illness, gets a stroke, a heart attack, organ failure, a traffic accident,...

This flatten the curve stuff kinda presupposes that we have more than zero capacity as things stand _today_.

There are almost no drawback to the health system by introducing strict measures sooner rather than later. Studies supporting stuff like lockdown or containment fatigue is also sorely lacking. Basing our epidemic response on this is completely bonkers.

The overwhelming consideration is the blow to the economy. The government should at least have the balls to admit it and not hide behind 'science'.

(The only issue with closing schools which might affect the healthcare system is childcare for healthcare workers. This is already in place as a mitigation in other countries.)

> There are almost no drawback to the health system by introducing strict measures sooner rather than later

Yes there are, as set out in the chief medical officer and chief scientific offer's press conference.

> The overwhelming consideration is the blow to the economy. The government should at least have the balls to admit it and not hide behind 'science'.

So, to be clear do you think the Chief Medical Officer and Chief Scientific advisor were simply lying about the science?

I'm so glad the tech bros, here and on twitter, are on top of this epidemic. I don't trust the professors of medicine and scientists advising our governments either if I can't see some Python code and a condescending tweet about how no one understands exponential growth.

The current response to the outbreak in the UK/US is supposedly being driven by "behavioral modeling", which basically means glorified techbro-Python code. So your argument is backwards, if anything. The WHO didn't used to think of "lockdowns" as a recommended approach either, but they're now changing their mind, as this has worked in China and elsewhere.

Let's turn the argument around: do you really think the top officials in charge in charge of advising the governments do not have in their directives a need to consider economic impacts of their recommendations (implicitly, explicitly or self imposed)? Do you think they would be open about that in their outward communication? If you think "no" or "yes" respectively, lets make sure to return to these comments when the dust settles.

I don't have the answer, but the observed behavior fits this scenario, at least with the British and Swedish authorities, those I have observed the closest.

>Yes there are, as set out in the medical officer and chief scientific offer's press conference.

And these drawbacks specifically to the health system are...?

>So, to be clear do you think the Chief Medical Officer and Chief Scientific advisor were simply lying about the science?

Did I imply that? Just because they chose a path with more emphasis on economic and social considerations (compared to other countries) doesn't mean they are lying and that it isn't science based.

Yes there are, as set out in the chief medical officer and chief scientific offer's press conference.

Can you link to a transcript or something?

Might be in here: https://www.youtube.com/watch?v=cAE8-e5_EKY

There's a very real risk of economic cataclysm, which will roil through the economy and hit many people very hard, causing all sorts of disruptions, negative health outcomes across the board.

Tourism, restaurants, entertainment is 3-7% of the economy (more in Italy) and layoffs are coming very swiftly. Taxes fall, unemployment payments spike, it rolls over into other parts of the economy, bad loans, credit dries up, stock markets dive, investment plummets. The rich will lose some net-worth it will hit the poor physically in many ways, for example, millions more left without health insurance in the middle of a crisis.

Taiwan and S. Korea have been able to keep a lid on the virus without getting draconian, maybe we can follow their example.

But there's quite a lot of risk in these 'lockdown' decisions, it's not just about immediate health outcomes.

So it's not an easy decision.

I should add, the letter is very well written, it's oddly not dramatic, given the gravity of the situation.

Do you think we in the UK will be insulated by this global event just because we didn't close our schools? Even if our hotels are open, who will come? This will only delay our recovery once the dust settles.

No-one is asking for a complete shutdown right now. In fact, the whole reason to start implementing more serious measures (like school closures) now is to prevent the type of lockdown we are seeing in Italy and Wuhan as a result of the health system being overrun.

"Even if our hotels are open, who will come?"

>>> only about 20% of hotel stays are international. [1]

"just because we didn't close our schools"

>> its far, far beyond schools.

"No-one is asking for a complete shutdown right now."

>> Well, public events, Football, and almost all Entertainment are shut down. Restaurants are down 50%. Taxis, trains, public transport. Tanning parlors. Yoga. Fitness clubs. Swimming pools. Theaters. Shopping malls, high-street - they're all getting clobbered, without 'total shut down' and it's going to hurt.

[1] https://www.statista.com/statistics/564673/accommodation-dom...

>only about 20% of hotel stays are international.

Over 60% here in London.

https://webcache.googleusercontent.com/search?q=cache:xnYJiW...

>its far, far beyond schools.

I was only using that as an example of one of the things that will cause a big change in people's seriousness in viewing the epidemic the government hasn't done yet.

>they're all getting clobbered, without 'total shut down' and it's going to hurt.

And a complete lockdown is going to hurt even worse, which would happen when the health service gets overrun.

The issue is that this can happen at any time and without much warning. Our visibility is lagging behind the spread of the virus by at least the incubation period. By the time the latest batch of people symptoms end up in hospital, our response is already behind the curve.

The UK has been testing more than a lot of European countries but it is trailing places like South Korea and Taiwan by a wide margin.

> which would happen when the health service gets overrun.

But the point is to prevent the health service from getting overrun. By the time it is, it's too late because you'll already have an order of magnitude more people who are infected but not yet showing symptoms.

Yeah, for sure, but how are you able to predict when the health service will be overrun when the current testing is lagging spread by at least a few day, if not more. But the time the sirens go off, it's already too late.

Well look at Italy. In terms or reported numbers, we're about a week behind when their health service was overrun. So I'd say within 1-2 weeks max. Which is why we ought to be putting in restrictions now.

Yes, my point is that this is being ignored by the government as it lends its ears to behavioural economists.

We have no good way to measure the CoV spread beforehand so being prudent and proactive with the response is better than to delay introducing additional measures until it is absolutely necessary because you won't know it until it hits you and then it's too late.

You are correct, but the government is saying "4 weeks". Terrifyingly.

UK is completely unprepared for what's about to hit.

> There's a very real risk of economic cataclysm, which will roil through the economy and hit many people very hard, causing all sorts of disruptions, negative health outcomes across the board.

Boost spending through government stimulus programs, loosened unemployment benefits, or simply writing cheques to people directly. Ten-year bond rates for most major industrialized countries are ridiculously low, and even negative in some cases:

* https://tradingeconomics.com/bonds

There's no sense in being cheap at this point in time.

"or simply writing cheques to people directly"

"There's no sense in being cheap at this point in time."

See this is the problem -> money does not grow on trees.

We can't just 'keep writing cheques'.

Given that some countries have negative bond rates: sure you can.

It's not like this cash is doing much of anything else.

> The overwhelming consideration is the blow to the economy.

But this is just as bonkers. It totally ignores the blow to the economy of people dying with no effective treatment because the healthcare system is overwhelmed. If that's really the covert motivation they're being penny-wise but pound foolish to an unprecedented degree, even if we were to ignore the obvious ethical issues with this sort of response.

> It totally ignores the blow to the economy of people dying

People who are over 70 dying in large numbers is a humanitarian crisis, not an economic one.

1. It won't be just the over 70s if no one can get proper treatment at a hospital for their traffic accident, chronic disease, hernia ... 2. Severe cases include a wide variety of ages. The over 70s are just the first to hit the ERs

This is complacency. A lot of under-50s, particularly male smokers and others with weakened lungs or immune system, are at risk; even fit under-40s can require weeks of externally-provided ventilation to survive.

> There are almost no drawback to the health system by introducing strict measures sooner rather than later. Studies supporting stuff like lockdown or containment fatigue is also sorely lacking. Basing our epidemic response on this is completely bonkers.

Anecdote: I'm in Singapore, which was one of the first countries hit by the virus. People are getting complacent from how well our government seems to be handling the virus.

I wouldn't say that places are as crowded as before (since we've been introducing gradual travel restrictions), but our public areas are still pretty packed, and people are still going out and mingling despite government advice on social distancing.

The government knows this, and has announced that they will introduce measures over a staggered period to slow down transmission [1].

[1] https://www.gov.sg/article/pm-lee-hsien-loong-on-the-covid-1... — "They will be extra 'brakes', to be implemented when we see a spike in cases. The extra brakes will slow down transmission of the virus, prevent our healthcare system from being overwhelmed, and help bring the numbers back down."

I take your point. I'm not disputing the existence of fatigue, but rather on whether we know enough about it to quantify it and to use it as our guiding principle for epidemic response.

And I think the the Singapore approach here is the right way - additional measure can be taken in order to shore up public behaviour as people's behaviour start to revert.

In any case the UK public by-and-large is behaving much less seriously than Singapore. Having just been back from Asia on a trip and working from home as a result, I still have people asking me as of a few days ago whether all of this talk in the news is an overreaction.

"The primary aim is to flatten the curve with specially timed interventions and any herd immunity is a by product of that"

That is my understanding too. I've read through a lot of the official publications[0] and nowhere found reference to "herd immunity". The best reference to "herd immunity" I've been able to find is the quote from the UK's Chief Scientific Advisor Patrick Vallance that "our aim is to try to reduce the peak, broaden the peak, not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission, at the same time we protect those who are most vulnerable to it."[1] but this still seems clear that the main aim is to "broaden the peak" and get the benefits from buying more time that this brings, possibly including the "herd immunity" point (but not limited to it - there will be other benefits, e.g. more time to find a vaccine).

What isn't clear to me is what the exit plan is for the countries that have a full lockdown in place at the moment. Are they going to keep lockdown in place indefinitely and hope a vaccine is found? Or are they going to lift the lockdown and then repeat when the virus begins spreading again?

[0] e.g. https://www.gov.uk/government/publications/coronavirus-actio...

[1] https://www.ft.com/content/38a81588-6508-11ea-b3f3-fe4680ea6...

> Herd immunity will be a by product

It won't, though: at least, not in the way that 'herd immunity' is commonly understood.

We technically had herd immunity from measles, but it wasn't effective at stopping people from dying until there was a mass vaccination program.

The R0 of measels is 12-18, and CFR of 25%. This is an entirely different set of parameters. If covid-19 looked like this, the response would be completely different.

Herd immunity isn't a binary thing. Outbreaks reduce as herd immunity increases. Nobody is saying covid-19 will go away thanks to these measures. Indeed, the government have been saying it'll probably become a mild seasonal illness much the same way the Spanish flu is now.

Remember our species has only eradicated one single infectious human disease in our history, Smallpox, and it took hundreds of years. Coronaviruses are notoriously hard to vaccinate. Locking down society indefinitely (which itself had a human cost) based on the hope we'll eradicating covid with vaccines seems like wishful thinking.

Scientists are saying a vaccine is at least a year away and this disease is beginning to spread through India and Africa.

What is the alternative plan here?

>Herd immunity isn't a binary thing.

Moreso than you'd think. The effect of some percentage of the population being immune is to reduce the effective R0 (transmission ratio). At an R0 of less than 1, the disease cannot sustain community transmission and dies out. Above 1, you get exponential growth. This is a stark threshold. Usually you need a population that's 60-80% immune to achieve this threshold.

Technically, yes, there is an R0 above which a virus is self sustaining. But if something has R0 of 1.25 the herd immunity threshold is about 20%, whereas if it's 18, the HIT is nearly 95%. Additionally, R0 isn't an absolute property of the pathogen, so even assuming there is this absolute HIT, if R0 is around 1, some people will be above 1 and some below 1.

As herd immunity increases, the R0 decreases. A disease with a low R0 spreads more slowly (hence the logistic curve) and is therefore easier to track and trace manually, and has a lower peak and total infection count.

I don't think this is binary at all, or even _that_ stark of a threshold. Transmission doesn't continue at the same exponential rate until it hits around 60% and then suddenly disappear. It doesn't even come close to approximating that behaviour.

Absolutely correct.

If re-infection with covids19 is possible, then herd immunity won't occur.

But flattening the curve involves things like cancelling events and closing bars/pubs/clubs/restaurants and telling businesses to have employees work from home if possible. And the government is doing none of that.

While they haven't officially done most of these things yet there's plenty of commentary from officials saying these are the next steps.

Yes, but now is the time to be doing it! The earlier the measures are started, the more eeffective they are.

I’d say that there are only two strategies that make sense: 1) early containment or 2) herd immunity. The west seems to have gone with herd immunity. Flattening the curve is just a no-brainer.

The common hepatitis virus stays in the body forever and may be responsible for countless things we have typically classified as auto immune disorders.

So to say the solution is to get most least at risk people infected without even knowing if those 60000 recovered Chinese are all going to die in 6 months, that's just stupid.

They didnt say that the most least at risk people should get infected. I interpreted their guidence to be more in line with what you just said "Avoid infection, because we do not yet know if this virus induces long-term immunity, as many other similar viruses do not."

Given the ambiguous use of pronouns, it seems you may be talking past one another. GP seems to be criticizing the UK government's approach whereas parent seems to be summarizing TFA's guidance.

Whaaaat? U.K. government health officials are asking strong healthy people to get infected?

Rather, accepting that people will get infected and proposing that if it's limited to healthy people, the community will develop a "herd immunity" due to the healthy people's new immunity.

They actually said that? That's some next level fuck-it-I-don-t-want-to-be-in-charge-anymore attitude. Wow. Where's Churchill when you need him?

Edit: yes, he said that. And more. Wow.

https://www.ft.com/content/38a81588-6508-11ea-b3f3-fe4680ea6...

I can't understand your reading of what is being said. Here is the quote :

'In another interview with the BBC, Sir Patrick said: “If you suppress something very, very hard, when you release those measures it bounces back and it bounces back at the wrong time.”

He added: “Our aim is to try to reduce the peak, broaden the peak, not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission, at the same time we protect those who are most vulnerable to it.”'

Churchill was very much in favour of making callous tradeoffs if he believed it had long term benefits, e.g. the Bengal famine. Churchill incidentally happens to be one of Boris Johnsons great heroes.

Churchill is not exactly a good example of solid decision making.

Bit of a trolley problem, when "accepting it" means "not trying very hard to stop it".

Absolutely not, there is still strong advice in terms of regular handwashing etc. Rather the government is saying that you have to time strong lock down procedures correctly. They are saying that outdoor gatherings such as you get at football matches don;t present a high risk (as long as you are washing your hands) compared to the risk of catching the disease from family members in doors.

Moreover they argue that demanding a long-term lock (14 weeks for schools, according to their modelling) is problematic if you go too early - they want to time it to be just before the peak. Basically is playing chicken with an unrushing truck, but a game of chicken with a purpose behind it.

The Chief Medical Officer Chris Whittey is an epidemiologist and I've only heard good things about him. I'm willing to take his advice. They government says it will be publishing the models.

Also worth noting that in his previous role in DFID Whitty coauthored papers advising the UK government funding isolation centres in Sierra Leone for Ebola, so it's unlikely that he has any particular radical bias against the efficacy of isolation as a disease prevention method.

I think GP was referring to the government's plan, not the suggestions in the letter.

Yes I was thanks for the clarification.

Yes sorry I didn't make it clear I was bashing the govt response, essentially agreeing with this open letter.

Got it

We've got this slightly weird "soon but not yet" thing going on at the moment, strangely reminiscent of Mark Carney Governor of the Bank of England's infamous and ill fated 'forward guidance' policy.

We're being told that some time in the next two weeks all over 70s will be told to self isolate for up to four months. Well if it's going to be four months I think my parents can jolly well start now, thank you very much. Similarly with "not quite but nearly" school closures.

It all seems to be predicated on the theory that if we start too early well get bored of it by the time the real pandemonium starts, which sounds like pretty strange thinking to me.

If you lock down too soon the spread will simply restart post lockdown. If you wait a hit, there will be some percentage of the population already exposed and immune post-lockdown which will slow the spread. That's my thought on timing.

Do you have any evidence to cite for this? The idea of a lockdown is to stop the spread, and during that time treat and isolate the sick, so the virus outbreak basically ends. When it's over, the idea, as far as I've known, is that the risks are gone.

Additionally, a lockdown causes the now-famous "flattening of the curve" to maintain the stability of the healthcare system.

It's the other way around.

You can't stop the spread to a complete halt, only slow it down.

If you want to stop the spread, you need to literally quarantine everyone for a months. Why? Because we don't really know yet how long some can infect people. The answer is probably "your mileage will vary" depending on how the disease evolves on an individual level. If you lift restrictions too soon, the few remaining infected will rekindle the epidemic among those who haven't had it yet.

> When it's over, the idea, as far as I've known, is that the risks are gone.

A highly contagious virus literally comes from Pandora's Box. Once out in the wild, it's extremely difficult to eradicate. We've only managed to willfully eradicate a handful of diseases thus far. Smallpox comes to mind. And that could only happen because of concerted vaccination program one the one hand, and the particular properties of the disease itself on the other hand.

Spanish flu disappeared after a year and an estimated 50 million dead - an optimistic estimate because no one really knows the true number. We don't really know why the flu disappeared. One theory simply holds that enough people had contracted the disease and had either survived or died by late 1918.

Without vaccination, social distancing and quarantining are the most viable strategies if we hope to slow down the spread in order to avoid the collapse of the healthcare system.

Why is that important? Because it's about avoiding as many deaths as we can while this runs it's course.

Every young-ish person who ends up in the ICU, is taking up a bed and resources of an older person or someone who suffers a precondition. Or even someone who got into an accident, had a stroke or a heart-attack.

It's your individual responsibility to avoid that you get infected, and equally important, that you don't pass it on to anyone else. Elderly and people your age alike.

As such, the entire strategy of achieving "herd immunity" is entirely backwards. Herd immunity will be achieved regardless how this plays out in the weeks and months to come. The real question is: At what price? And how many will we allow to die?

If the strategy is "let 'em have it", then the second order effect of that decision will be that many will die of causes that would have been treatable in other circumstances.

This is one of those “makes sense to me” kind of things, that the modelling shows is wrong.

Not “kind of makes sense, but needs a set of specific assumptions, so kind of true but risky.”

Wrong.

If you wait, you get a different infection rate curve.

That’s it. Flat out, it means more people get infected more quickly and more people die.

Long term, maybe the results are less clear, but given the best experts in the field are openly questioning the approach, you can be... pretty sure, your gut feel about it is wrong.

Long term is what they're thinking of. Ie next winter and beyond.

And there are plenty of experts among the uk Gov't advisers too. "Pandemic" is #1 on the UK's list of national threats, and has been for ages. I'm certain this will have been modelled to death all that time.

Tbh, the "correct" advice depends mainly on your assumptions and priorities, not the mathematics.

You may be certain this has been modelled, but that doesn't mean it's been modelled correctly.

I'm having some difficulty believing that a government with a decade-long track record of stupidity, craven dishonesty, and aggressive contempt for the poor, weak, and old, has suddenly decided to be a world-leading paragon of evidence-based health policy - in a way that's making epidemiologists in other countries say "Huh? What?"

And the question remains - if they're thinking next winter, what difference does two weeks make?

Two weeks means a significant difference in the number of people infected this season, which means a lower exponent in the rate of spread next time.

>> but given the best experts in the field are openly questioning the approach, you can be... pretty sure, your gut feel about it is wrong.

Aren't there some experts making the policy decisions in the UK or are they leaving it to the interns? There can be disagreements even among experts.

Italy has what, 0.1% infected currently? And hospitals are overrun already. To get herd immunity going, you need at least 60%. This is a trainwreck in slow motion, reminds me of that Chernobyl part where they knew what they were doing until they didn't.

We do not know of there are any long term immunity yet.

In some other thread here someone cited study on monkeys that seems to indicate immunity is indeed built: https://news.ycombinator.com/item?id=22582455

To be precise, hospitals are overwhelmed only in Lombardy right now. You are correct in that only a very small percentage of the population got infected, but it is densely clustered in a small area (https://lab24.ilsole24ore.com/coronavirus/).

However, I agree with your greater point. Reaching herd immunity levels will take months unless a country wants to sacrifice 100.000s or even millions of people.

The theory that people will get bored is fine, but the idea that people will respect a four month isolation period but not unless they have two weeks to prepare, or not a four month and two week isolation period is where their model perhaps warrants more scepticism ...

... to aid efforts, we call on the government to release their modelling data to allow scrutiny from the scientific community to better predict the course of this outbreak

It is possible of course that at the moment, no such thing exists to standards expected by members of the British Society for Immunology.

It’s possible, but given the calibre of the UK CMO and Chief Scientist, it seems unlikely.

I watched this https://www.youtube.com/watch?v=2XRc389TvG8 and in my mind the Chief Scientist is a political and not an academic figure anymore.

Vallance is a medical doctor with quarter of a century in academic medicine and private sector drug research and two years as Chief Scientific Advisor. Chris Whitty, who's identified even more closely with the development of the current strategy, is an epidemiologist.

I guess science no longer requires scrutiny and discussion. Two guys with credentials worked on it, that's all I need to hear to feel better.

I guess replying to comments no longer requires paying attention to the context. One person claimed, apropos of nothing, that the position was 'political, not academic' and I pointed out the obvious fact the relevant scientific advisor's academic credentials were impeccable and their political experience rather limited.

Apropo apropos of nothing, the point was that an argument from (academic) authority is weakned when the authority occupies a political role.

Strategy change: https://www.theguardian.com/world/2020/mar/16/new-data-new-p...

I agree. I wouldn't doubt Prof. Chris Whitty's credentials; a voice of reason.

Here he is at a Select Committee, a couple of weeks ago. https://www.youtube.com/watch?v=IfJcwDaZrsA&

If you need to know the role of a Select Committee: https://www.parliament.uk/about/how/committees/select/

The important point in the letter seems to be

>we don’t yet know if this novel virus will induce long-term immunity in those affected as other related viruses do not. Therefore, it would be prudent to prevent infection in the first place. More research is urgently needed on this front.

It might not be super long-term but it could be. It seems reasonable that immunity would last long enough until a vaccine was produced.

There's no guarantees. You have to balance the risks up, and not taking this approach is risky in itself.

Why in the face of absolute emergency do they communicate in such and understated manner open to ignoring and devaluing by politicians?

They should state with absolute clarity what they think should immediately happen instead of meekly asking two questions.

FFS

Maybe because the scientific advice may be ambiguous and leave room for interpretation which the politicians must exercise under the best of circumstances.

My reading of the letter is that it challenges the scientific advice, as it has been communicated in the media, and seeks to clarify the "wiggle space" politicians have to work with.

Scientific advice shouldn't be ambiguous.

...ever used a weather forecast?

They didn't ask two questions if I read the article correctly.

They asked for two specific actions: more social distancing and releasing modelling data behind decisions.

There you go. So unclear communication I got it wrong.

It’s beyond belief that any strategy could even be considered that does not have its primary goal to save as many lives as possible.

Containment attempts that.

“Herd immunity” is an experiment that the UK government is going to carry out on its citizens causing massive loss of life for no good reason at all.

To be brutally cold: the goal is almost never to save as many lives as possible. Even hospitals don't use that goal. We estimate the economic value of life and use quality adjusted life years to determine if a potentially life saving treatment is worth paying for.

We make these decisions constantly. You make these decisions every time you leave the house. People die every day from things we could have prevented if we had the inclination.

If the goal is to save as many lives as possible, why are driving and alcohol permitted? Because of personal freedom and the economy.

Treating this pandemic differently would be emotion driven.

WHO did the same thing with their oblique, opaque and 'without naming names' bulletins of urgency. Politics at a time like this is a very, very bad idea.

[T]here are many unknowns in how the SARS-CoV-2 virus interacts with the human immune system and how this might play into current scenarios. For example, we don’t yet know if this novel virus will induce long-term immunity in those affected as other related viruses do not.

That was really interesting to me. I didn't know infection with related viruses doesn't confer long-term immunity. Anybody know more precisely how closely related? All of Coronaviridae?

Has anyone found any good spreadsheet models that might show assumptions?

At a local level, I want to be able to help my mother-in-law. If I and my family got it now, I could help them in a month. That is clear and logical at a local level, but may be counterproductive at a global level. Conflict!

At a global level, flattening the curve is about hospitalization. Early infections among those highly unlikely to be hospitalized reduces future risk. But, how does that square with overall growth?

While the local scenario is clear, the global involves more assumptions that can't be modeled in ones head. Dying to play with models.

It remains to be seen whether it will answer these questions, but the government has agreed to publish its own models - https://twitter.com/janemerrick23/status/1238912217921335297

Not to mention, the high R0 of this virus means the threshold for herd immunity is unrealistically high. Plus, countries that are trying to delay transmission will also eventually get herd immunity , most probably with the help of a vaccine.

I think people believe that a vaccine is 18 mths away. Certainly it seems implausible that 100's of millions of doses of a new vaccine can be manufactured within a few months. The models and history that I have seen (ie. the 1918 flu) indicate that there will be another bump of infection after quarantine. I expect compliance with social distancing will be reduced in the next wave because people will be under economic pressure and also will have lost focus on the issue. In some places there may be events that mitigate against distancing - for example the presidential elections in the USA. I think that producing a plan that is predicated on something (production of a vaccine to any scale in less that 6mths) that is very unlikely to happen is not the best approach.

Here is a discussion including expert comments : https://www.theguardian.com/world/2020/mar/15/when-will-a-co...

The most effective strategy would be wave isolation. The virus cannot be contained except by clean-room quarantine for everyone, which is clearly impractical.

So the next best option is to spread the peak by alternate phases of more or less strict social distancing. The virus will still spread, most people will still get it, but the health care system isn't swamped, so resources remain to treat the elderly and vulnerable.

At the end of the season, most people have immunity - assuming it's possible - and you've limited the total number of deaths.

The economic cost is huge, but so is the economic cost of forcing your health care system to collapse.

It's possibly not obvious yet, but the economics of this are going to be ruinous whatever happens. So it would be wise to create some mitigation for that, and suspend the usual market-eats-everything rules.

> So the next best option is to spread the peak by alternate phases of more or less strict social distancing.

Has this been done before anywhere on a large scale?

How is it done, do they just say "it's safe, you can go back to work now wink wink", do they encourage virus parties like new-age-parents? Are they going to convince the public that everyone should get infected in their allotted wave for the common good? Will they go door to door and just shoot in a blast of viruses? Won't people catch on if they alternate between strict and lessened isolation rules and figure "they're trying to trick me into getting infected, I'm not going back to working at the office, thanks"?

I absolutely get the idea, but it's not like you're dealing with a population that has it's memory reset every morning and just acts on the information available today.

>I absolutely get the idea, but it's not like you're dealing with a population that has it's memory reset every morning and just acts on the information available today.

Ahhh... Errm... I am terribly afraid that you can see that happening on Twitter every day.

I don't know, can you? I believe what you see on Twitter is tribalism in it's purest and decentralized form. It's many smaller and larger tribes clashing all the time, because of how it's set up. People don't forget what $memberOfTheirTribe did or said last week, they fall in line because it's their tribe vs that other tribe, and consistence or purity or adherence to tribal values are less important than winning the battle.

Brit here:

I'm not a fan of Dominic's government, but the response seems to be well motivated by a series of reasonable arguments. As I understand it:

1. We either get herd immunity via infection or cure/end every case of the virus in the world. They discard the latter as impossible given the infection rate and forecast time-to-vaccine.

2. The counterfactual/needless damage done will be deaths due to NHS capacity saturation, which is a function of (maximum simultaneously infected) - (nhs capacity at that time).

3. Most controversially, they argue that people are going to be shit at implementing isolation policies of the needed severity, in the particular sense that the effectiveness of isolation measures will drop over time. That seems quite likely to me, having met some humans before. Hard to tell / interested in studies if anyone can point to some.

4. As a consequence of these things, the goal is to pass severe measures later than now (but perhaps at a relative point in time similar to italy's) such that during the period of these measures many young people will be sitting out the infection without passing it on, and the infection rate will fall to avoid saturating the NHS.

Or, put another way, they are going to do everything the US is doing but in about 7-14 days, as opposed to now, because the limited period of effective social isolation will hit a more high-growth period, and more young people will be sitting it out and becoming immune.

This doesn't sound super-obviously wrongheaded to me. It's unclear what the plan in the US is. Lockdown for ever? Lockdown-till-cure? Lockdown till herd immunity is pretty equivalent to the UK strategy, and seems likely to be the outcome. But herd immunity takes longer to achieve the earlier you start measures.

It's a gamble of whether this virus will persist like flu, in an era of mobility, pandemics are almost inevitable.

There's also no guarantee immunity will last long enough to be effective, or that the virus won't be a moving target like flu.

Conversely, buying time with isolation makes the odds of a treatment more likely. There won't be a vaccine until next year, but various other possible medical interventions are already being considered and tested.

The bits that are concerning are that we don't know if people will develop immunity after having covid-19; and any involvement from Cummings because he's employed literal eugenicists.

The problem with their thinking is that isolation shouldn't mean you can't go outdoors. The virus is very unlikely to spread outdoors except with very close personal contact. What it does mean is that food should be delivered wherever possible and people should not use public transport. So their thesis that people will get tired of it is built on a faulty assumption.

I believe their thesis is that people will get tired of not socialising in groups. At this time of year people aren't missing outdoors so much as the pub, cafe, restaurant, office etc.

You might want to read this:

https://giorgio.gilest.ro/2020/03/12/the-uk-strategy-of-figh...

That is indeed a good summary, thanks!

Thank you.

This is the first I've read about waves of infection.

What I gleened: UK government is concerned that China may experience a second wave of infection once the isolation efforts are lifted. So the UK govt is hoping to have a single, much slower wave.

I also like this article's assessment of the UK's strategy: tough choices based on data of uncertain quality.

Great summary. This should be upvoted - it covers most of the debate happening in this thread.

I agree with everything, including not normally being a fan of the government. But this is the most scientific and realistic approach. it's all been done quite sensibly, except maybe communication could have been better.

There have been some bold, counter-intuitive and unpopular decisions, which I really hope pay off. My prediction is that at the end of all this the UK will end up with significantly fewer deaths proportionally than most or even all other countries.

We either get herd immunity via infection or cure/end every case of the virus in the world. They discard the latter as impossible given the infection rate and forecast time-to-vaccine.

These aren't all the possible outcomes (as South Korea) shows. It's quite possible to slow the spread by intervening hard early.

As a consequence of these things, the goal is to pass severe measures later than now (but perhaps at a relative point in time similar to italy's) such that during the period of these measures many young people will be sitting out the infection without passing it on, and the infection rate will fall to avoid saturating the NHS.

The issue is that without vast testing it's really difficult to see how deep into the pandemic you are.

And this theory is going to require getting the timing exactly right. Too late and it's really really bad.

Too early, and it gets hard to keep people isolated later, maybe.

This doesn't sound super-obviously wrongheaded to me.

Well, it means a bunch more people will get sick quicker, there won't be enough hospital beds and ventilators so lots will die.

What do you think will happen longer term in South Korea? (Not meant to be provocative, curious about your forecast)

> Or, put another way, they are going to do everything the US is doing but in about 7-14 days, as opposed to now

But aren't 7-14 days from now, given the exponential infection rate, equivalent to waiting until you're in the same situation as Italy?

Basically, it sounds like the UK plan is actually to prioritize economic health at the cost of human health, hoping that the NHS is going to fare better when, not if, they get to the same level of infection as China; and disguising all of this with rational sounding rhetoric from epidemiologic scientists willing to take a risk with other people's lives.

They're going to overshoot. Based on confirmed cases / deaths, the UK doesn't have a correct picture of the current state of the epidemic. Accurately controlling and predicting a currently-exponential function like that is recklessly dangerous. This will not end well. My humble opinion.

Agreed, they are publicly stating 4 weeks behind Italy - that's at least 2 weeks behind the curve.

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