Search Results for: care homes

The coronavirus care-home scandal has been smouldering away in the media for some time, flaring now and then into a headline issue. During PMQs on May 13th, for instance, Sir Keir Starmer managed to bump the issue back up the agenda, skewering Boris with a quote from guidance issued very early on into the outbreak by Public Health England (PHE). According to Sir Keir, the guidance had advised that it was “unlikely that people receiving care in care homes will become infected”. Although it didn’t seem particularly convincing at the time, Boris’s subsequent claim that Sir Keir had quoted from the guidance “selectively and misleadingly” turns out to have been fair – the quote in question was preceded by a note that the guidance was “intended for the current position in the UK where there is currently no transmission of COVID-19 in the community”. At the time of issuance this was true. Alas, the media had its story and the political damage had been done. (The guidance both politicians were referring to is here). What’s unarguable, though, is the grim seriousness of the situation within UK care homes. If the central aim of the UK Government’s lockdown policy was to protect the most vulnerable, then it simply hasn’t succeeded in the social care sector. As the Health Foundation has noted, relative to the start of the COVID-19 outbreak in England and Wales, care homes have seen the biggest increase in deaths over time compared to deaths that have occurred in other settings. Data released by PHE recently (and cited in the Independent) showed more than 650 care homes were now declaring outbreaks of coronavirus. As of May 15th, deaths in care homes from all causes are starting to stabilise, but remain 159% higher than at the start of the COVID-19 outbreak. Again as of May 15th, that number of care home deaths due to COVID-19 stands at 8,244. That’s nearly a quarter of all COVID-19 deaths recorded in the UK.

So what’s happened?

There are some sad but inevitable reasons for the over-representation of elderly care-home residents in the UK’s COVID-19 mortality figures. As this HPA report makes clear, care homes are naturally vulnerable to outbreaks of airborne respiratory diseases: firstly, infections are able to spread quickly because of close contact between residents in what is largely a closed environment; secondly, and due to the nature of their work, carers are regularly in close physical proximity to residents, thereby unintentionally spreading the infection when there’s isn’t appropriate protection (more on this point later); and thirdly, residents are often elderly and have other underlying diseases (the BBC has a good summary of these points).

But as many commentators have been keen to point out, there are also various social and political factors at play. In fact, what we’re really dealing with –when it comes to care home deaths – are two distinct, yet interrelated issues. The first is: Why have there been so many care home deaths that we know, or strongly suspect, to have been caused by COVID-19? The second issue is a little more complicated. It’s to do with why there have been so many “excess deaths” in UK care homes that we know, or strongly suspect, have not been caused by COVID-19? It’s worth taking these in turn. But in the meantime, you can get an idea of what this second issue is all about, thanks to Professor David Spiegelhalter’s brilliant set of graphs below. To locate the unusual “excess deaths” in care homes, take a look at the graph at the top left, and pay attention to all the bits of grey in each bar that appear above the horizontal dotted line.

Fail to Prepare and Prepare to Fail!

Was a lack of planning and preparedness in the social care sector a factor? Professor Martin Green, Chief Executive of Care England, certainly seems to think so. In a stark and, as it turns out prophetic, warning on March 10^th he said he feared widespread care-home deaths were inevitable if the virus swept the country. Speaking to the Independent, he hit out at what he said was the Government’s ignorance of social care and its importance.

“The system is gearing up for an NHS response, not a whole system response. I believe there is a real ageism issue here,” he said. “We haven’t heard any detailed plans. All we have heard is there are contingency plans. There is a complete lack of information.”

The fragmented, privatised and for-profit nature of social care provision in the UK has also been foregrounded as a possible problem here. The Care Quality Commission (CQC) and PHE aside, did a lack of overall control and joined-up thinking contribute to the crisis? David Rowland, Director of the Centre for Health and the Public Interest at the LSE, has written a good piece on this, looking at the political economy of social care in the UK and how COVID-19 has exposed serious, structural flaws in its current operating model. He points out that in one local authority, as many as 800 different care businesses are delivering care services. That sounds like a pretty difficult system to control from the top down. This Guardian piece from September 2019 also gives pause for thought. So too does the manner in which PHE, the CQC and the Department of Health and Social Care have repeatedly passed the buck in relation to who should carry out care-home testing (again, more on this later).

Hospital- and Community-Testing Issues

A lack of COVID-19 testing in the social care sector has been a huge area of concern for many commentators. As early as April 24^th, for instance, the Telegraph reported scathingly on a government diktat that NHS hospitals should move hundreds of elderly patients to care homes. Two Government policy documents published on March 19^th and April 2^nd (which, by the way, you can’t see anymore because they’re currently being “reviewed” – check out the covering info on the gov.uk link here) instructed NHS hospitals to transfer any patients who no longer required hospital-level treatment back into the care home system. The aim here was, of course, to increase the NHS’s critical care capacity because of the epidemiological modelling highlighting the risk of it being overwhelmed. The Government also set out a blueprint for care homes to accept patients with COVID-19. But at that point, clinicians could only decide which patients did or did not have COVID-19 on the basis of their symptoms, not a PCR test. According to one senior manager at the NHS who spoke to ITV recently, care homes may have unknowingly been receiving coronavirus patients from NHS hospitals very early on in the outbreak. Government care home advice prior to April 15^th (which, again, you can’t see anymore because they’re currently “reviewing” it – check out the covering info here) said that “negative tests are not required prior to transfers/admissions into the care home”. The Prime Minister has now made clear that the Government has “a system of testing people going into care homes” and that testing is being “ramped up”. Good to hear, of course. But quite late in the day.

Concerns have also been raised around testing capacity inside care homes. As the Guardian reported on May 12^th, ministers have admitted it will be more than three weeks before all homes are offered tests. Detailing a series of emails between the CQC and care home managers, they paint a picture of a system that is – in the words of one public health director – “shambolic”. The BBC has also noted that although more than 400,000 people live in care homes and are looked after by a workforce of 1.5 million, the number of tests carried out in the sector so far remains in the tens of thousands (although, as of May 15^th, the Government was suggesting that all residents and staff in care homes will have been tested by early June – see here for more). That’s clearly not enough testing. To date, then, the major problem in care homes seems to have been an inability to adequately separate COVID-19 cases from non-COVID-19 cases. It’s not particularly difficult to see why that might have allowed the infection to spread like wildfire through care homes full of vulnerable, elderly people.

Difficulties in Accessing PPE

A lack of adequate PPE in care homes has also been identified as a possible causal factor. The Financial Times reports that over the Easter period, the Association of Directors of Adult Social Services wrote to the Government complaining that “shambolic” national delivery efforts had produced “paltry” supplies of essential kit to a care sector treated as an “afterthought”. In April, the government put the firm Clipper Logistics in charge of setting up a central hub for the supply and distribution of PPE. Perhaps unsurprisingly to those who’ve followed the chequered history of public-private outsourcing initiatives in the UK, the online ordering system is yet to be rolled out. According to Wired, part of the problem lies in the structuring of the highly-fragmented social care market in the UK. This for-profit system, largely privately owned, has meant that collective action to deal with the spread of COVID-19 has often been thwarted. As David Rowland, Director of the Centre for Health and the Public Interest hints, because most care homes are operated by separate businesses in competition with one another, they don’t buy in bulk, together, from (usually) large suppliers, but end up purchasing PPE directly at highly inflated prices from (usually) smaller suppliers whose distribution and delivery chains are often less reliable and more prone to breakdown.

The Black Hole in the Care Home Figures – Excess Deaths

So far in this summary, only those care home deaths caused directly by COVID-19 have been considered. But there’s also a big issue with increased mortality in care homes not related to COVID-19 (see the above graphs). According to Professor Spiegelhalter’s analysis (available here), this issue shows up as a pretty big black hole in our care home death figures. For the five weeks up to May 1^st in England and Wales, care homes and homes would, if in line with the five-year average, have recorded 22,500 deaths. (There’s a lag in collecting this data, so May 1st is currently as far as we can go with this – but see the table below). The Science Media Centre also has a nice breakdown of this data (see here).

In fact, what they’ve ended up with are 52,000 deaths. This equates to nearly 30,000 extra deaths across care homes and homes. (Technical note: “care homes” comprise patients receiving long-term residential care outside of the patient’s house; “homes,” however, is a category that includes more than just “normal” family households – it also includes home care provision where social care providers visit the elderly in their own homes. So both of these categories include large proportions of the same type of person: elderly, vulnerable, and in need of regular contact with social care staff.) The problem is that only around 10,000 of those deaths have been labelled as COVID-19. This means that around 20,000 (11,409 + 8,411 = 19,820; see the table above) extra non-COVID-19 deaths have been registered in the community over the last five weeks. (It’s worth noting here that Professor Spiegelhalter’s estimates tally with the work coming out of LSE’s Care Policy and Evaluation Centre – they’ve recently estimated in excess of 22,000 deaths during this same period.) If around 6,000 deaths (5,689; again, see the table above) have been “exported” from hospitals (as per Professor Spiegelhalter’s analysis), this still leaves around 14,000 excess deaths. Some of this excess will almost certainly be the result of under-diagnosis of COVID-19. As the Daily Mail points out, the true scale of the crisis in care homes has probably been masked by a lack of routine testing, meaning thousands of elderly residents may have died without ever being diagnosed. Some of this excess could also be due to the inherently fuzzy nature of medical death certification. (See the BMA on this.) But even taking all of that into account, you’re still left with a lot of unexplained, excess deaths.

One likely explanation is that some of the excess is comprised of care home residents with other diseases who were not admitted to hospital when they should have been. At a recent Science Media Centre briefing, the Professor of Epidemiology at the London School of Hygiene & Tropical Medicine David Leon said: “Some of these deaths may not have occurred if people had got to hospital. How many is unclear. This issue needs urgent attention, and steps taken to ensure that those who would benefit from hospital treatment and care for other conditions can get it.” The Health Foundation’s recent analysis of up-to-date emergency care admission figures certainly gives weight to this idea. As of May 14^th, A&E visits were 57% lower last month than in April 2019. They also note “particular concern about the implications of a reduction in A&E visits for acute conditions such as stroke and heart attack” (i.e. two conditions that are likely to be over-represented within care home populations). Spiked have a great Q&A with Knut Wittkowski, former Head of Biostatistics, Epidemiology, and Research Design at the Rockefeller University’s Centre for Clinical and Translational Science, that touches on this issue. But there’s something else that’s potentially a bit troubling here. According to Skills for Care, the care sector had approximately 120,000 vacancies prior to the COVID-19 outbreak. That’s a big staff shortage. As the BBC points out, this existing problem has been exacerbated by staff (in the absence of adequate testing procedures, see above) having to self-isolate if they or a member of their family has shown potential coronavirus symptoms. In addition, and to prevent the virus spreading between care homes, the Government – early on in the outbreak – requested that staff didn’t work in more than one care home.

So have some care home residents not been getting the care that they needed? Have early signs and symptoms of other, non-COVID-19 related symptoms, potentially not been caught early enough due to staffing shortages? It’s impossible to say right now, of course, but what price a public inquiry into this when the dust has settled on a post-COVID-19 UK?

Further Reading

‘Coronavirus outbreaks at four in ten care homes‘ by Francis Elliott, Times, 18th May 2020

by Dr Clare Craig FRCPath

Outbreaks of Covid in care homes appear to have spiked in September in the UK. Does this mean we will see a resulting spike in deaths? This article explores the possibility that a significant number of the alleged outbreaks in care homes could be based on false positive test results. The continuing absence of systemic cross-checking of alleged positive results against established clinical and diagnostic evidence such as loss of smell and distinctive CT chest scans remains deeply disappointing. At an absolute minimum, anyone who receives an alleged positive Covid result should be retested from scratch.

The percentage of tests carried out in the community that were reported as positives reached a steady state over the summer at 0.8 per cent of tests. Reaching a steady state like this over a period of weeks is suggestive of having arrived at the baseline false positive rate. Similar figures have been used by SAGE. Matt Hancock has said the figure is “less than one per cent”.

The argument in support of the idea that a significant proportion of national UK Covid diagnoses in July and August 2020 were actually due to false positives is provided in a separate blog post. This paper addresses the narrower issue of alleged outbreaks in care homes.

This is how a false positive ‘outbreak’ in care homes could conceivably happen:

Step 1

Start by testing the entire UK population of care home residents every 28 days for Covid. There are currently more than 460,000 people who are being systematically tested in this way in 17,000 care homes. With a 0.8 per cent false positive rate this will result in more than 3600 randomly distributed false positive results every month. These false positives are treated as if they are real cases. When two positive results occur in residents who have been in direct contact, an official outbreak is declared. Mass testing of this kind, with a constant false positive rate, would be sufficient for fake Covid ‘outbreaks’ to be officially declared at a steady monthly rate in random care homes all around the country. Indefinitely. This would happen without any actual Covid infections occurring at all.

Step 2

Once an outbreak has been declared in a particular home, residents of that care home are required to be tested at least every week (and sometimes as often as every 4 days). Let us consider, as a case study, a hypothetical care home with 40 residents (which happens to be an average number according to this report).

We will call our imaginary care home ‘Everglades’. After the outbreak is declared, Everglades test all their residents at least every week. As a direct result of the 0.8 per cent false positive rate, a new false positive case will be diagnosed in Everglades on average after every three rounds of further testing. If we include staff testing, then it would be even more frequent (because the average number of staff is 47 according to the same report).

When a further false positive result occurs, this will give the mistaken impression that the ‘outbreak’ is continuing in Everglades, even though no one in the home has had Covid at all. The same will happen in many other similar care homes where an ‘outbreak’ has been declared.

Step 3

Current policy is that an outbreak is not declared to be over until a full 28 days has passed with no new positive tests in that particular care home. To end an outbreak, each of the 40 individuals in Everglades must avoid the 0.8 per cent false positive rate on four occasions (without even considering tests on staff). This is assuming testing is carried out weekly – it would require seven lucky outcomes for each resident and staff member if testing is carried out every four days.

Consequently, if testing is weekly, there is only a 30 per cent chance that the non-existent ‘outbreak’ in Everglades will be declared to have ended after 28 days has passed. Over 70 per cent of the time, another false positive test will restart the 28-day clock and perpetuate the mistaken belief that an outbreak of Covid has occurred when there is no Covid outbreak.

These statistical realities mean that false positive results across care homes will continue to accumulate over time. Of course, larger care homes will be particularly prone to having fake outbreaks and will find it even more difficult to end them. After four months of weekly testing, a quarter of affected care homes with 40 residents could well still be stuck in their fake outbreak. The self-perpetuating statistically inevitable nightmare will have restarted the clock time and time again. The other three quarters are likely to have escaped after four months until their next unlucky false positive result. This is Kafkaesque.

Furthermore, all the residents affected may then think they are immune because they will mistakenly think that they have had Covid. They and their carers may start to alter their behaviour with potentially disastrous effects if a real outbreak occurs. Some residents may think they have caught Covid more than once as time goes by and the random false positive results keep coming. The terror and confusion this situation could cause amongst elderly people is a genuine disgrace.

Step 4

The fake outbreaks will inevitably feed through into the data on Covid deaths. A third of care home residents die every year which is equal to 3 per cent dying every month. Having mistakenly labelled multiple patients as having Covid, those that die within a month of ‘diagnosis’ will be recorded as having died of Covid because all deaths within 28 days of a positive result are presumptively labelled as having been caused by Covid, regardless of the clinical reality. As a pathologist, I find this kind of careless data gathering deeply frustrating. It is also potentially misleading on many levels.

Mass testing is leading to ‘outbreaks’

Mass testing in care homes, as described above, was started in July and was due to reach all such residents by September. Mass testing using a test with a false positive rate even as low as 0.8 per cent is a recipe for trouble. Public Health England’s guidelines were to test every care home resident (at least 460,000 people) every 28 days. This policy is questionable unless treated merely as a screening tool where subsequent confirmatory retesting is conducted de novo or where independent clinical evidence independently supports a positive diagnosis of Covid.

An attempt was made to try to avoid labelling hundreds of care homes as having outbreaks due to the known problem of false positives. It was mandated that an outbreak can only be confirmed where direct contact can be demonstrated between two residents who have both tested positive. The better policy option would have been mandatory retesting of all alleged positive Covid patients. The problem with the ‘direct contact’ rule is that the small size of many care homes means that direct contact could easily have happened by chance in such homes.

Across averaged sized care homes, like our imaginary Everglades, purely random allocation of positive results would statistically result in roughly a 1 in 4 chance of having one positive Covid test result and 1 in 25 chance of having two or more positive test results every month. Based on a random distribution of false positives to average sized cares homes, roughly 690 care homes would have two residents test positive every month.

There were 228 official outbreaks in the first week of September alone (see Figure 1). This was despite the care taken to ensure only direct contact between two alleged Covid patients could lead to the formal declaration of an outbreak. There is no way of knowing how many of these ‘outbreaks’ were generated by false positive test results due to the total failure to double check, by retesting, or clinically cross-check positive test results by requiring recognised independent diagnostic evidence.

The September spike now appears to be fading. Some, even many, of these may have been real outbreaks that are now slowing down. However, the decrease may have partially resulted from wider pressures on testing in September reducing the number of false positives found in care homes because results from testing were delayed significantly – but the data on this is opaque so no conclusions can be drawn yet. It is unconscionable that we cannot be sure how many of these official outbreaks were genuine.

Figure 1 is a graph from Prof Carl Heneghan showing government reported Covid outbreaks in red. The green line shows all acute respiratory infection outbreaks including Covid.

There have been at least 900 official outbreaks in care homes since July. The impact of these can be estimated based on a few assumptions. Say that 4 per cent of care homes have an outbreak currently, which is not an unreasonable percentage to assume. With that starting assumption, we can calculate that 4 per cent of the care home population equates to roughly 18,000 residents. The much higher-frequency testing of this cohort will therefore result in about 150 false positive diagnoses every week or roughly 600 a month.

Misdiagnosed patients can lead to distorted deaths data

If 600 nursing home residents are labelled as having Covid every month and 3 per cent of all nursing home residents die every month, then the random deaths of these patients within 28 days of them being labelled as having had Covid will be wrongly called Covid deaths. This translates to roughly 18 false positive Covid deaths every month.

These numbers will rise over time as more outbreaks are declared whilst simultaneously the declaration of the end of an existing outbreak is statistically fraught with difficulty, as we have seen. Assuming current policies are maintained then by Christmas, with accumulating fake outbreaks, we can statistically expect over 25,000 care home residents to be part of a fake outbreak in more than 1,000 homes. Based on the same calculations as above, these homes will account for over 26 deaths being wrongly attributed to Covid per month from fake ‘outbreaks’ because natural deaths will be wrongly attributed to Covid.

In addition to these 26 deaths from higher-frequency screening of fake ‘outbreaks’, the remainder of the care home population will still be screened every 28 days. This screening will result in thousands of further false positive diagnoses every month and the standard 3 per cent deaths per month from this cohort will result in 100 further wrongly labelled deaths per month. Finally, 95 false positive deaths could be expected per month when 30,000 tests were used screening the entire inpatient hospital population because a fairly steady proportion of the patients labelled with false positive Covid die from the problem that brought them to hospital in the first place. Inpatient testing has now increased to 70,000 tests a day. If patients are being tested twice the number of false positive deaths attributable to this screening will double.

Taken together, these errors could cumulatively account for around 50-70 deaths wrongly attributed to Covid per week from care homes and hospitals alone.

There is no evidence as to whether care homes with a declared outbreak are receiving inferior healthcare as a result, but since 3% of such residents of such homes die per month, anything that could result in a reduction in immediate and vital healthcare would be a serious cause for concern.

European comparators

Despite the striking rise in case numbers, death rates in Europe have remained minimal except in France and Spain. All countries are trying their best to contain the spread of what at first sight appears to be a second outbreak of Covid and carrying out screening testing in care homes is a common strategy.

Given the rise in deaths in Spain and France, it would be interesting to know if they have started screening care home residents in a way that looks similar to the UK. This may also have resulted in deaths being wrongly attributed to Covid if they have also failed to take steps to double check alleged positive cases.

The true death rate, which may still be significant, can only be observed once these false positive deaths are removed from the data both here and elsewhere in the world.

Figure 2 shows government recorded Covid deaths by date that the diagnosis was reported.

Data beyond death statistics may also be distorted due to misdiagnoses

As well as the distorting effect of false positives on the death statistics, a similar inference may be drawn about the data for total hospital and for intensive care admissions generally. Screening hospital patients on admission will result in a fraction being labelled as Covid due to false positive results. Worse still, the care home population being labelled as Covid positive are elderly, vulnerable and prone to respiratory infections at this time of year anyway so these patients may well present in hospital with symptoms consistent with Covid despite not having Covid. This could stretch the resources and facilities of hospitals unnecessarily if these cases are in fact false positives as well as skew the statistics on the alleged spread of Covid.

Diagnosing false positive test results as cases in care homes has the effect of increasing workload for the homes, instilling fear in residents, staff and relatives and artificially boosting the case numbers. Large numbers of elderly, frail patients may well be wrongly labelled as having Covid. When this is combined with their high risk of dying anyway, it is possible that multiple deaths could be wrongly attributed to Covid. The impact of these false positive Covid cases in care homes could easily have skewed the overall data on deaths from Covid, impacting negatively on policy making.

Suggested policy solution

All that is needed to distinguish real Covid outbreaks from fake ones is for the initial allegedly positive ‘cases’ to be retested from scratch with a different test kit. Testing needs to be carried out with care. A true Covid outbreak should only be declared when accompanied by clinically specific symptoms and signs. For example, 97 per cent of people suffering a sudden loss of their sense of smell in the spring had caught Covid. In addition, loss of smell is present in 65 per cent of real Covid cases and statistically would therefore be present in 96 per cent of true outbreaks of more than three individuals. Likewise, characteristic chest CT findings are also highly specific, even in mild cases.

The continued failure to cross check alleged Covid outbreaks using established clinical evidence of genuine Covid symptoms is a serious policy failure. The potentially material effect that the inflated figures relating to care home deaths may have had on public policy making means it is imperative that the evidence that such deaths have in fact been caused by Covid is watertight.

Key points

Vitamin D, contrary to popular thought, is not a vitamin. It is an inflammation-regulating steroid hormone involved in many of the body’s essential processes.¹ Leaked NHS internal guidance, issued in June 2020, states that “evidence supports a causal role in Vitamin D status and COVID-19 outcomes”, and urges clinicians to “monitor, report and treat”.²

Meanwhile, a NICE rapid evidence review also published in June, states “there is no evidence to support taking vitamin D supplements to specifically prevent or treat COVID‑19.” However, it does re-enforce its September 2018 advice that at-risk groups should take a 10µg supplement all year round.³

Rewind to March 2018: the ‘world’s biggest quango’ NHS England, released new guidance not to issue Vitamin D and many other commonly available over-the-counter (OTC) medicines on prescription, which was intended to save NHS costs by promoting patient self-care.⁴

Vulnerable elderly care home residents, many of whom lack mental capacity, are unable to obtain Vitamin D without a prescription, as Care and Quality Commission (CQC) regulations prevent tablets being given by care staff without GP Guidance.⁵

This logistical deadlock has not been resolved, and Vitamin D deficiency has long been known to be widespread in care homes.⁶ Over 19,000 care home residents in England have died with COVID-19, representing at least 36% of all COVID-19 fatalities in England and Wales.^7 8

Defining evidence: why the different guidelines?

Evidence is increasing that Vitamin D deficiency is causally linked to both likelihood of contracting COVID-19, and severity of infection.⁹

The NICE rapid evidence review,³ which states there is “no specific evidence” for Vitamin D in COVID-19, is heavily focused on the outcomes of the eight included studies, without corroborating this with the known physiological mechanism for how Vitamin D attenuates the inflammatory cascade in the lungs with coronaviruses.¹⁰ The physiology surely somewhat dispels the caution that NICE have that the correlation between low Vitamin D and severe COVID-19 may be incidental, or weakened by potential ‘confounders’. Confounders are factors which account for, or mask, an association. However, the confounders that the NICE review³ claim weaken three of the included studies could may actually strengthen when causal inference is considered. These confounders mentioned by NICE for Covid-19 severity included obesity, high blood pressure and socio-economic status: these are all independently linked to low vitamin D status.^11 12 13 Could Vitamin D status, therefore, be the common link? The physiological mechanism would support this. The NICE rapid evidence has excluded relevant data on countries affected by COVID-19 and their latitude, showing countries such as the UK, who are above the 30 ̊north latitude line, meaning there is not enough light for the skin to make Vitamin D all year round. Interestingly, in the UK, there is not enough sunlight between October and March, ⁶ meaning deficiency would be at its peak in the population at the end of March.

In short, the leaked report, now a published study,² is more comprehensive and credible than the NICE rapid evidence review, as it includes all the circumstantial as well as the forensic evidence.

Figure 1: SARS-CoV-2 enters the cell via the ACE-2 receptors within the renin-angiotensin system (RAS). Image courtesy of R&D systems.¹⁰

How vitamin D protects against COVID-19

Vitamin D acts to re-balance the renin angiotensin system (RAS). This is a hormone system that regulates blood pressure, fluid balance and vascular resistance. It is the dysregulation of the RAS that creates the pro-inflammatory cytokine storm in COVID-19, triggering the potentially fatal severe acute respiratory infection. Vitamin D moderates the RAS by binding to the ACE 2 receptor cells, attenuating the inflammatory response and lung injury. ^9 10

Known risk factors and vitamin D status

Well-known risk factors for COVID-19 have been well publicised to be age, obesity, ethnicity and socio-economic status. While there are social factors at play that increase risk for some groups, could Vitamin D also provide a physiological reason these groups are also at risk of severe COVID-19 infection? A very interesting study conducted in Israel showed that COVID-19 outcomes were worse in communities where traditional dress was worn, and where individuals had poor vitamin D status. This took into account and adjusted for baseline characteristics such as age.¹⁴

Table 1: Some better known risk factors for Covid-19 and their known link to Vitamin D deficiency

Risk Factor	Linked to low Vitamin D?	Linked to Covid-19?
Ethnicity		Darker skin less able to absorb. If cultural clothing covers skin, UV light cannot be absorbed 14		BAME communities identified in UK as more susceptible
Obesity		Vitamin D is fat soluble, and dilutes into fat cells, making it less available13		Obese identified as more likely to require ICU admission for COVID-19
Socio-economic status		An independent risk factor for Vitamin D deficiency11		Thought to be due to social factors such as working in hospitality and living in densely populated areas.
Type II Diabetes		VD protects against T2 diabetes by reducing parathyroid levels1 6		NHS trusts reported in spring that type II diabetics were more likely to require ICU treatment
Older age		Skin is less able to absorb with age3 6		The majority (estimated 74%) of COVID-19 deaths have occurred in over 70s.

Death stats for nerds

The evidence is increasingly undeniable that Vitamin D is linked to COVID-19. We also know that Vitamin D is not routinely given to residents in care homes,⁵ and in general, the guidance to take supplements is not widely promoted. Could this be partly to blame of the shockingly large number of deaths this year in England’s care homes?

The following data have been compiled by this author from the published ONS Excel spreadsheets on deaths in care homes,⁷ and total deaths attributed to COVID-19 in England and Wales⁸ with some totals and percentages worked out, so they can be viewed in a context that wouldn’t be seen on the BBC news.

Table 2: Covid-19 Death statistics for care homes in England

Percentage of all COVID-19 deaths (England and Wales) who are care home residents in England*	36% (19,726 of 54,678)
Percentage of deaths of all causes (England and Wales) who were care home residents in England	17% (84,740 of 494,975)
Percentage of care home COVID-19 deaths that occurred in the care home and not in hospital (indicating only palliative treatment offered)	75% (14,722 of 19,726)
Percentage of all England and Wales COVID-19 fatalities over 80 years of age	61% (33,352 of 54,678)
Percentage of all England and Wales COVID-19 fatalities over 70 years of age	74% (40,696 of 54,678)

*This is likely to be an underestimate, as ONS state that deaths recorded early in the pandemic were not attributed to COVID-19. ⁸

A shocking 36% of all deaths in England and Wales attributed to COVID-19 have been of care home residents under NHS England. These are the most vulnerable in our society, and have already been failed in many respects through the pandemic, as limited resources and PPE were prioritised for the NHS.

Ambiguity and conflicting guidelines preventing treatment

Before Vitamin D was linked to COVID-19, there was already an inequality with Vitamin D provision, detailed in this study. A Catch-22 between the NHS England prescribing ban, the CQC strict policing of supplement administration, and a failure of Local Authority Public Health promotion of existing guidelines (10µg per day), meant that giving much-needed Vitamin D supplementation to care home residents fell through a large but unnoticed gap between different agencies’ responsibilities, rules and regulations.^4 5

Given that most of the deaths from COVID-19 occurred in care homes and not in hospital, we may never know how many of these were vitamin D deficient, as recent blood tests are less likely to be available. However, the circumstantial evidence is stacking up well that this failure may have contributed to the care home death toll.

The million dollar question is, was NHS England’s do not prescribe guidance ever intended for care home residents in the first place? The document describes items not to be routinely prescribed in primary care. Primary care by definition, is ‘first’ point of contact care, e.g. an independent person rocking up to their GP and requesting a prescription. Quite rightly, if this prescription request is for something cheaply and easily available at the pharmacist, that person should go straight there. However, it could be argued that care home residents are not directly linking in with primary care, but their main source of care is in the tertiary/social care sector. Therefore, the NHS England prescribing guidance is arguably not applicable to them. Were local Clinical Commissioning Groups (CCG’s) ever intended to issue guidance that a care home resident with limited capacity should be responsible for their own Vitamin D as ‘self-care’, when all their other medications would be controlled on their prescription? Or was this a tragic error of interpretation by CCG’s of what is actually shockingly ambiguous guidance?

We don’t have the answer to that now, but this author has submitted a Freedom of Information request to obtain it. So within 20 days, we may have.

If the answer is no, then vulnerable care and nursing home residents have been left without a simple and cheap treatment that could have protected them from COVID-19 because of a misinterpretation of an ambiguous guideline, and because no-one along the chain of events sought to clarify it. If the answer is yes, it was intended for care home residents, then the next question is – why?

That answer is in the guidance – it’s to reduce NHS prescribing costs. But by now much? The recommended dose required to maintain good blood vitamin D levels and to prevent deficiency is 10µg, equivalent to 400 International Units (IU’s).⁶ Two months’ supply of a 100IU tablet (taken every other day, giving 12.5µg/500IU’s per day) can be obtained for as little as 59p by the NHS. That’s a cost of 30p per patient per month.¹⁵

Conclusion

The combination of loneliness, lockdown, and denial of a cheap and evidence-based treatment amounts to an abysmal failure of the most vulnerable members of our society. As we are locked down again, and the economy left to likely ruin, why is this safe, well-evidenced and ridiculously cheap treatment being ignored? This has to stop now. NHS England must review their position, and allow for and actively promote prescribing to those who cannot buy Vitamin D. If this Government really cared, instead of ‘stay home, protect the NHS, save lives’, they would stay ‘stay sane, take vitamin D, you could survive’.

References

1 Bilke, D.et al.: Vitamin D, an ancient hormone. Available at https://onlinelibrary.wiley.com/doi/abs/10.1562/2005-02-02-IR-430. Accessed 5^th November 2020.

2 Davies, G. et al.: Covid-19 and Vitamin D information. Available at https://docs.google.com/document/d/1jffdZOSuIA64L_Eur8qyCQ12T7NXrHSKPxtMe134C0Y/mobilebasic?fbclid=IwAR0lYaw5dKPFd-vUmvTm5GD8uZYZ_E6Hl9SSj32FjuuCkJBy-YB6heKy30w. Accessed 4^th November 2020.

3 National Institute of Clinical Excellence: COVID-19 rapid evidence summary: Vitamin D for COVID-19. Available at https://www.nice.org.uk/advice/es28/evidence. Accessed 4^th November 2020.

4 NHS England: Conditions for which over the counter items should not be routinely prescribed in primary care. March 2018. Available at: https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf. Accessed 4^th November 2020.

5 Williams, J et al.: Responsibility for vitamin D supplementation of elderly care home residents in England: falling through the gap between medicine and food. Available at https://www.medrxiv.org/content/10.1101/2020.06.21.20136697v1. Accessed 5^th November 2020.

6 SACN (Scientific Advisory Committee on Nutrition). Vitamin D and health. London, 2016 https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report

7 Office for National Statistics: Number of deaths in care homes reported to the Care Quality Commission. Available at https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/numberofdeathsincarehomesnotifiedtothecarequalitycommissionengland. Accessed 4^th November 2020.

8 Office for National Statistics: Deaths registered weekly in England and Wales, provisional. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales. Accessed 4^th November 2020.

9 Davies, G. et al: Evidence supports a causal role for Vitamin D status and Covid-19 outcomes. Available at https://www.medrxiv.org/content/10.1101/2020.05.01.20087965v3. Accessed 4^th November 2020.

10 R&D systems: ACE-2: The Receptor for SARS-Cov-2.AVilale at https://www.rndsystems.com/resources/articles/ace-2-sars-receptor-identified. Accessed 4^th November 2020.

11 J Léger-Guist’hau et al. Low socio-economic status is a newly identified independent risk factor for poor vitamin D status in severely obese adults. Available at: https://pubmed.ncbi.nlm.nih.gov/27524803/. Accessed 4^th November 2020.

12 Pils, S. et al.: Vitamin D status and arterial hypertension: a systematic review. Available at: https://www.nature.com/articles/nrcardio.2009.135. (Abstract). Accessed 4th November 2020

13 Walsh, J. et al.: Vitamin D in obesity. Available at https://pubmed.ncbi.nlm.nih.gov/28915134/. Accessed 4th November 2020.

14 Israel, A. et al.: The link between vitamin D deficiency and Covid-19 in a large population. September 2020. Available at https://www.medrxiv.org/content/10.1101/2020.09.04.20188268v1.full.pdf. Accessed 4^th November 2020

15 drugtarriff.co.uk: https://www.drugtariff.co.uk/DrugInfo/drugdetails.aspx?doseid=580784. Accessed4th November 2020.

by David Crowe

Sweden has been a political football in the argument over whether lockdowns work. Lockdown enthusiasts point to the higher death rate than in other Scandinavian countries while skeptics point out that the rate is lower than Italy, Spain and the UK. But the more important question is why the death rate is in the middle. The answer is because Sweden actually did lock down, in the most important way.

Before I defend this counter-intuitive position it is important to note that the term “COVID-19 lockdown” is not well defined. In several countries people were confined to their homes, but in other places, such as in my province of Alberta, Canada, people could go out, although they would find that all restaurants, bars, playgrounds, concert halls, swimming pools and shopping malls were closed. In reality every country’s lockdown (and in places like the United States and Canada, every state, province and even city) was different. In Alberta, Canada, when hair salons were opened, massages were still banned, but in Ontario, hair salons were banned but massages were allowed.

Sweden only chose two dishes from the lockdown menu: banning large group events and visitors to hospitals and nursing homes.¹I will use the term ‘nursing home’ for homes for the elderly, or seriously injured, who cannot look after themselves, who need help eating, dressing, going to the toilet etc. As opposed to retirement homes where people will perform these functions themselves. Different countries have different terms for the facilities that are provided for the oldest and sickest people in society who do not need hospitalization.

If we were God, we could assign two values to every item on the lengthy lockdown menu: the number of lives saved from death by SARS-CoV-2, and the number of deaths caused by that aspect of the lockdown. Of course we are not God, but there is evidence that the combined effect of whatever menu items were chosen has killed lots of people. For example, calls to suicide help lines and actual suicides are up. In Canada, opioid overdoses have been rising during the COVID-19 panic. Psychological distress among US adults has dramatically increased. We can guess that deaths from alcoholism, mental breakdowns, and domestic violence will also rise, although in many cases it will not be until next year that we have the statistics to prove this.

I am not the only person who believes that the intensity of the demonstrations, looting and rioting in the United States comes from keeping young people cooped up at home, taking away the socialization and stimulation that they get at school, at their part time jobs, at soccer practices, shooting hoops or just hanging out at the beach, park or shopping mall. Now that the murder of George Floyd by four white policemen has blown the lid off the pressure cooker it will take a long time for the pent-up energy to dissipate. But this is just a belief, nobody can prove that the anger and sometimes violence is partly due to the lockdown and not entirely due to the too frequent occurrence of abuse and killing of black men by police officers in the United States.

But, back to the issue of assigning relative numbers to the menu items. Readers of this article are likely not in the target zone for death by COVID-19. The majority are probably younger than 70, and those who are older are probably not suffering from multiple, serious pre-existing, health conditions. Naturally, you will see the effect of the lockdown on yourself most intensely, and may ignore the parts that do not affect you. During times and places where home confinement was mandated you couldn’t go out, you couldn’t visit relatives, you couldn’t go for a coffee with a friend, you couldn’t exercise, you couldn’t go for a drive, you might have had to try to juggle online work with online education of your children. You probably didn’t think about the people in nursing homes who were cocooned (to use a phrase recently employed on lockdownskeptics.org), out of sight, out of mind. If anything, you thought that perhaps their isolation had occurred too late, that the practice was protective, and if you had criticisms it might have been of events like the New York governor sending patients from hospitals to nursing homes where they could spread the virus, or that the banning of visitors occurred too late.

Each of our imagined relative numbers for the deaths from each lockdown menu item is the product of two factors: the likelihood of killing one person, and the number of people affected. Given that in many countries it is mostly old people in nursing homes or hospitals who are dying, we need to ask what aspects of the lockdown are most likely to harm these people. They are not affected by restaurants being closed, or playgrounds, or swimming pools, because they cannot use these facilities. But is the effect of their isolation in nursing homes (or hospital wards) purely benign, and protective from COVID-19? Are there any dangers?

I postulate that, in fact, the largest relative number for lockdown harms should be assigned to the dangers of banning visitors from nursing homes and hospitals, and the removal of almost all social contact from these frail old people. This may be the most dangerous aspect of the lockdown due to the severe impact on the elderly people housed there, and due to the large number of people affected (the largest portion of the population with deaths blamed on SARS-CoV-2). On this basis, Sweden, having banned visitors to nursing homes and hospitals like virtually every other European country, has a lockdown that is similar in negative affects to other western countries, hence the similar mortality rate.

Nursing Homes Under Lockdown

What is going on in nursing homes? Unless you work in one you are banned from entering, so it is difficult to know, but one can hypothesize a list of effects of the banning of visitors and the further isolation of residents within the nursing homes:

• Workers will be scared to death of being infected by their patients and therefore will keep contact to a minimum.
• Some workers will quit resulting in others being overworked.
• Other workers will test positive by the flawed COVID-19 RNA test and will be quarantined instead of working, for up to two weeks.
• The role that visitors play in ensuring that their loved ones are not neglected, not treated in unsanitary ways, and not abused will be removed.
• The assistance that visitors give the staff, in feeding their loved ones, helping them dress, and so on, will be gone.
• Any resident who is suspected of being infected will be confined to their room.
• Eating together will be banned.
• All social events will be cancelled.
• All outings will be cancelled.
• All non-essential health services, such as physiotherapy or exercise classes will be cancelled.

That there were horrors that were mostly hidden was actually known quite early, when in late March the Spanish army found abandoned people and dead bodies in nursing homes that they entered, because the staff had fled, out of fear.

More recently, we have more details on the nightmare within the nursing home walls, thanks to the Canadian Military. Soldiers were asked to go and assist in five of the most problematic nursing homes in Ontario, Canada, by the government, and what they saw shocked them so much that they wrote a detailed report to their superiors, which was released to the public, and needs to be read by everyone.

Awful treatment, that can easily be seen as leading to death, includes the following (read the entire report to be even more shocked):

• Unsanitary practices with parenteral (tube) feeding including liquid food that has curdled.
• Unsanitary catheter practices, and leaving them in too long (3 weeks in one patient).
• Fear of using supplies in a cost-conscious private facility.
• Wound changes that do not preserve sterility.
• Lack of wound care supplies, and consequent delayed changing of bandages.
• No mouth or eye care supplies.
• Poorly trained staff.
• Lack of staff (1 RN for 200 residents in one case).
• Patients sedated just because they are anxious, sad or depressed.
• Aggressive and rough treatment by staff.
• Forceful feeding and hydration leading to choking and aspiration.
• Leaving food in the mouth of a sleeping patient.
• Insufficient turning of patients in bed to prevent bed sores.
• Patients left in soiled diapers.
• Putting diapers on patients instead of letting them go to the toilet.
• Patients crying for hours without getting attention.
• Not putting patients in wheelchairs but leaving them in bed continuously.
• Taking mobility aids away from patients so they don’t wander.
• Cockroaches and flies.
• Trays stacked with rotten food.
• Lack of feeding and hydration.
• No way to receive personal supplies from outside, such as magazines, snacks, shampoo, and soap.

These horrifying practices of abuse and neglect need to be added to the intended neglect, the removal of virtually all sources of stimulation.
We could compare what is left for these unfortunates to the “Joy of Life” standards for nursing homes in Norway. They define five dimensions that they believe contribute to a nursing home that provides the best possible care:

1. Positive relations: Relations with caring and loving family members and friends. Being cared for by a positive healthcare staff.
2. Belongingness: The need of belonging to someone and the necessity of having someone to belong [to]. The need [to] love and care for someone and [to] be loved and cared for.
3. Sources of meaning: Participating and engaging in daily activities, being valuable to others and [capable] of helping others. Make their own decisions in daily life.
4. Moments of feeling well: Experience small glimpses of the world outside. Attend social and cultural activities like concerts, theatre, visit a restaurant and being out in the natural environment. Having visitors.
5. Acceptance: Being able [to accept] one’s life the way it is. Adapting and accepting one’s life situation.

Although standard nursing homes have probably never provided all of these aspects, at least not very well, the lockdown of old people, the banning of visitors, the panicked and overworked staff, has resulted in a complete and absolute removal of anything that could contribute to the “Joy of Life”. Did anyone ask even a single resident whether they would like to take their chance on the virus and continue to live life as normal?

The Canadian Forces report briefly mentioned sedation, but Spanish medical documents indicate that this is the solution when hospitals don’t want nursing home patients which, in Spain, is all the time right now. SECPAL, a Spanish palliative care society, writes (my translation):

In patients with COVID + a poor prognosis, and poor control of symptoms, who are not candidates for treatment in an ICU it could indicate that palliative sedation is necessary when the ordinary treatment is insufficient, and symptoms cannot be controlled.

Palliative sedation is performed with Midazolam, a benzodiazepine medication, that has a side effect of suppressing efforts to breathe. If the maximum dose of Midazolam is reached, then Levomepromazine should be used instead, a neuroleptic drug. Some of its side effects include on blood pressure and the heart.

It is important to understand that these patients may have health conditions that could be treated, and that untreated may cause pain. Sedation will not make the cause of the pain go away, but as the pain increases the patient will be pushed closer and closer to a coma.

Finally, the SECPAL recommendations suggest the removal of various types of medication, but also hydration. Lack of hydration will lead to death.
Little is known about the specific situation in Sweden, but according to a BBC report, workers are coming forward to state that transfer of residents to hospitals is discouraged, and that nursing home staff are not allowed to administer oxygen without the approval of a doctor.

Conclusions

I believe that the isolation of patients in nursing homes has not prevented deaths, but has caused deaths. Elderly, infirm people have nothing to live for any more, and poor care and abuse can no longer be observed, and stopped, by visiting friends and relatives. Underpaid staff, those who have not quit or been put in quarantine, are even more overworked than normal, resulting in poor care, frustration and abuse. Hospitals do not want nursing home patients, and the recommended alternative for the nursing home is to sedate and, if that doesn’t work, sedate some more.

Sweden, like virtually every other country, imposed an absolute ban on nursing home visitors. If this is the most destructive part of the lockdown then it is fair to say that Sweden did actually lock down when they banned visitors to nursing homes on March 31st, and this explains why its death rate is in the middle of the pack. We will never know if Sweden would have had a far lower death rate if the doors of their nursing homes had been left open to the outside world.

David Crowe is a Canadian independent researcher of infectious disease models and the host of a weekly radio show in Canada called The Infectious Myth.

This research was compiled by a financial researcher and fund manager who wishes to remain anonymous.

There are a few main reasons to be optimistic we should end lockdowns and get back to normal. 

1. We know who this coronavirus affects. The median age of death in almost all countries is over 80 with multiple existing conditions. We are failing to protect old people and are locking up the young and imposing social distancing when they have no risk of death. We can protect the vulnerable more intelligently.
2. Most people have immunity due to cross reactivity and cross immunization. The human immune system is not completely helpless against this virus. 
3. Herd immunity levels are much lower than people think and the virus appears to follow a Gompertz curve, which correctly anticipates the virus fizzling out.
4. In most countries, Covid deaths were 40-100% higher than a bad flu year.

The virus is bad but it is not the Spanish Flu and is most like the Hong Kong flu of 1968 and the Asian flu of 1957.  They were bad, but we never shut the entire world down for those. Flus are deadly, the world is dangerous, and we will all eventually die. But we won’t all die form Covid.   

Here is the complete collection of research and links categorized by subject. Examine the evidence for yourself.  

Lockdowns are Terrible Ideas and Not Standard Practice

Those in favor of lockdown present a false dichotomy. Either we have a hard lockdown or we let the virus rip and kill everyone. That is hardly the case.  Lockdowns and business closures are a sledgehammer that had no precedent in history and are not the way we have ever treated any virus or pandemic before.  The costs are out of all proportion to the benefits. Many other strategies would be far better. 

Here is a great case against lockdowns. How a Free Society Deals with Pandemics, According to Legendary Epidemiologist and Smallpox Eradicator Donald Henderson.

It concluded with this important paper.

There are no historical observations or scientific studies that support the confinement by quarantine of groups of possibly infected people for extended periods in order to slow the spread of influenza. A World Health Organization (WHO) Writing Group, after reviewing the literature and considering contemporary international experience, concluded that “forced isolation and quarantine are ineffective and impractical”. Despite this recommendation by experts, mandatory large-scale quarantine continues to be considered as an option by some authorities and government officials.

The interest in quarantine reflects the views and conditions prevalent more than 50 years ago, when much less was known about the epidemiology of infectious diseases and when there was far less international and domestic travel in a less densely populated world. It is difficult to identify circumstances in the past half-century when large-scale quarantine has been effectively used in the control of any disease. 

The negative consequences of large-scale quarantine are so extreme (forced confinement of sick people with the well; complete restriction of movement of large populations; difficulty in getting critical supplies, medicines, and food to people inside the quarantine zone) that this mitigation measure should be eliminated from serious consideration.

No country had lockdowns in their playbook. 

• For example, Canada’s pandemic guidelines concluded that restrictions on movement were “impractical if not impossible.” 
• Also, according to the Wall Street Journal, “The U.S. Centers for Disease Control and Prevention, in its 2017 community mitigation guidelines for pandemic flu, didn’t recommend stay-at-home orders or closing nonessential businesses even for a flu as severe as the one a century ago.” Lockdowns were never part of the US response
• Lockdowns were never part of the WHO standard responses for pandemics. You can read here all their policies and how they rated the evidence for various measures.
• Most Asian countries like Taiwan, Japan and South Korea didn’t have lockdowns and had far better experiences than the European countries that did. Those who are sick are not sent home to infect family members and are separated, which is the exact opposite of European lockdowns.

Here is a very good read on the arguments against lockdowns. In most European countries, cases were already falling before the lockdowns as people were voluntarily taking preventive measures: social distancing, hand washing, wearing masks. 

Many epidemiologists have been completely opposed to government plans and have in fact been right.  

Only pro-lockdown scientists are amplified. Here is a good read on “the science“.

Here is Sunetra Gupta of Oxford, who opposed lockdowns are gave a great interview on UnHerd. Likewise, Martin Kuldorff, a Harvard epidemiologist who has been ignored. He’s argued in favor an age and risk-based approach.

But what do these people know about science? They’re only epidemiologists at Oxford and Harvard. 

Lockdowns Were Not Needed or Effective

Lockdowns had almost no effect and the main determinants of death across countries was the percentage of people who were over 80, particularly men, and the % of people who are obese.

Here is a study in The Lancet showing lockdowns had no effect. The primary factors explaining deaths are obesity and age structure.

Here is a detailed study showing the virus behaved the same everywhere regardless of policy

Same is true on a county by county basis in the US, as you can read from this study. Whether a county had a lockdown has no effect on COVID-19 deaths; a non-effect that persists over time.

One of the biggest determinant of deaths from Covid related to the share of the population that was over 80, not to lockdowns. “Population age structures alone may account for four-fold variation in average regional infection-fatality ratios across Europe.”

and a useful visualization showing the high correlation between men over 80 as a percentage of the population vs death rates.

The other explainers for death rates are percentage of the population with hypertension:

and percentage of population with obesity/diabetes:

And a global look at obesity and death rates:

Deaths were falling before the lockdowns were imposed, as this study shows:

This is confirmed by many other papers, here and here. Here is a good article discussing these studies.

The same is true in other European countries. The decline in infections started before Germany even instituted lockdowns.

Bloomberg also found little correlation between severity of measures and death rates.  

The Collateral Damage From Lockdowns is Vast and Will Kill Millions

Lockdowns are the moral equivalent of carpet bombing, ineffective with vast collateral damage. 

Disruptions to food due to lockdowns may kill more from hunger than Covid.

Covid is not the only illness in the world and millions will die from interrupted care, for example from tuberculosis and HIV, as the New York Times reports.

“COVID-19 risks derailing all our efforts and taking us back to where we were 20 years ago,” said Dr. Pedro L. Alonso, the director of the World Health Organization’s global malaria program.

It’s not just that the coronavirus has diverted scientific attention from TB, H.I.V. and malaria. The lockdowns, particularly across parts of Africa, Asia and Latin America, have raised insurmountable barriers to patients who must travel to obtain diagnoses or drugs, according to interviews with more than two dozen public health officials, doctors and patients worldwide.

Unicef warns on the consequences of poverty and malnutrition for kids could harm millions. 

According to a stark report published in Lancet Global Health journal on Wednesday, almost 1.2 million children could die in the next six months due to the disruption to health services and food supplies caused by the coronavirus pandemic. 

The first famines of the coronavirus era are at the world’s doorstep, the UN warns.

COVID-19 could reverse decades of progress toward eliminating preventable child deaths, the WHO warns.

The Gates Foundation estimates that the response to Covid has set back vaccination 25 years.

Furthermore, there is good reason to believe that lockdowns increased deaths of the vulnerable and elderly. 

This is true in much of the world. Here is a study looking at how lockdowns drove excess deaths for non-Covid illnesses.

Interrupting medical care kills people.  More people died in Denver of unattended heart attacks during lockdown than from Covid.

New cancer diagnoses collapsed in the United States as the coronavirus pandemic first hit. Almost all diagnoses collapsed in the UK as well. 

And same was true for heart attacks and strokes in the NHS in the UK.

Analysis of NHS data reveals the deadly consequences of the government’s messaging to “stay at home, save lives, protect the NHS”. During the lockdown, there was a near 50 per cent decline in admissions for heart attacks. The risks of COVID-19 outweighed the risk of seeking NHS care despite worsening symptoms for many people: 40 per cent more people died from lower-risk treatable heart attacks than usual. For strokes, the situation is further exacerbated by living alone and not having visitors as 98% of emergency calls for strokes are made by someone else.

The economic damage is also horrific.

The World Bank estimates over 71 million will be plunged into extreme poverty due to lockdowns/quarantines

The United Nations has warned that response to Covid is reversing decades of gains in poverty, healthcare and disease

More Than Half of US Business Closures Permanent, Yelp Says. Half of black businesses in the US have been wiped out. 

The Virus is Not at all Deadly For Those Under 55

One paper looking at Infection fatality rates by age summarized it well. 

“The estimated IFR is close to zero for younger adults but rises exponentially with age, reaching about 0.3% for ages 50-59, 1.3% for ages 60-69, 4% for ages 70-79, 10% for ages 80-89.” 

In fact, the distribution of risk matches “normal” risk of death by age.

The Infection Fatality Rate is far lower than initially estimated.  

Here is the link to all the studies on infection fatality rates for Covid.  The evidence is overwhelming.

The virus is not at all deadly to younger people.  Here are death breakdowns by age group in the US and Europe

https://twitter.com/MLevitt_NP2013/status/1286177208583815168?s=20

and another visualization.

And from the Oxford for Evidence Based Medicine (scroll to bottom).

The median age for death in most countries is over 80 and the average person has multiple pre-existing conditions.

In Italy the median age was over 80 and 96% of people had existing conditions.

Spain showed exactly the same pattern.

Ireland is the same.

US – Median death age from Covid in the US was 80 years.  

That is slightly above the average life expectancy overall. 

In many countries the median age of death is above life expectancy, i.e. people had already lived longer than the average person. 

Covid is not at all deadly for those without significant co-morbidities.

Table 3 of the CDC’s data on deaths between 2/1 and 8/22 2020 says directly that only 6% of the 161,392 reported COVID deaths were listed as COVID-19 alone, just 9,684. All other US deaths had, on average, 2.6 additional conditions. 

Population-level COVID-19 mortality risk for non-elderly individuals overall and for non-elderly individuals without underlying diseases in pandemic epicenters was very low.

The COVID-19 mortality rate in people <65 years old during the period of fatalities from the epidemic was equivalent to the mortality rate from driving between 4 and 82 miles per day for 13 countries and 5 states, and was higher (equivalent to the mortality rate from driving 106–483 miles per day) for 8 other states and the UK. People <65 years old without underlying predisposing conditions accounted for only 0.7–3.6% of all COVID-19 deaths in France, Italy, Netherlands, Sweden, Georgia, and New York City and 17.7% in Mexico.

People <65 years old have very small risks of COVID-19 death even in pandemic epicenters and deaths for people <65 years without underlying predisposing conditions are remarkably uncommon. Strategies focusing specifically on protecting high-risk elderly individuals should be considered in managing the pandemic.

Most people had hypertension as a co-morbidity. People with hypertension have a lower life expectancy with or without Covid

Irrespective of sex 50-year-old hypertensives compared with normotensives had a shorter life expectancy a shorter life expectancy free of cardiovascular disease myocardial infarction and stroke and a longer life expectancy lived with these diseases. Normotensive men (22% of men) survived 7.2 years (95% confidence interval, 5.6 to 9.0) longer without cardiovascular disease compared with hypertensives and spent 2.1 (0.9 to 3.4) fewer years of life with cardiovascular disease. Similar differences were observed in women…. Compared with hypertensives total life expectancy was 5.1 and 4.9 years longer for normotensive men and women respectively. Increased blood pressure in adulthood is associated with large reductions in life expectancy and more years lived with cardiovascular disease. This effect is larger than estimated previously and affects both sexes similarly. Our findings underline the tremendous importance of preventing high blood pressure and its consequences in the population.

The same is true for diabetes. Diabetes significantly shortens people’s lives with or without Covid.

According to the reports of Journal of American Medical Association (JAMA); men with type 1 diabetes have a shortened lifespan of 11 years than normal men. Women with the condition have their lives cut short by 13 years.

A 2010 report by the Diabetes UK claims that type 2 diabetes reduces the lifespan by 10 years. A 2012 Canadian study claimed that women aged over 55 years with type 2 diabetes lost on an average of 6 years while men lost 5.

The probability of dying under 65 without co-morbidities is extremely low to non-existent.  

It is far more sensible to protect the vulnerable than close society.

Children Do Not Spread the Virus and are Not at Risk

Sweden kept their schools open and not a single child died from Covid of over 1.8 million kids. 

Closure or not of schools has had little if any impact on the number of laboratory confirmed cases in school aged children in Finland and Sweden. Children are more likely to die from flu than Covid. 

https://twitter.com/gummibear737/status/1291399160827125762

No transmission from children in Greece. Transmission dynamics of SARS‐CoV‐2 within families with children in Greece: a study of 23 clusters.

From the Official Journal of the American Academy of Pediatrics. COVID-19 Transmission and Children: The Child Is Not to Blame.

No evidence of secondary transmission of COVID-19 from children attending school in Ireland 2020.  

German study shows low coronavirus infection rates in schools.

Children are not COVID-19 super spreaders: time to go back to school, from the BMJ.

The Royal College of Paediatricans and Child Health review of the evidence shows children don’t transmit the virus.

A CDC study showed very limited transmission in childcare settings.

Here are government reports all showing children are not the main source of transmission from the EU and Norway and Netherlands. In fact, children are more likely to be hit by lightning than die from Covid. The evidence is overwhelming.

Public Policy Response to Age Differences

Strategies targeted by age are likely to be much more useful at reaching herd immunity with less damage.

An age and risk based approach is by far the most sensible and what is advocated by epidemiologists like Martin Kulldorff from Harvard. Here is an article he wrote in The Spectator and LinkedIn. Here is a podcast he did. And here is another article in Contagion. In fact, he argues that delaying herd immunity is costing lives. The current lockdown is protecting the healthy instead of the vulnerable. He also wrote a very good piece on the proper response. Given the age differences in risk, policy responses should be age-specific.

The irony of shutting schools and universities and creating unemployment is that the very young and very old mix more than ever before. That is the unintended consequence of the response to the virus. We have the worst of all worlds. 

Elderly are Most Vulnerable, 50–60% of All Deaths Were Care Home Deaths

In most countries between 50-60% of deaths from Covid are from care homes. In some countries and states it is as high as 80%. What is extraordinary, though, is that this is largely a self-inflicted wound. Many infected old people were sent away from hospitals to care homes to infect others. This is true in the UK, NY and California.

This is by far the best site on all issues relating to care homes internationally. It shows percentage of all Covid deaths are 50-60% for almost all countries. Here is their main report with extensive data by country and 50-60% of deaths on average

In the first few months of the pandemic, 42% Of U.S. Deaths Are From 0.6% Of The Population in Care homes. As of September, according to the New York Times, 40% of US deaths were in care homes.

And you can read more here. The Real Pandemic Was a Nursing Home Problem. Here is a Wall Street Journal article with more data from US nursing homes regarding deaths

Some countries and states have 70-80% of all deaths in care homes. 

• Canada 82%  
• Northern Ireland 80%
• New Jersey at 76% 
• Sweden 70% (Very few non-elderly died in Sweden. This is a very good read on the problems of Swedish care homes.)  
• Ohio 70%  
• Pennsylvania 70% 
• Arizona 70% 
• Florida 70%  
  
  

This is an extraordinary resource that shows care home deaths in the US. In some states up to 10% of all nursing home residents died. It is likely care home deaths are understated and hospital overstated.  For example, 15% of hospital deaths in the UK were actually care home patients who went to the hospital according to the ONS. While Covid deaths are horrible, it is worth considering what life expectancy without Covid would be in care homes. Even without Covid, life expectancy is extremely short in care homes. You can read here and here. The length of stay data are striking:

• The median length of stay in a nursing home before death was 5 months 
• 65% died within 1 year of nursing home admission 
• 53% died within 6 months of nursing home admission 

The finding of median death in nursing homes being less than one year is confirmed in other studies. Those placed in care homes are often in worse health. Caregivers who institutionalise their relatives are substantially more likely to become bereaved than those whose relatives continue to reside at home. The zero-order odds of patient death more than double following admission to a nursing home. Instead of locking down children and young people, it might make more sense to protect the elderly.

Politicians Caused Care Home Deaths Through Bad Policy

In many states, infected old people were sent into care homes to infect others. Here was New York in April. Here is New Jersey, Pennsylvania and the Northeast. Here is the United Kingdom. This was not only done early in the crisis but as late as May when it was clear that care homes were hotspots. Governor Gavin Newsom ordered care homes take in infected residents in May. This is packed with links and further reading.  

The only correct historical analogy is the Siege of Caffa where Tartars threw infected bodies of the dead over city walls to spread the disease. 

Why Herd Immunity Thresholds Are Lower Than Assumed

It is highly likely that herd immunity for Covid is at much lower levels than people think. The main reasons are 1) populations are not homogenous i.e. we have different age groups with different susceptibilities, and 2) we all don’t mix randomly, i.e. most people live boring lives and see the same people every day.  Simply put, heterogeneity and non-random mixing massively reduce the threshold for herd immunity.

• Here is a good accessible explanation of why herd immunity levels are much lower than expected for many diseases.
• Here is an accessible introduction to the question of why estimating herd immunity isn’t straightforward or high as many articles claim.
• Here is a detailed blog post with links to studies on how the herd immunity threshold is lower than people think.  And a slightly more technical explanation and another one
• Here is a discussion of why immunity levels are lower than assumed.
• Here is a very good read from the British Medical Journal making the case. 
• Here is an academic paper on why Covid will have lower herd immunity thresholds. Here is a great podcast with the author who specializes in modeling herd immunity.  She wrote a paper arguing that herd immunity is closer to 20% for Covid due to high heterogeneity of population and low susceptibility.  So far, given how the virus is fizzling out almost everywhere there is a first wave, and the results of antibody tests, it looks like she’s right.  It is worth a listen.
• Here is a paper noting that Herd Immunity Thresholds are much lower in Sweden.  Given they had no lockdown and now have zero deaths or people in ICUs, this is the explanation.
• Another paper arguing, the disease-induced herd immunity level for COVID-19 is substantially lower than assumed
• Another paper showing that most first wave Covid locations are at herd immunity based on heterogeneous susceptibility
• Heterogenous transmission is likely why we have more cases with lower deaths, as this paper shows. The virus spreads in less susceptible people
• The reason care homes are so vulnerable is that populations are not heterogenous, as this paper shows. 
• Here is a broader read on heterogeneity of populations and the effectiveness of vaccines, which touches on the same issues of heterogeneity of susceptibility.
• Here is a discussion of the role of non-random mixing from a few months ago, which was much more accurate than the early estimates of vast deaths.

It is highly unlikely a majority of a population will not get Covid. Much lower effective herd immunization thresholds fit what we see every year with flus, even bad ones. 

• According to the WHO about 15% of people get flu a year.
• According to the CDC about 3-11%% of the population gets the flu any year, and that includes asymptomatic people.
• A 2018 CDC study published in Clinical Infectious Diseases looked at the percentage of the U.S. population who were sickened by flu using two different methods and compared the findings. Both methods had similar findings, which suggested that on average, about 8% of the U.S. population gets sick from flu each season, with a range of between 3% and 11%, depending on the season.

The last pandemic was H1N1 and that peaked at 20-24% of the global population during the first year. That is one the very high end.  

If you want further background reading, here is a terrific overview of herd immunity.

Most People Have Immunity and a Defence Response T-Cell Cross Reactivity and Cross Immunization

Early on, many politicians and scientists assumed Covid was very deadly because we had no existing immunity to Covid. This is not true. Many people do have some existing immunity to Covid. This comes from T-cells, which provide us with an immune response.

• A study of patients and their families shows that an unexpected six out of eight family members who caught the virus at home had T-cell responses but no detectable antibodies. Intrafamilial Exposure to SARS-CoV-2 Induces Cellular Immune Response without Seroconversion
• Important peer-reviewed paper in Nature about the likely immunity to COVID-19 conferred by T cells ‘SARS-CoV-2-specific T cell immunity in cases of COVID-19 and SARS, and uninfected controls‘
• Here is a paper on cross reactivity in Cell journal indicating 40-50% cross reactivity 
• Here is a paper on T-cell response to #SARSCoV2 was observed in 81% of uninfected individuals. This immune response was caused by prior exposure to ‘common cold’ coronaviruses.
• Here is a study done in Sweden showing 30% of blood donors had T-cell responses
• Here is very good piece explaining cross reactivity and why kids don’t get it and another and another
• Here is a brief discussion of another paper and the paper
• And another on SARS-1 providing cross reactivity

Cross reactivity is likely to come from other vaccines people already have. There is a strong relationship between MMR vaccine and age-stratified COVID fatality rates. Here is the study. MMR Vaccine Appears to Confer Strong Protection from COVID-19: Few Deaths from SARS-CoV-2 in Highly Vaccinated Populations.

Here is good summary of the issue of existing immunity and cross-reactivity for non-scientists in the Guardian and American Conservative.

In this interview, Sunetra Gupta from Oxford University hits on cross reactivity but doesn’t go into technical details. As she sees it, the antibody studies, although useful, do not indicate the true level of exposure or level of immunity. First, many of the antibody tests are “extremely unreliable” and rely on hard-to-achieve representative groups. But more important, many people who have been exposed to the virus will have other kinds of immunity that don’t show up on antibody tests – either for genetic reasons or the result of pre-existing immunities to related coronaviruses such as the common cold. 

Karl Friston has noted that up to 80% not even susceptible to COVID-19.

The Virus Naturally Fizzles Out and Most States/Regions Follow the Gompertz Curve 

We know that the virus naturally fizzles out because we have Sweden and Manaus in Brazil and other natural experiments where there were no lockdowns. In Manaus, there were no distancing measures either, and the virus fizzled out. 

In Sweden you can see deaths and ICU cases are in the single digits They had 5,800 deaths (70% in care homes, which they could have handled better) and today deaths and hospitalizations are in the single digits and zero most days. Their policy worked.  

Believe it or not, Sweden, where everyone was supposed to die due to no lockdowns, has had worse months of deaths from flu in the last 30 years in 1993 and 2000.    

All of this explains stories like this where experts wonder about why the virus fizzles out at a certain point. A curious pattern in coronavirus infection rate emerges, hinting it can ‘burn out’ at a certain point.

Farr’s law explains why viruses don’t grow exponentially and infect everyone. 

Nobel prize winner Michael Levitt has written a paper on the math behind how viruses fizzle out, which fits much lower herd immunity levels. Here is an explanation in plain English. 

Interestingly, there were a few papers from China and Spain (in Spanish, but you can use Google or Bing translator) that correctly predicted the peaks and end of the virus and number of deaths using Gompertz curves as far back as March. There are specific reasons why the virus follows a Gompertz function.

While some countries look like they’re having second waves or not following the Gompertz curve, the truth is they are. For example, Brazil is actually many big cities that have their own curves.

And deaths are following the Gompertz curve by city, so see Rio, for example.

All European cases are now close to zero and all curves look the same by country, and for Europe as a whole.

UK is at zero and looks exactly the same:

https://twitter.com/AlistairHaimes/status/1296477016531886080?s=20

The same is true in the US. Early states like NY and NJ have almost no deaths and look like Europe. Later states that had no first wave looked like Eastern Europe. It is now peaking and turning down.  

The Virus is Fizzling Out

Notice in every single Western European country the virus has fizzled out and deaths are running below one per million per day and in most countries are near zero. 

Here is Europe’s aggregate chart:

Today everyone is worried about cases, but there are almost no deaths and it is all due to more testing.  

Despite the media’s breathless reporting of deaths, in most European countries, Covid deaths were 40-100% worse than a bad flu year (see below on all links for data).  

The hotspots in the sunbelt saw deaths peak in July.  Hospitalisations peaked in mid-July in all hotspots as well as visits for influenza, pneumonia and Covid according to CDC:  

You can see the trend in deaths has been falling:

Here is Arizona with all trends in the right direction with fall in hospitalizations, ICUs and even deaths:

Florida is the same.

Texas is the same.

Believe it or not, in the US excess mortality is now almost back to normal. 

While some countries look like they’re having second waves or not following the Gompertz curve and fizzling out, the truth is they are.  For example, Brazil is actually many big cities that have their own curves.  And deaths are following the Gompertz curve by city, so see Rio de Janeiro, for example.

Putting Covid in Perspective vs the Flu Globally

Currently, global deaths are 800,000 from Covid. 

Globally, the World Health Organization (WHO) estimates that the flu kills 290,000 to 650,000 people per year.  

So Covid is running a little over the upper end of world flu deaths annually. 

Europe

180,000 people have died in all of Western Europe from Covid. Here is a study of 2017/18 season. It states that 152,000 people died during flu season from flu and unknown pathogens. 

The impact of the 2017/18 influenza epidemic on mortality was similar to that of the previous influenza A(H3N2) dominated seasons in 2014/15 and 2016/17. The European number of deaths attributable to influenza was estimated to be 152 thousand persons. We found a lower influenza-attributable mortality compared to excess mortality, which may indicated that other circulating pathogens might also have contributed to the all-cause excess mortality.

See the European flu monitoring site showing flu vs Covid.  It isn’t twice as bad as previous bad flu seasons 2014/15 and 2017/18

Italy had 35,000 Covid deaths. 

But Italy always has more deaths from influenza than other European countries. 

It had excess deaths of 7,027 20,259 15,801 and 24,981 attributable to influenza epidemics in the 2013/14 2014/15 2015/16 and 2016/17 respectively.

That means Covid was only 40% worse than their worst flu year in the last five years.  

The UK has had ~46,000 deaths from Covid.

For some perspective, there were 28,000 and 26,000 deaths from influenza in the UK in 2014 and 2017.   

So the end result is the virus is about 40% worse than a bad flu year.

France has had 30,000 Covid deaths.

That is only 60% worse than the 2014/15 flu season in France with 18,300 deaths. 

Spain has had 28,000 Covid deaths.

But it has had about 15,000 deaths from flu in previous flu seasons, notably 2014/15. ”Using population models, it has been estimated that in the last two seasons, the flu may have been responsible for up to 15,000 deaths attributable to this disease.”

The Instituto Nacional de Estadistica says 15,000 for last two seasons, so that is a bad year. 

So Covid is basically twice as bad as a bad flu season in Spain. 

The US has had 190,000 deaths.

The flu season in 2017-18 had a median estimate of 61,000 deaths, but upper bound of the estimate is 95,000 deaths.  

The 2014-15 had 64,000 as top estimate for flu deaths. 

So Covid is roughly 60%-100% worse than the worst flu season we’ve had in the US.  

Another issue that is rarely mentioned is that Covid deaths and hospitalizations have been inflated. Here is the Irish Government’s analysis of Covid deaths.  Many people had the virus but did not die of Covid. 

Likewise, Britain’s official death toll from the COVID-19 pandemic was lowered by over 5,000.

Sites avoiding groupthink

They are worth bookmarking

Lockdown Sceptics

Swiss Doctor

Rational Ground

In Proportion

Lockdown Truth

The Iceberg