I'm replying to the below response from Andrei 'on-list', sort-of 'by
invitation', but I don't really intend this as a general change to
the practice I have implemented. I simply cannot guess which of the
things I write may be of interest to a significant number of list
members and which will simply annoy them!
I'm still pretty confused about the 'testing' and 'counting' issues,
particularly in the UK. However, I've made most of my points before,
so this will probably be a bit repetitive.
To start with, as I've said before, I am not at all convinced that,
for most purposes, a 'count' (of infected people) is really very
necessary or useful. Provided only that (particularly within a
country) one assumes that (because of Covid-19 infection) the number
of people requiring hospitalisation, the number requiring intensive
care and the number dying are fairly constant proportions of the
number of people infected, then any of those measures (all easy to
determine with a reasonable degree of accuracy) is an adequate
surrogate for the total number of people infected - and therefore can
be used for monitoring of progress/evolution of the outbreak, the
effect of various measures taken etc.
The one obvious value of testing is in relation to
tracing/identifying (and then isolating) infected contacts of
infected people (at least to determine 'who they may have caught it
from', even if they have been isolated since the onset of their own
infectivity). However, we seem to have largely lost the ability to
do that in the UK. Since people believed (clinically) to have been
infected are now being told not to tell anyone, it seems that we have
lost our ability to attempt to trace (and test) contacts in maybe 80%
of infected people, since the only 'known infected people' will be
those who became ill enough to require hospitalisation or those
(probably fairly few) healthcare workers found to 'be positive' on
routine testing. This all seems rather unfortunate - and I'm not
sure how much notice I am going to be taking of the published UK
'cases' figures from now on!
As you say, it will be good once an antibody test is
available. However, although, like you, I do not think such a thing
yet exists, I gather that, in addition to the PCR test, at least a
couple of tests for the virus based on immunoassay have been
developed (or are being developed (well, that's what Mr Wikipedia
says!). If that's the case then, speaking from a position of almost
total ignorance about such matters, it sounds as detection/assay of
the antibodies may well be possible.
As for my clinical question (albeit rather off-topic for this list),
I think you have left it largely unanswered! As I said, it could be
a lot to do with the passage of time, given that most of my relevant
clinical experience (in 70s and early 80s) pre-dates yours by a
couple of decades.
Apart from anything else, most hospitals I worked in or knew about
had less than a dozen ICU beds, many of which were usually occupied
by post-op patients, trauma patients and youngsters with various
illnesses, whilst the geriatric and general medical wards were
teeming with elderly patients dying of pneumonia of one sort or
another (many without an underlying lethal disease). Whilst that
alone would have explained 'dispassionate age discrimination', I
don't think that was the main consideration. As you say, the primary
criterion for deciding whether or not to offer
intensive/sophisticated care to someone is the judgement as to
whether such care is likely to 'save their life' - and, as I've said,
the general belief in those days was that intensive care (including
ventilation) would rarely prevent the death of an elderly patient
with severe pneumonia (of any type). That is why, as I said, I'm not
sure that a suggestion from me that a person of 70s+ with pneumonia
should be offered intensive care back then would have been taken very
seriously.
However, as I've said, maybe thinking has changed about
that. Indeed, whatever the current clinical thinking, the
public/politicians/media certainly seem to be implying that anyone,
of any age, suffering from severe Covid-19 infection should be able
to expect, and receive, intensive care (including ventilation, where
appropriate), even if the circumstances (including age) are such that
recovery is unlikely.
Kind Regards,
John
At 08:34 18/03/2020, Andrei Morgan wrote:
>Hi John, hi all,
>
>You raise a number of really interesting points, so I'm also replying to
>the list (as you indicated you were ok with in a previous mail).... I am
>not sure why you didn't send this mail there as it is a really good
>example of a great and interesting mail that I am sure people would love
>to read!
>
>So, first point to address which I will also re-address is you are right,
>list traffic seems to be a pendulum and has now hit near zero, can we
>have a happy medium? I did not want to stop all discussion!
>
>The issue regards testing is, clearly, a major issue in the UK - and
>perhaps even more so in the USA. Simply put, if we don't test, we don't
>know. But to me, the more important thing is to be very strict and clear
>with diagnostic criteria: we saw that already with the Chinese in
>January when they changed their diagnostic criteria overnight from those
>with a positive PCR test to those with the clinical symptoms - the
>numbers jumped and it appeared as if the epidemic had surged. In the UK,
>to my mind the biggest problem is the government has not been
>clear. Obviously testing is better than clinical diagnosis but mixing
>the two (e.g. saying "you probaby have COVID-19 if you have these
>symptoms, so stay home for 2 weeks" but only recording people with
>positive PCR results in the figures) is actually pretty dangerous as you
>just sow confusion. That said, the most useful test is going to be when
>we can measure antibodies - i.e. resistance to the disease. As far as I
>know, that's not yet possible.
>
>Regarding your question/point in relation to ITU provision... I trained
>at Bristol in the South West in the 1990s. I remember the Care of the
>Elderly ("geriatrics") placement that we did: like all the other
>placements, people got posted from Truro to Gloucester. And the
>definition of "elderly" varied very strongly by location, depending upon
>the local demographic. In many/most places it was 70-75 - but in Torquay
>the care of the elderly team only became involved with patients over 90!
>Furthermore, the availability of resources will also influence things -
>how many beds are there per local population (and what is that
>population make-up)? My second story related to this is that the
>implementation of advanced medical technology is very related to (the
>perception of) underlying pathology. If you have something that will get
>better (pneumonia) you are much more likely to have aggressive treatment
>initiated than if there is an irreversible condition (end stage lung
>cancer, for example).
>
>Best wishes,
>
> -- Andrei
>
>On Wed, Mar 18, 2020 at 01:08:12AM +0000, John Whittington wrote:
> > Hi Andrei,
> >
> > At 23:44 17/03/2020, Andrei Morgan wrote:
> >
> > I've spent quite a lot of time today writing some analysis about it:
> > [1]https://www.andreimorgan.net/posts/covid_strategy/
> >
> > Many thanks - that's very interesting, so many thanks for all your
> > effort. Needless to say, there are plenty of points you raise that I
> > would like to discuss, if there were time, but everything you
> write seems
> > very reasonable.
> >
> > If you have the time to read, just a couple of thoughts/questions ...
> >
> > Firstly, I'm not at all clear as to what the reported UK 'case' figures
> > will mean as we move forward. Although the politicians are
> now promising
> > that we will 'do a lot more tests', I'm not at all clear on
> who we will be
> > testing, given that the advice given to the UK population a few days ago
> > seems to have cut off the supply of indicators of who should be tested.
> > Maybe I'm missing something, but it looks as if the figures will come
> > increasingly to be dominated by those ill enough to require
> > hospitalisation, together with (mainly uninfected) healthcare
> workers. In
> > particular, the potential contacts of those who have been
> infected cannot,
> > in general, now be detected and tested, because infected people have now
> > been instructed not to tell anyone who they are (unless they become
> > seriously ill)!
> >
> > Secondly, I'm just had a very interesting look around your website. I
> > hadn't realised that you were a clinician, so I will try
> bounce a clinical
> > question off you. We know that the majority of people who
> develop severe
> > illness (including those who die) will be elderly. We are
> also seeing an
> > awful lot of excitement about the availability (or
> 'overwhelming') of ICU
> > resources and the need to manufacture a lot more ventilators etc. This
> > leads me to wonder whether perhaps 'times (and expectations)
> have changed'
> > a lot more than I would have imagined.
> >
> > It's not a particularly comfortable thing for me to think about, given
> > that I am now a few months past my 70th birthday, but I think
> that if, ~30
> > years ago, I had suggested that a person in their 70s, let
> alone 80s, with
> > a life-threatening chest infection should be admitted to ICU/ITU and
> > ventilated, I might well have been laughed at - both because
> (even without
> > epidemics/pandemics) pressure on ICU beds was always very high
> but, also,
> > since it was generally believed that such a patient would be
> very unlikely
> > to survive even if they were ventilated - but maybe that wasn't correct,
> > since what you write in your.report implies that 50% of ventilated
> > patients with Covid-19 infection might actually survive.
> >
> > So I can't help but wonder whether things/expectations have changed. I
> > suppose that I might gain some comfort from that, in as much as it seems
> > to imply that if I found myself suffering from a life-threatening viral
> > pneumonia I could expect to be ventilated (whereas just a few
> weeks ago I
> > would have doubted that anyone would consider doing that!) and
> that, if I
> > were ventilated, I might stand a 50% chance of surviving. Is
> that how you
> > understand the present situation/intent/practice in the NHS? I suppose
> > another possibility is that, ironically, expectations of treatment
> > available during a crisis situation such as we are in might be greater
> > than they would have been in a non-crisis situation - i.e. maybe I would
> > be ventilated because we are having a Covid-19 outbreak
> whereas I wouldn't
> > have been ventilated if I had been suffering from an equally
> severe chest
> > infection a few weeks earlier, but from a different cause?!
> >
> > As a final comment, it certainly does seem that (unless you believe in
> > co-incidences!) my taking my activities 'off-list' seems to have put a
> > stop to discussions about Covid-19 on RadStats - all we've
> really seen in
> > the past 24 hours are really a small handful of posts with links, and
> > nothing that I would call 'discussion'. Although things were getting a
> > bit out of hand, I think it's a bit of a pity that we've seemingly 'gone
> > from the sublime to the ridiculous' - but maybe that's what people want!
> >
> > Thanks again, and try to keep safe.
> >
> > Kindest Regards,
> >
> > John
> > ----------------------------------------------------------------
> > Dr John Whittington, Voice: +44 (0) 1296 730225
> > Mediscience Services Fax: +44 (0) 1296 738893
> > Twyford Manor, Twyford, E-mail: [log in to unmask]
> > Buckingham MK18 4EL, UK
> > ----------------------------------------------------------------
> >
> > References
> >
> > Visible links
> > 1. https://www.andreimorgan.net/posts/covid_strategy/
>
>--
>Andrei Morgan MRCPCH, MSc, PhD (Epidemiology / Neonatology)
>https://www.andreimorgan.net
>
>Honorary Clinical Lecturer,
>Department of Neonatology,
>Institute for Women's Health,
>University College London
>
>
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Buckingham MK18 4EL, UK
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