In view of recent controversies caused by an article in The Irish Times on Saturday, September 12th, I think it is important to articulate my position on the present Covid crisis and its management, and to comment also on more recent developments.
How lethal is Covid-19?
Up to August 10th, the number of Europeans who died from a Covid-19 illness (182,639) was slightly above the number who died three years ago as a result of “flu” (152,000). The number of patients who died in Europe from the 1917/18 Spanish flu was approximately 2.64 million – this would be equivalent to approximately 7.4 million deaths of today’s European population.
It is not for want of good reason that deaths are now referred to as Covid-19-associated deaths. Of 5,700 patients admitted to New York hospitals, 88 per cent had more than one underlying condition (co-morbidity) and the US Centres for Disease Control and Prevention reported that from January to May, 19.5 per cent of Covid-19 patients with co-morbidity died compared to 1.6 per cent with no other illness.
The Irish experience is very similar – up to mid-August 94 per cent of deaths were in patients with underlying medical conditions. A Stanford-led group analysed over 100,000 Covid-19-related deaths in Europe, including Ireland, and the US and concluded that “deaths for people under 65 without predisposing conditions were remarkably uncommon” .
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Another important feature is the number of people who contract the virus and remain completely asymptomatic. In extremely well-defined scenarios such as the Diamond Princess cruise liner and the Theodore Roosevelt aircraft carrier almost 66 per cent of the positive tests were completely asymptomatic, while a report from China suggests 78 per cent of cases were asymptomatic.
Who is at risk?
For most respiratory diseases, such as the common cold and influenza, children are the primary carriers. However, this does not appear to be the case with the Corona viruses which caused SARS in 2003 and Covid-19. Six weeks after opening schools in Denmark there was no evidence of a spike in cases. A University of Southampton review found no reported incident of pupil-to-teacher transmission.
While children are at negligible risk if healthy and not obese, conversely the individuals at the opposite end of the age spectrum are at greatest risk. The case mortality rate regardless of co-morbidities at 60 years is about 1 per cent, at 70 years about 2 per cent, and increases dramatically to above 15 per cent in individuals over 80 years.
The presence of a chronic illness is the all-important factor in determining the risk even in the elderly; up to mid-September approximately 6,000 nursing home residents had tested positive for Covid-19 and 83 per cent recovered. Diseases of the cardiovascular and respiratory systems are high risk; as is diabetes mellitus, although distinguishing its risk from the obesity risk is difficult.
The best kept secret regarding Covid-19 is the vulnerability of overweight individuals. For reasons unknown this is not publicised to the degree required. Unfortunately this lack of awareness is exacerbated, if not caused, by HSE-published data on risk factors. In its definition of obesity the HSE uses a body mass index (BMI) of 40 whereas most international literature uses a BMI of 30.
BMI is a crude measure of body fat; briefly, an individual of 178cm (5’10”) height weighing 95kg (15 stone), about 25 per cent over ideal, has a BMI of 30 and is by definition obese.
This disease is profoundly different to the Spanish flu which was an indiscriminate killer, with the average age of victims just 27 years of age
By using a BMI of 40 about 3 per cent of the adult population is considered at risk, but if the international BMI standard of 30 is used the at-risk proportion increases to about 23 per cent. The HSE data, therefore, grossly understates the obesity risk, and under-records the effects of obesity by using a BMI of 40.
In the New York study referenced above, 41.7 per cent of admitted patients had a BMI of 30, the second most common risk factor after hypertension. It has been shown that the highest risk factor for ICU admission is obesity; in Ireland even when using BMI of 40 as the criterion, 19 per cent of those admitted to ICU had this risk factor.
Should we be more worried about increasing numbers of cases?
From mid-July to mid-September there were almost 6,000 reported Covid-19 cases. The media and political reaction has amounted to a foreboding narrative akin to a major catastrophe.
The top TV story night after night features numbers of people testing positive for a condition associated with hospital and ICU admission rates of 2.5 per cent and 0.2 per cent respectively. Admission rates are about one fifth of prior months and lower than those associated with seasonal flu. Such reporting would be more appropriate were the country dealing with an Ebola outbreak.
What is happening is what should be happening – the young are working in essential services and socialising and contracting the virus, while the vulnerable, the elderly and those with illness are being cautious and, importantly, are being protected by the rest of society.
However, there is one worrying trend – over four successive fortnight periods the proportion of cases in the over-65 age group has been 4 per cent, 5 per cent, 7 per cent, and 10 per cent. This suggests a gradual relaxation in the at-risk group or by those around them? If so, this is where we need absolute vigilance.
Is there an alternative strategy?
Many scientists from around the world are now of the view that eradicating SARS-Covid-2 is not realistic in the short term. I say this as eradication appears to be the new goal in Ireland.
The initial response was entirely appropriate for a contagious disease with the suspected virulence of the 1917/18 Spanish flu. However, after nine months of intensive scientific scrutiny of the virus’ behaviour globally concludes this is no longer the case.
This disease is profoundly different to the Spanish flu which was an indiscriminate killer, with the average age of victims just 27 years of age. It’s also profoundly different to the seasonal Influenza. Therefore different strategies are required to manage Covid-19.
The Government deserves enormous credit for opening our schools. What is needed now is an extension of that thinking
Experience has taught us that the at-risk and vulnerable individuals are identifiable with remarkable accuracy, and that protective measures – hygiene, masks, social distancing and cocooning – are extremely effective.
Common sense might dictate that we expose the low-risk population to this condition and protect the at-risk, ie, the red rag of “herd immunity”. That is what was happening and yet the policy seems to be to prevent this happening. This should particularly have been allowed to happen during the summer months before the “flu season” and thus reduce the workload on the health services during winter months.
Achieving a balance
The Government deserves enormous credit for opening our schools. What is needed now is an extension of that thinking to strike the right balance and avoid the cost greatly exceeding the benefit.
The at-risk can be protected by themselves and others adhering to proven protective measures. By definition, almost all emergency hospital admissions are at risk and therefore the protective measures for patients and for the staff need to be retained; similarly for nursing homes. This policy will involve those “at risk” not going to work, which is much better than nobody going to work.
The young and healthy majority need to be allowed to live rather than exist, while being mindful of those at risk.
In living with this disease the able elderly may feel disinclined to comply with restrictions or cocoon, as indeed may others at risk. This, however, poses the mountain climber dilemma – “by putting myself in danger I am possibly asking others to risk their lives to save mine”.
Regardless, we need to stop scaring the nation; be honest with the nation and consider how to better facilitate personal choice.