H5N1

The UK's COVID response: "Lies, deceptions and callous conceit"

Via The Lancet, editor Richard Horton studies the UK's dismal government response to COVID-19: Offline: “Laughing at the Italians”.

A former minister for health in England wrote to me that “The COVID-19 inquiry will make us the laughing stock in the eyes of the world.” But it is worse than that. The level of criminal incompetence exposed by recent witnesses to the UK COVID-19 Inquiry, chaired by Baroness Heather Hallett, has proven that many, if not most, of over 230 000 deaths were preventable. Amid the claims of extreme misogyny, profanity, and chaos that litter the evidence is a story of complete government breakdown.  

WHO declared a Public Health Emergency of International Concern on Jan 30, 2020. The UK Government was confident it could ride out the storm coming from China. Martin Reynolds, who was at the time Prime Minister Boris Johnson's Principal Private Secretary, believed “the system [was] gripping the challenge”. Lee Cain, who was Downing Street's Director of Communications, thought the outbreak was simply a matter for the Department of Health and Social Care. Chris Whitty, the Chief Medical Officer (CMO), briefed Johnson about the risk of a pandemic on Feb 4, 2020. Johnson expressed concern about over-reacting.  

The discussion focused on repatriating UK nationals from China, according to Imran Shafi, then Private Secretary to the Prime Minister for Public Services. Government committees were waking up to the threat. COBR (Cabinet Office Briefing Rooms), a group responsible for managing national crises, concluded that the UK's public health system lacked capacity for dealing with a pandemic.  

But the extent of the danger did not penetrate to the centre of government. The CMO reassured Downing Street that there was no sustained transmission outside Wuhan. Then something very strange took place. Johnson took a 2-week holiday. From Feb 14 to Feb 24, he absented himself from Cabinet and COBR meetings, and received little or no further information about the growing risk of COVID-19. Yet it was clear by mid-February that there was sustained coronavirus transmission in the UK.  

Matt Hancock, then Secretary of State for Health and Social Care, reassured colleagues that a plan was in place. By the time Johnson returned from his vacation, clusters of infection were being reported in Italy's Lombardy region. The “macho culture” of No 10 translated into politicians and their advisers “laughing at the Italians”, according to Helen MacNamara, who was Deputy Cabinet Secretary.  

They remained supremely confident that the UK would be world-beating at conquering COVID-19. A meeting of the Civil Contingencies Secretariat on Feb 28 concluded that a global pandemic was now likely (Shafi). Still Johnson and his closest advisers failed to engage.

Johnson chaired his first COBR meeting on March 2. A COVID-19 Action Plan appeared the next day but, according to Cain, it was nothing more than a “thin overview”. By the time Italy locked down on March 9, Reynolds readily agreed that the UK was “playing catch up”. But there was still no plan, no strategic direction, and no leadership. Instead, a debate raged about mitigation versus suppression. 

 

The evening of March 13 was the moment Downing Street realised that the NHS would be overwhelmed if it continued to pursue a policy of mitigation (herd immunity). Only now did the principals have NHS data showing that hospitalisations were rising faster than models predicted. Dominic Cummings, Johnson's main adviser, drew out the threat on a whiteboard that became the instrument for persuading politicians that lockdown was the only option. Treating coronavirus like influenza had been a monumental mistake—“something had gone horrifyingly wrong” (Cummings). “We were heading for a total disaster” (MacNamara). 

 

Yet Johnson still remained sceptical. In a meeting on March 19 between Johnson and Rishi Sunak, his Chancellor, Johnson said, “We’re killing the patient to tackle the tumour…Why are we destroying the economy for people who will die soon anyway” (Shafi). The UK Government finally locked the nation down on March 23. 

 

Officials who have given evidence looked wearily astonished as they described the country's biggest national crisis since World War 2. After Johnson's landslide election victory in December, 2019, they had expected to serve a two-term government. But as the pandemic spread, they admitted that “we weren’t ready for the crisis” (Reynolds). It was a “historic catastrophe” based on “disastrous groupthink” (Cummings). 

 

The lies, deceptions, and callous conceit that characterised the UK's initial response to COVID-19 must surely bring some kind of reckoning.

 

How covid-19 spreads: Narratives, counter narratives, and social dramas

Via The BMJ: How covid-19 spreads: narratives, counter narratives, and social dramas. The key points:

• A flawed narrative that SARS-CoV-2 was transmitted by droplets rather than being airborne became entrenched early in the pandemic 

• Measures aimed at an assumed droplet pathogen (handwashing, surface cleansing, physical distancing) were over-emphasised 

• Measures to reduce airborne transmission (improving indoor air quality, reducing indoor crowding and time spent indoors, and high-grade respiratory protection) were under-emphasised 

• UK policy makers seemed to favour narratives from a narrow group of scientific advisers 

• Consequences included care home deaths, mission critical delays in public masking, and avoidable infections of healthcare workers

Lockdowns and face masks ‘unequivocally’ cut spread of Covid, report finds

Via The Guardian: Lockdowns and face masks ‘unequivocally’ cut spread of Covid, report finds. Excerpt:

Measures taken during the Covid pandemic such as social distancing and wearing face masks “unequivocally” reduced the spread of infections, a report has found.  

Experts looked at the effectiveness of non-pharmaceutical interventions (NPIs) – not drugs or vaccines – when applied in packages that combine a number of measures that complement one another.  

The Royal Society report, called Covid-19: examining the effectiveness of non-pharmaceutical interventions, reviewed the evidence gathered during the pandemic for six groups of NPIs and their effectiveness in reducing transmission.  

These included masks and face coverings, social distancing and lockdowns, test, trace and isolate, travel restrictions and controls across international borders, environmental controls, and communications.  

When assessed individually, there was positive – if limited – evidence of transmission reduction from many of the NPIs used in the pandemic, the review found. However, evidence of a positive effect was clear when countries used combinations of NPIs.  

Additionally, evidence showed NPIs were most effective when the intensity of transmission was low, supporting their use early in a pandemic and at first sign of resurgence.  

During the early stages of responding to an emerging infectious disease, NPIs tend to be the only controls available before the development of drug treatments and vaccines.  

However, as was seen during the pandemic, their use can have adverse personal, educational and economic consequences – making assessment of their effectiveness essential.  

Prof Sir Mark Walport, the foreign secretary of the Royal Society and chair of the report’s expert working group, said: “There is sufficient evidence to conclude that early, stringent implementation of packages of complementary NPIs was unequivocally effective in limiting Sars-CoV-2 infections.  

“That does not mean every NPI was effective in every setting, or at all times, but learning the lessons from the wealth of research generated in this pandemic will be key to equipping ourselves for the next one.”  

The review found social distancing and lockdowns were the most effective category of NPIs. Stay-at-home orders, physical distancing and restrictions on gathering size were repeatedly found to be associated with significant reduction in Sars-CoV-2 transmission. The more stringent the measures were the greater the effect they had, the experts found.  

In care homes, measures such as cohorting and visitor restrictions were associated with reduced transmission and reduced outbreaks.  

Additionally, the report found that in school settings, closures and other distancing measures were associated with reduced Covid-19 cases, but the effectiveness varied depending on a range of factors, including adherence and pupils’ ages.

Communication of COVID-19 misinformation on social media by physicians in the US

Via JAMA Network: Communication of COVID-19 Misinformation on Social Media by Physicians in the US. The key points and abstract:

Key Points  

Question  What types of COVID-19 misinformation have been propagated online by US physicians and through what channels?  

Findings  In this mixed-methods study of high-use social media platforms, physicians from across the US and representing a range of medical specialties were found to propagate COVID-19 misinformation about vaccines, treatments, and masks on large social media and other online platforms and that many had a wide reach based on number of followers.  

Meaning  This study’s findings suggest a need for rigorous evaluation of harm that may be caused by physicians, who hold a uniquely trusted position in society, propagating misinformation; ethical and legal guidelines for propagation of misinformation are needed.  

Abstract  

Importance  Approximately one-third of the more than 1 100 000 confirmed COVID-19–related deaths as of January 18, 2023, were considered preventable if public health recommendations had been followed. Physicians’ propagation of misinformation about COVID-19 on social media and other internet-based platforms has raised professional, public health, and ethical concerns.  

Objective  To characterize (1) the types of COVID-19 misinformation propagated by US physicians after vaccines became available, (2) the online platforms used, and (3) the characteristics of the physicians spreading misinformation.  

Design, Setting, and Participants  Using US Centers for Disease Control and Prevention guidelines for the prevention and treatment of COVID-19 infection during the study window to define misinformation, structured searches of high-use social media platforms (Twitter, Facebook, Instagram, Parler, and YouTube) and news sources (The New York Times, National Public Radio) were conducted to identify COVID-19 misinformation communicated by US-based physicians between January 2021 and December 2022. Physicians’ state of licensure and medical specialty were identified. The number of followers for each physician on 4 major platforms was extracted to estimate reach and qualitative content analysis of the messages was performed.  

Main Outcomes and Measures  Outcome measures included categories of COVID-19 misinformation propagated, the number and traits of physicians engaged in misinformation propagation, and the type of online media channels used to propagate misinformation and potential reach.  

Results  The propagation of COVID-19 misinformation was attributed to 52 physicians in 28 different specialties across all regions of the country. General misinformation categories included vaccines, medication, masks, and other (ie, conspiracy theories). Forty-two physicians (80.8%) posted vaccine misinformation, 40 (76.9%) propagated information in more than 1 category, and 20 (38.5%) posted misinformation on 5 or more platforms. Major themes identified included (1) disputing vaccine safety and effectiveness, (2) promoting medical treatments lacking scientific evidence and/or US Food and Drug Administration approval, (3) disputing mask-wearing effectiveness, and (4) other (unsubstantiated claims, eg, virus origin, government lies, and other conspiracy theories).  

Conclusions and Relevance  In this mixed-methods study of US physician propagation of COVID-19 misinformation on social media, results suggest widespread, inaccurate, and potentially harmful assertions made by physicians across the country who represented a range of subspecialties. Further research is needed to assess the extent of the potential harms associated with physician propagation of misinformation, the motivations for these behaviors, and potential legal and professional recourse to improve accountability for misinformation propagation.

How Canada’s decentralised covid-19 response affected public health data and decision making

This is a major report that deserves close attention. Via The BMJ: How Canada’s decentralised covid-19 response affected public health data and decision making. Excerpts:

Highs and lows of covid-19 response in Canada  

Highs 

• Public health leadership included women at each level of decision making. 

• Canada became one of the most vaccinated countries with >83% of the population receiving at least one vaccine dose in February 2023. After Health Canada approved Pfizer-BioNTech and the Moderna covid-19 vaccine in December 2020, rollout was prioritised for indigenous populations and those living and working in long term care homes  

• Research collaborations from basic science through to clinical and health services research emerged rapidly to address urgent questions of seroprevalence (eg, covid-19 Immunity Task Force), correlates of infection and immunity, and outbreak mitigation factors and engagement of patients in research conduct such as knowledge synthesis  

Lows  

• Failure to learn from previous reports led to failure to protect older adults and staff in long term care homes and among the highest proportions of deaths in this sector globally  

• Challenges to access and delivery of effective covid-19 medications such as tocilizumab, remdesivir, and ritonavir-nirmatrelvir resulted in provinces and hospitals rationing use  

• An exodus of exhausted and distressed healthcare workers, coupled with inadequate training paths for replacements, produced a critical workforce shortage that is ongoing  

• Canada lacked a coordinated system for evidence generation and use across government jurisdictions  

• Lack of research infrastructure embedded within the healthcare system limited Canada’s ability to participate in or lead clinical trials or other international studies 

• Lack of a clear and standardised approach to case definitions and testing contributed to inability to share use of data and make decisions           

• Absence of data sharing agreements across federal and provincial or territorial jurisdictions slowed or limited data sharing

Key messages

• Canada’s public health system was insufficiently prepared for the covid-19 pandemic

• Public health decisions and outcomes varied across jurisdictions and were hampered by outdated health information systems and lack of integration 

• Decentralisation of public health decision making has benefits such as tailoring interventions to local constituencies, but during a crisis, governance structures need to pivot to enable coordination and systematisation of data collection and analyses 

• Gaps in data and decision structures created a vacuum, filled by science advisory committees with disparate roles, responsibilities, and accountabilities within different jurisdictions 

• A shift to a culture of data access and shared analysis is needed to enhance health system learning and population health benefit, and for future crisis and pandemic preparedness

Official data hinted at China’s hidden Covid toll. Then it vanished.

Via The New York Times: Official Data Hinted at China’s Hidden Covid Toll. Then it Vanished. Excerpt:

Official data from China offered a rare, but brief, glimpse of the true toll of Covid, indicating that nearly as many people may have died from the virus in a single province earlier this year as Beijing has said died in the mainland during the entire pandemic.  

The data was deleted from a provincial government website just days after it was published on Thursday. But epidemiologists who reviewed a cached version of the information said it was the latest indication that the country’s official tally is a vast undercount.  

The number of cremations in the eastern province of Zhejiang rose to 171,000 in the first quarter of this year, the website said. That was 72,000 more cremations, a roughly 70 percent increase, than had been reported in the same period last year.  

In February, China said the official death toll in the mainland since the start of the pandemic was 83,150 — a remarkably low number that independent researchers have said is not credible. Since then, the government has released only weekly or monthly death tolls that, when added up, raise the overall total to about 83,700.

Covid surged across China late last year, forcing the government to abandon its strict pandemic restrictions in December. The government’s abrupt policy reversal, however, left hospitals and pharmacies unprepared for the onslaught and likely accelerated the spread of infections and a wave of deaths across the country.  

That surge of Covid infections across China lasted for about two months. The majority of the deaths occurred in January, but many people died in December as well. Epidemiologists estimate that 80 to 90 percent of the population was infected.  

The Zhejiang data offered a window into cremation figures that have been closely guarded by the Chinese government. While the data does not include the cause of death, researchers regularly use excess death statistics to estimate the impact of major deadly events like disasters and pandemics. Everybody who dies in Zhejiang is cremated, officials say.  

Many local and national authorities have withheld regularly published cremation data since that first major Covid wave started late last year. It is unclear why Zhejiang Province published data for the first quarter of this year, but three days after it surfaced, the report was removed.  

Calls on Tuesday to multiple numbers at Zhejiang’s civil affairs bureau went unanswered. The Beijing-based media outlet Caixin reported on the figures Monday, but its article was also quickly taken down.

An analysis by The New York Times published in February estimated that China’s recent Covid wave may have killed between a million and 1.5 million people, based on research from four teams of epidemiologists.  

The new data from Zhejiang — which is limited to a province of 65.8 million people — when extrapolated to the country’s population of 1.4 billion people, is roughly consistent with that range, experts from two of those teams said.

Swift and extensive Omicron outbreak in China after sudden exit from ‘zero-COVID’ policy

Via Nature Communications, a shocking report: Swift and extensive Omicron outbreak in China after sudden exit from ‘zero-COVID’ policy. The abstract, with my bolding, and then a comment:

In late 2022, China transitioned from a strict ‘zero-COVID’ policy to rapidly abandoning nearly all interventions and data reporting. This raised great concern about the presumably-rapid but unreported spread of the SARS-CoV-2 Omicron variant in a very large population of very low pre-existing immunity. 

By modeling a combination of case count and survey data, we show that Omicron spread extremely rapidly, at a rate of 0.42/day (95% credibility interval: [0.35, 0.51]/day), translating to an epidemic doubling time of 1.6 days ([1.6, 2.0] days) after the full exit from zero-COVID on Dec. 7, 2022. Consequently, we estimate that the vast majority of the population (97% [95%, 99%], sensitivity analysis lower limit of 90%) was infected during December, with the nation-wide epidemic peaking on Dec. 23. 

Overall, our results highlight the extremely high transmissibility of the variant and the importance of proper design of intervention exit strategies to avoid large infection waves.

In the discussion section of the report, the authors write:

With an infection fatality ratio between 0.1 and 0.2% for the Omicron variant, we would expect between 1.3 and 2.6 million COVID-19 deaths in China during Dec. 2022 as well as Jan. 2023 (because of the delay from infection to death).

And that is with a case fatality rate of 0.1-0.2 percent. So 1.37 billion people in China contracted the Omicron strain of SARS-CoV-2 in December 2022, and at least one or two in a thousand died of it. The government saw it coming because Omicron was already spreading, and dropped most "lockdown" measures. It was a calculated risk: one or two million dead in a little over a month, millions more needing hospitalization, and the country survived the blow.

Animal health body urges bird flu vaccination to avoid pandemic

Via Reuters: Animal health body urges bird flu vaccination to avoid pandemic. Excerpt:

PARIS, May 21 (Reuters) - Governments should consider vaccinating birds against bird flu to avoid the virus - which has already killed hundreds of millions of birds and infected mammals worldwide - turning into a new pandemic, the head of the World Animal Health Organisation (WOAH) said.  

The severity of the current outbreak of avian influenza, commonly called bird flu, and the economic and personal damage it has caused, has led governments to reconsider vaccinating poultry. However, some, like the United States, remain reluctant mainly because of the trade curbs this would entail.

"We are coming out of a COVID crisis where every country realised the hypothesis of a pandemic was real," WOAH Director General Monique Eloit told Reuters in an interview.  

"Since almost every country that does international trade has now been infected, maybe it's time to discuss vaccination, in addition to systematic culling which remains the main tool (to control the disease)," she said.  

The WOAH is holding a five-day general session from Sunday, and will be focus on global control of highly pathogenic avian influenza, or HPAI. 

A WOAH survey showed only 25% of its member states would accept imports of products from poultry vaccinated against HPAI.  

The European Union's 27 member states agreed last year to implement a bird flu vaccine strategy. France is set to be the first one, starting with ducks in the autumn.  

"If a bloc like the EU, which is a large exporter, starts moving in that direction, it will have a ricochet impact," Eloit said.  

The U.S. department of Agriculture (USDA) told Reuters on Friday that "in the interest of leaving no stone unturned in the fight against HPAI, USDA continues to research vaccine options that can protect poultry from this persistent threat".  

However, it still considers biosecurity measures to be the most effective tool for mitigating the virus in commercial flocks, it said in emailed answers.

Excess mortality and years of potential life lost among the Black population in the US, 1999-2020

Via JAMA, an appalling report: Excess Mortality and Years of Potential Life Lost Among the Black Population in the US, 1999-2020. The key points and abstract:

Key Points 

Question  How many excess deaths and years of potential life lost for the Black population, compared with the White population, occurred in the United States from 1999 through 2020?  

Findings  Based on Centers for Disease Control and Prevention data, excess deaths and years of potential life lost persisted throughout the period, with initial progress followed by stagnation of improvement and substantial worsening in 2020. The Black population had 1.63 million excess deaths, representing more than 80 million years of potential life lost over the study period.  

Meaning  After initial progress, excess mortality and years of potential life lost among the US Black population stagnated and then worsened, indicating a need for new approaches.  

Abstract  

Importance  Amid efforts in the US to promote health equity, there is a need to assess recent progress in reducing excess deaths and years of potential life lost among the Black population compared with the White population.  

Objective  To evaluate trends in excess mortality and years of potential life lost among the Black population compared with the White population.  

Design, setting, and participants  Serial cross-sectional study using US national data from the Centers for Disease Control and Prevention from 1999 through 2020. We included data from non-Hispanic White and non-Hispanic Black populations across all age groups.  

Exposures  Race as documented in the death certificates.  

Main outcomes and measures  Excess age-adjusted all-cause mortality, cause-specific mortality, age-specific mortality, and years of potential life lost rates (per 100 000 individuals) among the Black population compared with the White population.  

Results  From 1999 to 2011, the age-adjusted excess mortality rate declined from 404 to 211 excess deaths per 100 000 individuals among Black males (P for trend <.001). However, the rate plateaued from 2011 through 2019 (P for trend = .98) and increased in 2020 to 395—rates not seen since 2000. Among Black females, the rate declined from 224 excess deaths per 100 000 individuals in 1999 to 87 in 2015 (P for trend <.001). There was no significant change between 2016 and 2019 (P for trend = .71) and in 2020 rates increased to 192—levels not seen since 2005. The trends in rates of excess years of potential life lost followed a similar pattern. From 1999 to 2020, the disproportionately higher mortality rates in Black males and females resulted in 997 623 and 628 464 excess deaths, respectively, representing a loss of more than 80 million years of life. Heart disease had the highest excess mortality rates, and the excess years of potential life lost rates were largest among infants and middle-aged adults.  

Conclusions and relevance  Over a recent 22-year period, the Black population in the US experienced more than 1.63 million excess deaths and more than 80 million excess years of life lost when compared with the White population. After a period of progress in reducing disparities, improvements stalled, and differences between the Black population and the White population worsened in 2020.

Bird flu could become the next human pandemic – and politicians aren’t paying attention

Via The Guardian, an op-ed: Bird flu could become the next human pandemic – and politicians aren’t paying attention. Excerpt:

Since November, the signals emerging across the world continue to be worrying. In January and February this year, more than 3,000 sea lions died of bird flu in Peru (where the death toll in wild birds reached an estimated 50,000). In Russia, 700 Caspian seals died. Then several dolphins in Britain and the US died of H5N1. Normally, even if an animal catches H5N1 from a bird, it can’t pass it to other mammals. This limits its spread. But the large number of cases in these outbreaks suggest the possibility of mammal-to-mammal transmission, although this hasn’t been confirmed yet by genetic sequencing. A more likely hypothesis is that these outbreaks are groups of animals feeding on infected birds. It is not yet 100% clear what’s happening.  

But the risk of spread among mammals is ever-present. A new research pre-print from Canada showed that H5N1 samples could spread efficiently between ferrets with fatal outcomes. In order to spread efficiently to humans, H5 would need three major categories of genetic changes, according to bird flu expert Prof Richard Webby. So far, the virus has been able to make one of these changes, but not the other two. 

So right now, H5N1 is a theoretical risk for the next human pandemic, rather than one requiring urgency in response today. And a prime minister or health secretary might say, “Why prepare for something that might never happen?” 

To those of us scientists working in global health, there are enough concerning signals that action should already be happening. So that if a certain set of mutations do occur and we see an outbreak in humans in Peru or China or Britain, that the harm it could cause is minimal. This is a disease with an estimated 50-60% fatality rate in humans, including children.  

The cornerstone of infectious disease preparedness is in: surveillance (to know what strain is spreading and where in birds); testing (to identify disease quickly in humans); vaccines (for protection against disease and death); and antivirals (to improve clinical outcomes). The US government is already moving in this direction. Rebecca Katz, professor at Georgetown University Medical Center, has noted that a H5 candidate vaccine virus recently produced by the US Centers for Disease Control and Prevention is likely to provide good protection against the circulating H5N1 viruses.  

The information has been shared with vaccine manufacturers to start the process of stockpiling adequate doses. But this is a challenge because most influenza vaccines are created by incubating doses in chicken eggs (called egg-based production). If bird flu has killed off many of the chickens, then egg shortages are likely. There’s another H5N1 vaccine which is non-egg based, but they could have a maximum of 150m doses ready within six months. The world’s population is almost 8 billion.  

In addition, the FDA-approved antiviral treatments for seasonal influenza could also work against bird flu. But again, getting doses to all parts of the world is a challenge given shortages. Preparation must also involve appropriate PPE for healthcare workers to protect against a respiratory disease (flu) and diagnostics to quickly identify if someone is infectious in hospitals.  

All of these issues are solvable with precise planning, collaboration across countries, scientific ingenuity and good leadership. With post Covid-19 fatigue, the bigger problem is bringing the public along and communicating the facts so that they are trusted and believed. With so much – often understandable – mistrust in our current political leadership, authorities like chief medical officers and independent government advisers become crucial.