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Now ye're talking - to a consultant in the HSE [ANSWERS thread]

Boards.ie: Niamh

Answers from our AMA guest to questions asked in the Questions thread.

Please only post your questions in the dedicated thread here.

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Pseudonym121

derb12 wrote: »

I’ve always understood that a fever is the bodies way of fighting back at an infection and so I’m wondering if it’s always best to take paracetamol straightaway if I get a temp. I know that an extreme temp of 40(?) can be dangerous, but could it be better to see where a 37 or 38 temp goes before taking something to lower it? I’ve always given my kids calpol as they are so wretched with a temperature and to be honest, I can’t remember the last time I had a temp myself but just wondering.

The best thing to do here is, IMO, to point you to the portion of the HSE website re: symptomatic relief.

Cork Boy 53 wrote: »

Hi. Does it concern you that the number of ICU cases has jumped from 13 to 29 in a single day? Do you still think we are on track for the best case scenario of fatalities from this outbreak?

I don't think this progression surprised most doctors. This is what happens with a disease which doubles every 3.5 days.

aquarius10 wrote: »

My question is if she has COVID19 but has ‘recovered’ by the time she’s tested will it still show in her swab ??

It depends. Even after recovery there is still enough viral RNA present to yield a positive result for some time. How many days exactly is this? Figures vary but I wouldn't be confident enough in any figure to give you an exact number.

up for anything wrote: »

Do you have any idea what ages the four people were who have died from Covid19? All I can find are vague references to elderly.

Sure, but I said that I wouldn't reveal privileged information which I come across through the day job. I am answering questions using publicly available information, official websites, publications and extrapolations.

shesty wrote: »

This question may be more around epidemiology and disease spread, than one you can answer directly, but I will throw it out there anyway.

I am not asking you to commit to a time line here, but does there come a point on the graph of the disease spread where we decide that there is a certain amount of saturation in society, and that people can start moving about normally again?

My angle on this is that if we have flattened the (infamous) curve enough, we essentially have extended the timeline. If you look at it as a mathematical exercise, I don't know what that time extension is, but say it extended to maybe 1 year. It isn't practical to shut the country down for a year. So are there citeria, or decision points along the way where the balance stops being about stopping the spread and become about slowly allowing the herd immunity to build instead?? Is there any information anywhere on that - I think the main point of the question is when does it stop becoming about prevention and move into some form of building up immunity, or whatever the phrase is?

I guess, I am at home with 3 kids, all healthy, keeping away from everyone....how long are we supposed to go on trying to run away from it vs just accepting getting it anyway?

I wouldn't be in a rush to get this even if everyone in your home is healthy. People without underlying conditions can get quite sick also. People act as though not having underlying conditions and being under 60 is a guarantee of good outcome. It certainly makes it much more likely but it isn't certain.

As to quarantine - it won't be for a year. I'll link to an interesting piece from the Imperial College COVID-19 team which shows how, in the longer run, "lockdown" ( or whatever you want to call it ) will most likely be switched on and off in response to ICU capacity issues. It'll be at the end... I suspect that is the model they and we will adopt if we can't get full control like they seem to be achieving in South Korea and Singapore.... with that said I think we should totally aim for the South Korean model if at all possible --- this appears to be what is being done.

I'll also link to an interesting website in the US which, while it may not be a perfect mathematical model, does show how various levels of physical distancing to lockdown impact peak figures and total dead over the next year. I see I'm getting given out to for being direct about possibilities so I think I'll let other models do the talking here - then people can go give out to those model creators.

Purple Mountain wrote: »

Would you ever forsee home testing kits that could even be purchased for a small fee at a pharmacy to cut down on testing clinics?

Certainly. Four things dictate this will certainly happen.
1. Capitalism - there will be lots of money to be made from home testing kits.

2. DIY tests will reduce the exposure of healthcare workers to infection when they swab people.

3. It'll reduce the stress on laboratories reading the tests.

4. Public demand - once home kits become available people WILL buy them. Especially once they have an antibody kit which will show exposure as people will want to know if they can go back to behaving as normal without anxiety and will pay for that privilege.

The Americans are already working on DIY swabbing kits. They said it in the daily Trump/Pence pony show today.

Purple Mountain wrote: »

Also, those who are hospitalised as a result of this, are they going to be billed for their care in the hospital?

I would presume not as we have socialised medicine in Ireland but I honestly haven't given the billing of patients even one second of thought in this whole situation so I haven't explored it and sought out an answer one way or the other.

xzanti wrote: »

Hi, thanks for doing this. Very informative.

I've been giving my kids probiotics for years (FMD Udo's Choice).

I read somewhere that this virus actually uses a persons immune system against them.

Sorry, if this is a stupid question, but could the probiotics actually be a hinderance to them should they catch the virus? Should I stop or continue with them in your opinion?

Edit. They are fit and healthy with no underlying conditions.

Cheers.

I honestly don't know. I haven't seen any evidence one way or the other in terms of probiotics and COVID-19. I can't imagine a way in which probiotics would help or hinder things much either way but I am not aware of any research proving this.

Sorry I can't be more helpful on this question.

Mwengwe wrote: »

This isn't technically a question and feel free to delete it but i've been reading his answers and I think this is going way, way over the line between informing people/impressing on them the gravity of the situation and just plain terrifying people into paralysis. I've read some bleak articles over the past few weeks but the thread of answers by this guy leaves me feeling completely, utterly hopeless. There's got to be a better way to inform.

Thanks for the comment. Yes, I get this can be difficult and upsetting. But understanding how difficult and dangerous a time this could be might move people to:
a) physically distance more and
b) prepare and
c) be more cautious and thus prevent themselves and others becoming infected.

Cynically speaking people don't change behaviours because they're asked. They change because they're motivated by either self-interest ( the vast majority ), group interest ( a minority ) or altruism ( an even smaller minority ).

Reading this thread should, IMO, give people the following messages:
1. You are underestimating how bad this could be if you do nothing.

2. The sooner you do something/change behaviour the better for you and society in terms of personal and overall outcomes. With a doubling time of 3.5 days a week's delay in acting results in four times the cases. So time is of the essence.

3. BUT if you DO change your behaviours then you CAN play a major role in protecting yourself and protecting others.

4. SO, change those behaviours and stay safe, keep others safe and stop the health service from becoming overwhelmed.

I think that last point is crucial --- by changing the behaviours and focusing on that you can focus on something YOU CAN CONTROL and that is a great way of coping with anxiety... Don't focus on the stuff outside your control, focus on the stuff in your control.

With that said if you find this thread too stark for you then the best advice is not to read it. That isn't a dig at you or anyone else, it is simply a realisation that different people have different thresholds for what they can handle and remain functional. This thread may exceed that for you and if it does you shouldn't keep reading it. No casting of aspersions or anything like that just don't read it if it isn't helpful to you. If you find it helpful and can cope with it then keep reading.

I certainly wish you and yours the best and I hope you can read the above in the spirit in which it is intended.

beolight wrote: »

The HSE tells us they have plenty of PPE... How else do you propose we get the message across?

There are definitely issues with availability of PPE. To be fair it would be unfair to expect that the HSE or any health organisation would have enough PPE for a pandemic situation like this just sitting around. I do believe management are doing the best they can... Sure there are failures but they're actually doing the best they can.

Mwengwe wrote: »

There's a medium point (happy medium seems an inappropriate phrase to use) is what I'm saying... I was someone who was already really conscious of social distancing to the point of anxiety. After reading the Answers thread for this I feel like I just want to go to bed for 12 months, or check out altogether. It's too much, he's going on about disinfecting shopping for 6 hours. He's going to lose people who are fighting his corner.
I think some of his more extreme points could really do with a bit more perspective and a bit of challenging. We're not going to get through these dark times by fostering despair.

Thanks for the comments again. I'll deal with them in series....

1. You were already anxious.
If you were already conscious of social distancing to the point of anxiety then you probably don't need to read things which would make you more anxious. You should consider taking a break from media and social media except for maybe the 9 o'clock news and just focus on what you can do.

I, personally, have begun a big decluttering of the place and am planning to start a new exercise regime next week. I'd do it this week but I need to get some work stuff sorted first for obvious reasons. Both of those things are helpful to me in keeping me occupied and giving me something within my control that I can do at home.

At work I just focus on running the best service possible for the patients and supporting the staff so they can sustain themselves through this difficult time.

2. Shopping disinfection.
Well, you make it sound way more extreme and prepper-ish than it really is. My system is pretty simple and is as follows:
A) I assume the delivery man is infected ( this is no different than what the GP was saying on Claire Byrne tonight so isn't really an extreme position to take ) and so ask him to leave the things in the hall.

Since he breathed in the hall and it is a small space I follow HSE guidelines of allowing one hour for droplets to settle. Since nothing will defrost too badly if I give it a little extra time just to be on the safe side I leave it for three hours. In that time I can do whatever I want in the living room, kitchen etc. So it really doesn't impact on me much.

C) After three hours of doing whatever else I'm doing that evening I move the food onto a table beside my UV light steriliser. Now I'm sure I'll be accused of scaremongering for this but the Chinese are on record as saying UV light works to destroy SARS-CoV2, we have used UV light to destroy viruses on surfaces for quite some time and there's a lot of evidence that UV light sterilisation is quicker and more effective than sterilisation by hand for those who aren't trained in disinfection techniques - I also got this same UV steriliser for my parents who need a simple solution.

Here's a nice NY Times article about what the University of Nebrasks has been doing with UV light --- sterilising masks was a significant use case for me.

The other reason I got a UV light steriliser is that it relies on electricity to work and I figured electricity supplies would be protected by all means necessary whereas disinfectant wipes are a consumable resource which I assumed would quickly be very difficult to replace once panic started. Having the UV light steriliser allows me to preserve the limited resource of disinfectant wipes by using the plentiful resource of electricity. It was logical, effective and efficient and this is how Consultants' minds work. We're trained to think logically, be effective and efficient and follow the evidence base without allowing emotions get in the way.

The UV light steriliser was not something I had even dreamed of 5 weeks ago but when I read the Chinese evidence base and worked through the likely actions of governments and the public and the timeline for all of this I realised that buying a UV light steriliser would actually be a reasonable course of action and save me money ( vs using disinfectant wipes even if they had unlimited availability ) over the next year. So it is also economically efficient, an important consideration.

Why do I assume all delivery items are infected?
1. An excess of caution.

2. Here's a link to a New England Journal of Medicine article which points out that SARS-CoV2 can exist for several hours on cardboard and plastic ( the majority of packaging of delivered foodstuffs ). I feel this article supports my assumptions ( which, to be fair, I was operating from for several weeks out of an excess of caution ).

D) I then put the items into the UV light steriliser one or two at a time (frozen food first of course ) , press one button on top and then go and do something else ( TV, cooking, work etc ) until it pings 11 minutes later. The item(s) are now sterilised and I can put them in the fridge or cupboards without having to worry about contaminating anything.

So, the process takes me the time it takes to move things from the hallway to the table where they await UV light sterilisation and maybe 10 seconds per item to put them in the steriliser and turn it on. If I have a 24 item shop that is only about 4 or 5 minutes of extra work above and beyond the normal work of putting them away I'd be doing anyway.

So, not quite the all-day nightmare you seem to think and, to me, it seems like a really efficient, effective and logical solution both in terms of time and money. You may well draw the line differently and you're welcome to do so.

Perhaps the issue lies more in your perception of what I say and less in what I say?

Either way I wish you the best and I would re-iterate my advice that if reading this makes you so anxious then you probably shouldn't read it. I am fine with making people anxious enough to change their behaviour so that they keep themselves and others safer but I amn't interested in making people so anxious it is harmful. If I've done that to you I apologise.

Heighway61 wrote: »

Would you know if any consideration is given to health care workers who live with family members (or others) who are in a high risk category? For example, a spouse or child with cancer, COPD etc.

The percentages are large for:
health care workers infected
rate of transmission in the home
death rates due to existing condtions?

Also, "cocooning" fails in such a scenario.

I'm sorry but I'm unclear on what you mean by "consideration". Consideration in terms of where they would be deployed? I think that is what you're asking. Yes I've seen consideration given to that but the reality is that if everyone who lived with someone who had a significant risk factor was redeployed to a non-COVID ward/location then the shortages of staff would be even worse so the amount of consideration which can be given is limited. That's what I've seen where I work. I am not an HR professional and so can't give you a breakdown across the HSE on that question though, sorry.

rn wrote: »

There's a fine balance that our politicians have to achieve between not invoking complete panic in the population, but yet take the right measures.

What do you think of the German proposal for groups more than 2 to be banned?

Firstly, congratulations to you and your wife. Secondly, best wishes to you all going forward.

Thirdly, I don't have any insight into high-level planning for lockdown etc etc but I expect that most countries worldwide will end up with something pretty close to lockdown ( a la Germany or the UK ) sooner rather than later. I see no reason to expect Ireland will be an outlier. I have wanted this level of enforced distancing for some time but I can understand why the government etc have gotten there in stages as they had to bring people along with them.

begbysback wrote: »

I agree, the tone from the very outset has been condescending, the forecast of death rate exaggerated with no specific reasoning, the request that the public are failing to take directions and need to do more, basically asking the public to get tested and if your positive then stay home and hope it doesn’t get too bad, and if it does get bad then all we can do is put you on a ventilator, if we have one which is unlikely given that they are in short supply.

I apologize that I am a bit irate, but unless some of the answers start including some hope then I don’t see any point of continuing the AMA

I will refer you to the Imperial College COVID 19 Response Team's estimate for UK deaths without mitigation measures. Their estimate was 510,000 deaths in the UK and 2.2 million in the US. That would translate to approximately 50,000 dead in Ireland. So, I don't think the possible death rates for very limited mitigation in Ireland are "exaggerated with no specific reasoning". I understand you may not like those figures but liking them doesn't change the model.

Here is a requote from Post 27 of this thread with the figures I estimated:
"I'm on record previously as stating that the best case scenarios I foresaw for Ireland over the next year were as follows:
Optimistic Best: 2,000 Dead.
Reasonable Best: 5,000 Dead.
Pessimistic Best: 10,000 Dead

Optimistic Middle: 20,000 Dead.
Reasonable Middle 50,000 Dead."

FYI Here's a link to the Imperial College COVID 19 Response Team paper where you can read their model. It came out last week and makes interesting reading.

FYI the UK population is about 65 million, the Irish population about 5 million so just divide their numbers by 13 to get the Irish numbers - assuming you think the HSE is as good and well prepared as the NHS. Divide by more if you think the HSE is better prepared, divide by less if you think the HSE is less prepared.

And lastly, if you find this thread troubling then feel free not to read it. There's no point reading it if you find it so upsetting. I wish you and yours the best at this difficult time and in the months to come.

Yester wrote: »

I've been hearing a bit about "viral load" which seems to mean the longer you are exposed to the virus the more infected/sicker you are likely to get. Do you think there is any truth to this?

Wow, this is one of those... it seems easy but is really complex questions. Are you asking about viral load within the person who is infected or viral load in the environment in which a person is exposed? Sorry I'm just not clear on which you mean. If it is higher viral load in the infected individual I think we are still learning about COVID-19 and there is some evidence that one of the mechanisms of poor prognosis is immunopathological. Here's a summary of a study which is due out in the Lancet next week based on research from Hong Kong. So I think it is fair to say the picture isn't entirely clear yet as regards this new virus. With that said, in general, with other viruses lower viral loads are usually better.... I assume it will end up being the same with COVID-19 but I can't say it has been definitively proven yet.

swirley wrote: »

Thank you for taking the time to answer all the questions.

Is it known how long the virus can live on different surfaces? we have been getting groceries delivered and I have been trying to wipe them down with Dettol wipes in case it's on them - my husband says I am being over cautious.
Do you think it is a good idea?

I think it is a good idea based on the paper I'm linking to here.

I think that if you want to be very cautious you should assume everyone you meet is infected and everthing delivered to your house has been exposed. That way you can clean it and remove the risk. Some may see that as extreme and in that case you do you but the GP on Claire Byrne tonight was saying exactly the same thing so take that for what it is worth.

I use a UV Light Steriliser for this purpose and find it a simple one button push solution to the problem. I much prefer it to wiping things down manually because that takes longer, relies on disinfectant wipes which are/will be difficult to replace and is just a lot more hassle. I think in the long run a UV light steriliser will be cheaper also - although there is, admittedly, more up front cost.

WhiteLight20 wrote: »

Not at all. I am doing the same thing. It’s time consuming but it’s worth it. Supermarkets are the places people are going so it’s definitely in there!!! I’ve also been leaving my post. In a few weeks we’ll be wishing we did more.

Ah, the post... Again I think a UV light steriliser is great for this. I had initially considered just microwaving or heating things in the oven to over 80 degrees centigrade to destroy the virus but that would have spoiled food and wouldn't be suitable for mail. This is one major reason I went with a UV light steriliser as it really doesn't heat anything.

I've been using it on any mail I receive since I received the UV light steriliser. I will provide a link to the one I purchased below. I am NOT endorsing it or anything, just trying to show what I went with. I got this before they started price gouging. I think the price has gone up about 40 euro in just the last few days and even more over the last few weeks.

Anyways, it is big enough to fit any mail, a ready meal, several tins at the same time, my car and house keys at the same time and/or my iphone ( I always pop my phone in there when i get home because I've been using it through gloves during the day and so I assume it is absolutely riddled ). 11 Minutes after I pop any of those items in they come out nicely disinfected without me having to do anything but a button press.

Of note... there appears to be a risk that the UV light might discolour the case or phone over time but, frankly, I couldn't care less about that vs the peace of mind and simplicity of the UV light steriliser.

Also, if you buy a UV wand do NOT use it on your own skin. It can irritate and harm your skin... Another reason I bought my parents the box-type steriliser. They get weird ideas sometimes and I wouldn't put it past them to try to UV sterilise their skin with a UV light if given half the opportunity. I love them but sometimes you just have to smile and shake your head...

UV Light Steriliser

There are loads of different types on Amazon for you to choose from. i'm just showing the one I chose in the hope it will be helpful.

So, interesting links:
1. Imperial College COVID group study

2. I quite like this site which was shown me by a US colleague which shows the impact of different levels of isolation/lockdown very vividly and illustrates the impact of the peak overwhelming health systems there very visually. Obviously their numbers are based on their model which is based on their assumptions and we don't know for certain how accurate their assumptions are ( although I've read the model and underlying assumptions and it seems fairly reasonable to me ). Anyways, here's the link.

Pseudonym121

up for anything wrote: »

Ah sorry, I didn't realise it was privileged information although that's a bit disingenuous because I suppose I did on some level based on the fact that the actual ages are not released. Why is it privileged? Surely knowing what ages they were would not violate patient confidentiality?

Thank you for answering all the questions. It is reassuring to have somewhere to come and get some clarification from the coal face so to speak. I had another question but can't for the life of me remember what it was now.

That's not how I meant privileged information. At the beginning of the thread I said I wouldn't divulge information which I came across through the day job. I know that information from the day job and so I won't answer that question.

Once that information comes out through other means then I would be able to address it. I resent you saying that my response was disingenuous. Doctors may make incorrect assessments and diagnoses but we don't lie to people/patients. A doctor who lies isn't fit to practice. You may not like where I draw the line, that is your right. But to say I'm being disingenuous is entirely uncalled for.

Wanderer78 wrote: »

I just want to say thank you, thank you for putting your life in danger every time you go to work, we need our health professionals more than ever now, going to work must be a truly terrifying experience for you now. Thank you and best of luck

Lots of people are taking risks. We all have to do our part in order to get through this with as few deaths and long-term complications as possible. I think all of this talk of heroes etc is all very American and not something I and my colleagues ( Consultants, NCHDs, nurses etc ) identify with much. Sure we are scared but we are needed and the overwhelming sense is one of not wanting to let our patients or the public down and not letting our colleagues down. That's important because that will help staff cope.

On the other hand I have heard a few ( including myself ) say that we hope the public remember this the next time we advocate for more resources for the health service and proper staffing levels, in particular the number of consultant posts and equal pay for equal work so our well-trained NCHDs no longer emigrate to Australia, the UK and Canada instead of choosing to stay here. Functionally doing that will help us and you all a lot more in years to come than nice words... and mean that the next time you need us the right numbers and calibre of people are available to help you and give you the best chance of survival.

As to going to work being terrifying... Well, I think what I see people doing is just blocking it out, focusing on what is in front of them, doing what they can to practice safely and then recognising that there's a chance they'll get it and then what will happen will happen. Coping with what is directly in front of you and ignoring the scary context is a time-honoured coping mechanism and I see a lot of that around. But, yeah, a lot of people are scared.

I think that some of the higher levels of management and clinical staff are more scared than the front-line because they are looking into the future more and what MAY be instead of what IS TODAY. For example, I'm doing the day job ( all of my existing patients ), an influx of new patients and redesigning services/re-allocating resources in order to meet future needs. That latter part, redesigning services and re-allocating resources is by far the most stressful part of my day and what I've spent my non-working time largely doing for the past week and a bit. It involves a lot of friction, stress and frustration as well as some really scary possibilities. Mostly I ( and others ) are just worried about letting people down and I find the realisation that if I get the design and resource allocation wrong then people may die and/or suffer life-long consequences.... and since I'm just a jobbing consultant and not a specially trained disaster management expert I'm just going with my best guesses and what I've gleaned from whatever research I can do online and by phone I know I won't get every choice right. I will do my best but I know I'll make mistakes and mistakes will result in ruined lives.

That is the heaviest of all burdens. When I talk to senior management ( hospital management, CHO management etc, the ones looking into the future as opposed to middle management and clinical roles focused on the here and now ) the senior management sound really, really fatigued... and not just physically.

But now isn't a time for weakness. It is definitely affecting people though... I was up working on service re-allocation and re-design for multiple services till about 3:30am and then woke up at 6:45am... and I'm a really good sleeper normally. So, for me, that's a sign that I'm feeling stressed, my sleep goes off. But, what am I going to do? Quit? Of course not.

In terms of disaster response healthcare workers etc are in the heroic phase of response. That won't last. Over the coming weeks I expect we'll begin to see a lot of staff becoming dysfunctional and having to be moved into non-critical tasks ( this isn't cowardice, it is just the reality that different people have different abilities to cope with things and some will become dysfunctional when this is exceeded - and what they face could be very bad ) while others just have nervous breakdowns and become psychiatric casualties. We will have to support them acutely and in the long-term --- this is another area we will need the public's support. When this is all done with, healthcare workers and other front-line staff ( Gardai, Fire Brigade, paramedics ) are going to have much higher rates of mental health problems ( addiction issues, suicide, marriage breakdown, PTSD etc ). I hope that the public will ensure the politicians ring-fence the funding required to help these psychologically wounded individuals recover as much as is possible.

If you want to give thanks then please do it through advocating for all of the people on the front line to receive the supports they will need in the future and support us when we advocate for a better health service for the public and the staff within it.

With that said thanks for the sentiment.

joeguevara wrote: »

Thank you and to all medics (and everyone else involved) for the work that you are doing.

I think politicians should not have a platform like we are seeing. It is clear that medics and scientists have issues with what is being said to the public. That frightens me.

https://time.com/5808283/infectious-disease-fauci-trump-coronavirus/

Well Fauci has had the temerity to disagree with Trump recently. Based on what I've seen he wasn't at the last two press briefings so it looks to me like he's done for... He has criticised The Great Leader and that isn't tolerated... irrespective of how correct he was.

The only question is whether they'll get rid of him now or keep him around and then use him as a sacrificial scapegoat, blaming him for their poor response to this crisis. My money is on the latter.

My colleagues in America are really freaking out about this at this stage. Ones who were pretty chilled five days ago are beginning to freak out. It is also interesting to see it cascade down the levels... Attendings ( their equivalent of consultant ) got scared first, then it went down to Fellows and has proceeded down the grades... I've seen some of their interns begin to really get scared via online postings in the past couple of days as their individual hospitals are enacting measures which have made it all real for them. It is escalating really rapidly and none of the ones I'm in contact with ( a small sample size to be sure ) don't have any faith in the Trump government's response.

As regards the heroic phase I mentioned above. Here's a little reading about what healthcare workers and society as a whole are currently going through and will be going through going forward.

Pseudonym121

Yester wrote: »

Thank you for all your answers so far. Could I get your opinion on this? Recently we have met 2 separate people that believe it is perfectly safe to be within 2 meters of us as long as it is for less than 15 minutes. One even thought they were going to be invited in for a quick cup of tea. That wasn't going to happen as we are being very careful. They seem to be getting the 15 minute idea from articles like this

https://www.rte.ie/news/2020/0323/1124891-irish-figures-coronavirus/

The relevant bit says "Generally, you need to be 15 minutes or more in the vicinity of an infected person, within 1-2 metres, to be considered at-risk or a close contact."

It seems like dangerous advice to be giving and makes it harder to get people to stay away when they are getting the impression that less than 15 mins is fine.

What do you think of this?

Well, I wouldn’t trust my life to “general advice” especially when all it takes is the other person, who thinks they’re fine, having one cough unexpectedly and suddenly you’re covered with droplets.

The government had to draw the line somewhere and I think they’re balancing panic with practicality. It is my life and my choice when I’m not at work and so I get to err on the side of caution when not in work. I think that for something potentially this severe it is reasonable to err on the side of caution and stick rigidly to the 2 metre distance + whatever level of protection you feel is appropriate for you ( gloves, masks etc ).

With that said I’ve been keeping an eye out for mask usage in public and in recent days I’ve counted 8 people wearing masks in public - not a single one of them was wearing the mask properly and so was getting almost no benefit ( other than psychological ) from wearing the mask.

RiseAbove4 wrote: »

Thanks for asking my previous question

I was wondering;

If you’re living with someone in their mid 60s and you get it or have strong symptoms of it, what do you do if you share a kitchen with them?

Is going to a budget hotel for 3 weeks a bit much Going to the kitchen would be fairly essential for all

Or maybe order tskeaways and clean down door latch after?

Thanks

I believe the advice in that situation is to isolate yourself in a bedroom with en suite if possible, have food left at the door and picked up at the door. I do not believe that the possibly infected person going to the kitchen is at all essential. Isolate yourself and let the other person make and deliver your meals and pick them up after you are done for the duration of the isolation.

If you both use the same kitchen while one person is infective I believe that it is almost inevitable it would be passed on.

Our definitions of what is “essential and necessary” need to change a bit for the next 3 months... and then possibly in Q4 again.

As to a hotel... I doubt you’d get into one especially as they’d be suspicious you were self-isolating and thus putting their staff at risk.

locohobo wrote: »

Hi again....Just reading you're reply on UV sterilization on home items. As you said the cost of them has gone through the roof and then if can be got...
Am wondering here if a home made option could be put together..
I have one of these..https://www.nisbets.ie/electric-fly-killers
Would it be of enough UV intensity to be effective..
Just put it in a light proof box for 20/30 nmins along with items to be sterilized...
What you reckon??

I honestly don’t know. I’m a doctor not an electrician. WIth that said the UV light used to sterilise medical equipment is VERY strong. It would seriously irritate skin if you exposed your skin to it. These fly zappers are very weak in comparison so I seriously doubt they’d have the power to sterilise things successfully.... but I’m no electrician so cannot be sure.

If you want to sterilise things and don’t have a UV light steriliser then you can simply use disinfectant wipes or a cloth with some water containing bleach etc ( and you wearing gloves to protect your hands). There’s lots of other options which will be effective with a little additional effort without going to something like an extempore UV light box which probably won’t work. I’m just super lazy cloaked in a guise of trying to be efficient ;-)

fishy_fishy wrote: »

You mentioned that a lot of support will be needed for medical and emergency services staff in time to come, and that it will be afterwards that it hits (badly paraphrasing, sorry, but I think that is something that the public will be 100% behind in the aftermath of this).

Are there any formal techniques that are taught to medical staff for dealing with crises? It's one thing to be busy and sort of just keep going and not stop, but presumably staff all go home and have time alone and need some sort of coping mechanism then, even with the crisis ongoing.

The whole crisis has caused a knot of anxiety to develop in my throat so can't imagine how tough it must be for medical staff at the moment.

Well, I think there will be a requirement for a lot of support afterwards but I think a lot of staff will need psychological and even psychiatric support during the next 2 to 3 months. This is going to be rough, especially if and when colleagues die puncturing their belief that it won’t happen to them. I think those of us, like me, who have calculated the odds and made the preparations ( will etc ) may make it through better because we will suffer less shock to our preconceptions when doctors and nurses start dying.... I don’t know if that’s true, just my sense/hope.

As to how staff cope. Lots and lots of dark humour... the sort of stuff that if the public ever overheard us would result in massive levels of complaints for inappropriate behaviour.

So, teams band together by making light of the unbearable to make it bearable. It is either laugh or have a breakdown sometimes. There are some techniques people are taught but they are much more focused at either:
A) coping with stress over the long-term or

support after one off overwhelming incidents.

Earlier today I got a bit overwhelmed at something I considered stupid and hindering effective working and really got annoyed, felt very stressed and at one point felt a little like saying F it all and retiring but I knew that was just the stress getting to me - I have NEVER worked as hard as I have in the last two weeks and I’m sure many others feel the same - and I finished the work i was doing, went and did something else and knew that when I got home I could sleep for a bit and that once I’d slept I’d feel better. Experience gives you the knowledge that whatever it is will pass.

Of course I made sure that none of my NCHDs or my team heard or saw that... I just vented to another consultant who knows the drill - we sometimes form our own pity party when we’re annoyed at HSE stuff ;-) - and got on with it. I’m sure there’s a lot of that going on at all levels and in all types of worker within the HSE/ other first line responders right now. Some level of showing junior staff that it is OK to be stressed is useful as it gives them permission to admit the same but showing them the true stress levels just isn’t helpful. Before I was a Consultant I just assumed they were always entirely unflappable ( except for the ones who had legendary tempers ) now I know they were all very mindful of the fact that if they looked like they were going to crack then the entire team would suffer and I wonder just what was really going on when the NCHDs etc couldn’t see them. I figure it was much the same stuff as I think about when making sure the team doesn’t see the cracks.

THe other thing that helps is the thing that was bothering me is something which I can deliver on by the end of the week - one of the reasons I’ve been working on this every day after work, cause it is urgent - and so I know that once it is done I can go back to focusing more on the clinical day to day stuff which is actually less stressful. I think that is important cause I;m conscious that I can’t go into this worn out or I’ll be at very high risk of burning out and becoming ineffective. So, same as with the need to take care of oneself physically in order to be available for patients etc I think we all are conscious of the need to take care of ourselves a bit mentally so we are available too. So, burn out to get this piece of work done ASAP and then recover ready for the next few weeks.

This is likely to be a long-term overwhelming incident and so I think what has gotten people through up until now will fail a lot of them.... especially the younger doctors and nurses, Gardai etc who haven’t had the time to build up the mental calluses us older, more senior folks have. I think it will also hit staff who have been redeployed quite hard because they may be much more clinically facing and see a lot more death and suffering than they’re used to. I think a lot of them will find it very difficult also.

I think we’ll need to look out for and support them both acutely and with, ideally, ring-fenced funding for mental health supports and a compassionate HR/Occupational Health policy etc going forward.

volchitsa wrote: »

Hi and thanks for making yourself available to answer questions in such detail.

Like many others, including our government, I've been worried by the Neil Ferguson/Imperial College model of death rates, but there is another more upbeat model, mentioned in the Financial Times (sorry, it's behind a paywall, here's another: https://theweek.com/speedreads/904584/new-oxford-study-suggests-millions-people-may-have-already-built-coronavirus-immunity)

This is an Oxford University study by Prof Gupta IIRC, and they believe that the virus had been circulating for a month or more in the UK before it was identified there, and that many people are already infected and have been fine.

That should mean that the more optimistic herd immunity approach could be the right one, although they do call for far more widespread testing, like SK is doing. But basically, is it wishful thinking to say 50% could already be better?

I'm dubious, going by what I hear from Italy (won't count China as I know nothing of their health service) but do you have any technical detail of why the Neil Ferguson model seems to have been adopted without reserve? Does the Oxford study have some massive flaws we should know of?

I’m dubious about the idea that it was circulating for a long time for a number of reasons:
1. The phylogenetic that Ive seen simply don’t support that view. We’d see much more divergence in Irish and UK samples than we currently do if that were true.

2. If, let’s say, 2.5 million Irish had it and it has at least a 1% overall death rate then where are the 25,000 dead since October/November ( which is when I hear a lot of people say this was circulating ). We WOULD have noticed 25,000 people dropping dead over 3 to 5 months. Obviously this is oversimplified but the general gist of “If that’s so then where are the bodies?” Is, I think, a persuasive argument against that hypothesis. In Britain that number would be even higher.

3. Even if you take the one month circulation hypothesis the nature of exponential growth is that if you started with one person infected at the beginning of that month then with a doubling rate of 3.5 days ( twice a week ) that would have become 256 by the end of the month. It would have had to circulate for at least 13 weeks to infected half the British populace.

4. If it HAD infected half the British populace then it should have infected the rest within 3.5 days of infecting half the populace. This simply isn’t what is being seen.

So, I get that they are approaching it from a different angle and thinking outside the box is good and it is good to challenge orthodoxies of thought BUT I just don’t find this view to fit with the facts as we know them.

Even if you assume it had been circulating for 2 months before it was officially spotted - which I think is unlikely - it would only have infected about 65,000 people (doubling every 3.5 days) not enough to give herd immunity. But if that was true then over the NEXT month the number of infections would have jumped to 16 million and we’d have been looking at over 167,000 dead with just a 1% mortality rate. That simply isn’t what we are seeing.

So, it is an interesting hypothesis but even if it is correct it wouldn’t have resulted in the sort of herd immunity that they posit without causing a LOT more deaths than the UK is currently seeing. They seem to have some weird obsession with this herd immunity concept over there. I can only imagine that it is because it would allow them to restart the economy much more quickly.

I don’t get why so many people online ( not you, just a general observation ) seem to be pushing this idea that it has been around since earlier this year or last year because “what I had was no flu”. The maths of exponential growth, phylogenetic and death rates just do not support those theories.

And lastly, I thought I’d provide a link to a sobering site. It is from the Italian doctors council ( I can’t read Italian so I’m sure I’m off in my translation ) and lists the number of doctors who have died. I have tried to find a similar list for nurses but can’t. If anyone finds it I’d be happy to list it also. We’re all in this together and the virus surely doesn’t discriminate.

So, the stand out number yesterday was 24, today it is 33.... 33 dead doctors. https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/ It’ll be higher tomorrow. Sobering stuff.

And now I’m off to fit a little work in around the leisurely days on the golf course ;-). Good luck to all and take care.

Pseudonym121

Strawberry Swan wrote: »

Thank you for giving such detailed information on all this. All your posts over the past month have been an eye opener for me and this is an invaluable place to come to for honest upfront advice and information. I've shared with others.

I have donated to the Rape Crisis Centre on your behalf. What other charities / campaigns would you recommend donating to, to help the fight?

Thanks for the comment. I don't have any other charities or campaigns I'd recommend donating to to help the fight. In general I support the ISPCA because how some people mistreat pets/animals in general is very upsetting but at this time I'd just keep my powder dry and wait the 8 weeks or so of this lockdown.

If you want to support medical staff/help the fight then the best things you can do are (IMO):
1. Stick to the lockdown and advise anyone else who chafes at the restrictions to stick by them.

2. Afterward keep social distancing and handwashing - this isn't over yet. In fact the next two months may only be a dress rehearsal for winter time if this follows the Spanish Flu pattern.

3. Keep supporting healthcare workers - not by going on clapping hands, breaking social distancing and actually picking it up from your neighbours - but by actually listening over the next few years when we advocate for more resources for our hospitals and better pay and conditions so good doctors and nurses stay in the health service to look after you all the next time this happens, and it will.

IrishAlice wrote: »

Thank you for everything you are doing.

I have seen an increased amount of coverage about the supplies of PPE dwindling.

Paddy Cosgrave has been particularly vocal about this on twitter and tweeted last night that one of Ireland's shipments was intercepted and taken by a larger EU country.

Are you concerned that there won't be enough supplies when we actually reach the peak of the curve?

There aren't enough now. It is a race between getting the supplies in from China, figuring out how to sterilise and re-use what we have - beautician/hair dresser UV light sterilisers may have a role there - and the onset of the peak.

If the peak outstrips our ability to re-use and fly in from China then things are going to get even worse for healthcare workers. It is out of our hands - this is why I and others were begging you all to socially isolate, distance and hand wash over the past few weeks. The more you did that the more you helped keep the peak low, ensure we won't run out of PPE and that we won't have to expose ourselves to risk unnecessarily.

This is what people misunderstood about my tone earlier. It wasn't condescending or hopeless... It was simply realistic about where I could see we were going to end up if people didn't listen. I know a lot of people listened to doctors' messages on TV and radio ( and in my small way here ) and hopefully it will have proven to be enough.

Buford T. Justice VI wrote: »

I'd like to echo the many thanks from all of us here for what you are doing and the risks you're taking for us.

A small question if you get time, I'm curious about the strong male bias in the infection rate, some 55% versus 45% for females.

Would this be mostly due to males having riskier behaviour and not washing/disinfecting as often as women or is there a higher susceptibility in males to the virus?

I wouldn't be as worried about the disparity in infection rate vs gender in Ireland as I would be about the expected disparity in death rate vs gender.

Essentially men are dying at a disproportionate rate to women. So, men are more likely to get infected and more likely to die if infected.

Here's a good article for the guardian which makes easy reading for those who want to disseminate it. https://www.theguardian.com/world/2020/mar/26/men-are-much-more-likely-to-die-from-coronavirus-but-why

I think you can see some reflection of this on the page listing the Italian doctors who have died from COVID-19... They are overwhelmingly male.

And on that note the number is now 51, that's up from 33 yesterday.
https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/

And our first here

. Sad but inevitable news.

As to the 23% healthcare worker infection proportion... It isn't what it seems.
FWIW the 23% figure for health care worker infections is an artefact of the low level of community testing. I expect the actual the percentage of healthcare workers infected vs total number of infected will probably be closer to 10% by the time the first wave is done - sometime end of May/beginning of June. By this time next year I expect that the number of healthcare workers infected relative to total infections ( absent a vaccine ) would tend to fall towards the percentage of healthcare workers in society as more of society becomes infected during the putative second wave we might see over winter 2020 ( absent a vaccine ).

At present it simply reflects that we haven't done enough community testing to get a true sense of the number of infected in the community.

Pseudonym121

feargale wrote: »

Could the virus be carried by paper? Should I cancel delivery of newspapers and magazines?

We are clear that it can survive on paper ( and other surfaces ). It is unclear how long it survives but most research I've seen says it survives at least 12 hours and possibly for several days.

One of the steps I took when I realised how serious this would be in February was that I stopped getting newspapers and magazines in person and subscribed to the online versions. They're actually great on a laptop, tablet or ipad.

That way you still get the newspaper and magazine, frequently save money as the online version is cheaper than the paper version AND you cut down the risk of fomite transmission within the home. Win, win, win.

With that said I can't tell you what to do as regards your magazine or newspaper delivery except to say that if the delivery person has it on their hand and delivers the paper to you then it is likely to be on the paper you bring into your home.

s1ippy wrote: »

Hi Pseudonym,

Just wanted to say thanks for everything. Reading your information has been a great consolation and help. I donated in to the local RCC and women's refuge in your name. Your input is so appreciated.

I was looking at UV lamps, this one says not to have humans or animals present when it's in use.
http://vi.raptor.ebaydesc.com/ws/eBayISAPI.dll?ViewItemDescV4&item=372985569977&category=20706&pm=1&ds=0&t=1585363933585&cspheader=1

Do you think this would be more or less risky to use than a bleach solution to sterilise shopping? Just to note that I don't spray the solution directly onto goods that will be consumed, just packaging, and once the veg are unwrapped, I scrub them thoroughly with warm water.

I think UV lamps are really irritating to skin and I think people who buy those sorts of wands are highly likely to damage their skin and eyes. That's why I avoided them myself and why I eschewed them for my parents/siblings.

If you can't get an enclosed UV light steriliser I would just stick with disinfectant wipes etc as I think those wands are more dangerous than beneficial to the average person. That's just an opinion though and not something I can point to research papers on, I just know I wouldn't trust my parents to use them properly.

s1ippy wrote: »

We follow protocols similar to what you outlined. We do click and collect for our shopping quarantining an area for when we return, adhering to rigorous IPC measures, disinfecting everything and then leaving area for a few hours and washing clothes and showering off any potential virus on skin. Even then, when we load the shopping into the cupboards and fridge, we use gloves to pack the stuff up and keep it separate and don't use it for a few days.

It's possibly overkill but we are exercising an abundance of caution. I wonder what your thoughts might be on this University of Nebraska study. It's as-yet not peer reviewed, to my knowledge, as it's only five days old.
https://t.co/ZpCXu3JBv2?amp=1

No worries if you can't get to it, I'm sure you are amply occupied at this particular juncture. Thanks again.

I had a quick scan and it seems to simply say that SARS-CoV2 is spread by droplets, toileting and fomites and thus can be spread directly and indirectly. That has always been my understanding. I definitely assume that it can survive on paper, cardboard, plastic etc on deliveries to my place.

Purple Mountain wrote: »

Hi.

I just wanted to ask about what actually kills a CoVid patient?
I read today about a patient in another country who actually was stabilised in hospital after it but then got a superbug.
Is it a case of the fluid on the lungs gets too much and that's what takes the patient or in some cases does the virus travel to the heart and cause cardiac arrest?

Well the main cause of death seems to be Bilateral Interstitial Pneumonia which appears to be directly caused by COVID-19. However as with any viral infection you can get superimposed infections ( superbugs and ordinary pneumonias ) and you can get involvement of other organs... figures I have seen show 20%+ of patients have elevated Troponin levels - indicative of heart damage - and colleagues in America have told me patients there have died of cardiac complications. SARS-CoV2 has also been isolated from cerebrospinal fluid and found to be shed in stools.

So, it seems to get pretty much everywhere and if any organ system is weakened/vulnerable that could be a pathway for it to cause death. With that said the main avenue certainly appears to be the lungs.

About 3 to 4 months from now when Europe has had time to get over the peak and crunch the numbers I think we'll have a very clear sense of the ways in which it killed people relative to their underlying risk factors. I think this will help us tremendously in preparing for the likely second wave of infections in Q4.

Purple Mountain wrote: »

I mentioned this in another thread but I'll ask here and I hope you don't take offence because none is intended.
With the Dept of Health quoting ICU beds going overcapacity, they don't seem (in my opinion) to take into account people leaving ICU and going back to a regular isolation ward or unfortunately god forbid dying.

Many thanks for your information and of course your service.
Wishing you a good night's rest hopefully if you're off.

Well, someone tubed in an ICU bed with COVID-19 is going to be there for quite some time - likely more than two weeks - and over the next two weeks as we experience the peak people tubed today are going to either die or still be taking up a ventilator. With an exponentially growing infection like this which is doubling ever 3 or 4 days the growth is such that 2 weeks from now we could be seeing 16 times the number of new people needing a ventilator per day than currently newly need one.

So for two weeks, until we peak, the only people coming off will be the ones dying, not recovering and by the time the people from today recover we'll need so many more new ventilators per day that the number recovering will be a small % of the new ventilators needed that day ( 5 to 10%).

So, statistically right now the number of people recovering over the next 2 weeks is a small proportion of the number who will need ventilation over the next 2 weeks. I think people still don't quite "get" how bad this is going to be. We are likely to see between 30 to 60 deaths per day for an extended period of time ( 4 weeks or so ) when this hits its peak. Somewhere between 1,000 to 2,000 people are going to die from this in April and May if we do everything right. If we make mistakes during this period then even more will die.

Add in the fact that 80% of all deaths from this are likely to occur in Q4 unless we get an experimental vaccine/absolutely massive increases in ventilator capacity weekly between now and October and you can see that my pessimistic best case scenario of 10,000 dead in the 12 months from 1st March 2020 to end February 2021 is pretty much what we're looking at now.

If we get even an experimental vaccine for high risk people by September than we should be able to reduce the 8,000 additional deaths (after May ) massively but up to 2,000 by the end of May is pretty much guaranteed at this point.

With that said the reason I started speaking out about a month ago was that we were sleep-walking to my reasonable middle case estimate of 50,000 dead in the year with about 10,000 of them being in April to May so by the actions taken we have avoided many thousands of deaths over the next 8 weeks. The state has done an amazing job - yeah, lots of mistakes have been made too and the lack of PPE is a real tragedy but this is a crisis and to expect a perfect response when there's such a dearth of information is unreasonable. They've done well once they got going... I just wish they'd gotten going about 2 weeks earlier. It would have saved a lot of lives.

avalidusername wrote: »

Hi Pseudonym,

Just a couple of questions.

1) Long term, do you think the lockdown/social isolation could have a beneficial effect on Irish society in general? By this I mean an increased awareness of hygiene, maybe reducing the winter vomiting bug outbreaks. Or people generally having more respect for the health services and not running to the hospital for minor ailments?

Well, I think the next time we get a pandemic - and we will get another one given human encroachment into natural areas and attitudes to bushmeat/live markets etc - people will order masks in earlier and wear them more. I think people will also be more tolerant of moving to mass testing and self-isolation more rapidly. The state will be able to do that in days rather than weeks.

Do I think it'll result in more respect for the health service?
I hope so. I doubt it though. I think it'll be like Rudyard Kipling's poem, Tommy. At a time of crisis people will go out clapping and call everyone in the health service "heroes" - so Fing American - but when it comes time to advocate for equal pay for equal work for Consultants and nursing staff a year or two from now people will have forgotten and go back to calling Consultants lazy, privileged etc etc. And if they do that then more and more of the juniors will emigrate once they finish their training and the Public will be left with a hollowed out HSE for the next pandemic, resulting in more deaths.

So, do I think the public will change and maintain that change? No, it isn't the way people work. Sorry for sounding so jaded but this is what happens when you have to read what the public write about us online or say on the media for years running. It'll go back to that vitriol soon enough.

Will it change people running to hospital for minor ailments?
No, I doubt it. A lot of Irish people have a tremendous sense of personal entitlement and very little sense of personal responsibility and, in the long run, I expect that they'll revert back to thinking that their minor ailment is the most important thing in the history of important things and needs to be treated RIGHT NOW!!!! The number of people who have had a niggle for 4 to 6 months and then decide at 2am on a weekend morning that they should call an ambulance and be brought to A&E to have it treated RIGHT NOW would amaze you if you could experience it.

I see that happening every week and the sorts of people who do that will continue to do that in years to come.

With that said a lot of people are brilliant and don't over-react but a significant minority ruin it for the rest of the population. One of the real privileges of my work is that you get to meet so many people and, even when they're in a bad place - sick, scared, in pain - many of them are just decent human beings... and to be a decent human being when you're sick, scare and in pain is magnificent to see. Some days I feel the job grinds me down and makes me think everyone is a selfish you know what.... and then I have an interaction where I genuinely laugh at someone's wry sense of humour or the thoughtfulness they have towards others while they themselves are ill or see them being more worried for their family than themselves. It really gives you hope for humanity.

Recently I've been touched by the number of my routine out-patient reviews which have finished by the patient actually sincerely wishing me good luck over the next few weeks with the full knowledge that the next few weeks are going to be tough for people in the health service. Several colleagues have reported the same. It has been very unexpected and quite touching really.

avalidusername wrote: »

2) A former colleague of mine has recovered from the virus. He's from Bergamo and we think he contracted it at the Atalanta v Valencia Champions League game they're calling Game 0 now. With this game being possibly linked to the massive outbreak, what was your view on Cheltenham going ahead this year?

I was on record at the time as saying it was ridiculous and would act as a major nexus of infection. I'm certain this will be proven so when we look back at who was infected and where they were exposed. Same for letting the Italian fans into Ireland. Those were two of the mistakes made by the state.

avalidusername wrote: »

Finally, many thanks for your input. You will be blessed for your efforts, if not by a higher being, then by science for protecting your nearest and dearest with your isolation.

LOL! Wow that sounds amazing... I could be a hero of science ;-). Nah, I'm just a jobbing consultant trying to do my best for the people of Ireland as I and my colleagues try to do every day - whether there's a pandemic or not.

The one self-serving thing I'd ask is that the next time you hear Consultants and nurses advocate for better services and equal pay for equal work don't just dismiss their pleas out of hand. Don't necessarily agree but at least remember that these are the same people who put their bodies and lives on the line for the rest of you and just hear us out the next time we speak up on our and your behalves.

leggo wrote: »

What are your thoughts on doctors in NYC using antibodies of recovered patients or patients in Norway and Spain being trialled with new medication? Obviously the point of these trials means you don’t have an answer for whether they’ll work or not, but with industry knowledge do you see how quickly these are being developed as a positive sign or would this be standard fare expected of a situation like this? And say one of these treatments were to have initial success, how would you anticipate that playing out and affecting the overall global fight against this?

In a situation like this? We haven't had a situation like this since 1918. Without lockdowns and massive medical interventions SARS-CoV2/COVID-19 had the potential to kill a minimum of 2% of the world's population ( 150 million people ) and a maximum of about 10% (750 million ).

We won't see those numbers... In Italy the 2% number would have meant 1.2 million dead by end of February 2021 with about 240,000 of those dying by the end of May 2020. Instead I think Italy is looking at between 25,000 to 30,000 dead by the end of May. So that's a tremendously good results all things considered. Absent a vaccine it still means they are on track to have 200,000 to 240,000 dead by the end of February 2021 though.

I've said for some time that American is going to be the Western liberal democracy which comes out of this the worst. Right now it is difficult to imagine them having less than 100,000 dead by the end of May with a minimum of 500,000 dead by the end of February 2021. America is really difficult to predict though because when you run a model for someplace like Italy you can at least assume the government acts rationally. They may not listen to medical experts for some time as they re-orient to the new reality but they are at least rational. Trump is just chaos and you can't predict what he'll do from one day to the next. America SHOULD have been well able to deal with this. They have tremendous resources and reserves of equipment but Trump is squandering time and these reserves and resources. I wouldn't be at all surprised to see 2 million dead in American by end of February 2021 if Trump continues with his current "management" style.

I think that what we are currently seeing will go quite some way to accelerating China's overtaking of American, at least in terms of soft power, on the world stage and will obviate the Thucydides Trap that we have been looking at occurring sometime around 2030. America will fall faster, China will rise more quickly and America will become far more insular with Trump on a second term. All in all that will obviate the military outcome of the Thucydides Trap. IMO of course.

Anyways, back to your question: Everywhere will throw everything they have at this. Rushed vaccine trials, compassionate trials of unproven meds on dying patients, retooling of factories, repurposing of entire sections of the economy etc. I think trying to use convalescent antibodies is a reasonable thing to try. It has a long history in medicine with variable results but in this situation it is absolutely a reasonable thing to try.

Let us be clear though, absent a vaccine by Q4, more people are about to die worldwide than died during the entirety of World War 2. By that I mean about 1% of the current world's population of approximately 7.5 Billion people. This is unprecedented since the Spanish Flu of 1918 to 1920. That 1% figure won't apply to countries like Ireland ( I've said before I think we're in the top 15 countries in the world for getting through this well, America is only in the top 30 ) but when this really gets going in Africa, Indonesia and South America it will easily kill 20% of the elderly infected there... the one bit of "good" news is that a lot of those areas are relatively young but if you're old and not rich in those areas then you are in deep, deep trouble.

So I think we'll see a mix of 20% mortality in the elderly in countries with a lot of income inequality, poor healthcare systems and poor/weak centralised governments and 2% mortality among the elderly in rich western countries with socialised healthcare/ Asian countries with a culture of obedience to social norms and experience of surviving SARS. You then need to take those stratified death rates and run them through the % of elderly in those countries. Rich western countries with good healthcare systems have a lot of elderly people --- because of those healthcare systems being good - while the countries with high income inequality and poor healthcare systems frequently have much lower %s of elderly as so many die young. So it all gets very complex.

With that said I'd rather be elderly in a European liberal democracy than almost anywhere in the world right now - Singapore and Taiwan excepted.

dermob wrote: »

Hi, and thanks for all your help!

Is there a specific test for Covid 19

Yes and tests for antibody presence are also being developed/deployed so soon we will be able to tell if you've ever had it, not just if you have it now.

Purple Mountain wrote: »

I just thought of another question, sorry maybe this isn't a medical question really!

If Ireland is very successful with curtailing the spread of this with our restriction measures and in a few weeks/months, it's all but eradicated here - great.
But then if our airports and ports are open and we have traffic from countries that haven't taken the same measures or been successful, then we just go back to square one again?

This will be around until we have a vaccine. At that point it all depends on whether there is sufficient genetic change in the virus to constitute a new strain. If there is then this will circulate seasonally just like the flu.

So, yes, I'd expect that most countries around the world with any sense will institute a 14 day mandatory or voluntary self-isolation for visitors. Countries reliant on tourism may not do so. Ireland could be one of those countries. Theoretically if we have massive testing regimes then we could open the borders without mandatory quarantine for incoming travelers. Right now though I'm just focused on the next 8 weeks for obvious reasons.

The good news is that the evolutionary pressure on a virus like this is to select for increased infectivity and decreases mortality so if we do get strains circulating and changing seasonally they should select for decreased mortality rates and over time it will become more flu-like. People not born now won't be able to believe, when they are 30 or 40, that we were ever so scared of COVID-2060 because by then it'll have selected for decreased mortality so many times that it won't be the threat it is now.

The reason it is such a threat now is that it has spread around the world so rapidly after transferring from animals and so is still in a very lethal form.

This sort of stuff is what makes virology/epidemiology and the study of pandemics so fascinating. So, bottom line, the vast majority of the world's population will be just fine and 20 to 40 years from now even if this is seasonal it will be massively attenuated and people not born now won't understand what all the fuss is about when people alive now are anxious about getting their yearly vaccine. I look forward to that day.

Pseudonym121

I think this deserves a separate post:

I think one key message here is that with the efforts the medical community, aided by management ( for once, they're usually an Fing hindrance

), the Gardai etc and the government are making we are going to come out of this better than the vast majority of countries in the world. Europe in general, Taiwan, Singapore and possibly China are going to come out of this better than elsewhere.

This endless - the HSE is sh!t, the Irish response has been woeful commentary is ridiculous. I am FAR from a cheerleader for the HSE or the government BUT both have done quite well ( albeit with some mistakes ) given the unprecedented nature of this.

We all need to do our part - including the public by staying at home for a couple of months and keeping the b!tching about it to a minimum but, as a country, we are going to be OK and come out of this better than most others.

I'm not in favour of mindless optimism BUT I am in favour of keeping this in perspective. We're about to take a really painful hit but this isn't armageddon on a societal basis.

Pseudonym121

barrymanilow wrote: »

Hi thank you for taking the time to do this.

My Question is if you were going to go to the trouble of wearing a properly fitted suitable mask in public then should you not also be wearing goggles ? could droplets get in through the eyes as easily as through the mouth or nose ?

I think I'd feel too self conscious to wear goggles in a shop for example , I might wear a mask but what would be the point of doing one without the other?

Well, I have goggles in addition to respirator N99 and general N95 masks and while one could be infected through someone sneezing into your eyes while out in public I rate that as quite low risk at the moment. If we hadn't gone through with all of the mitigation that has been enacted over the past month I think I might be wearing goggles by now but, as it is, I think that unless someone sneezed in my face from close range in public then I don't think goggles are necessary.

We all have to draw the line in terms of protection vs looking like a Mad Max extra for ourselves and that's where I draw the line. We don't have enough community spread ( and likely won't have during this phase of the pandemic ) for goggles to be something I deem essential. Your mileage may well vary obviously.

Walking through a space where there are droplets or even aerosols with your eyes open without goggles vs breathing that air into your lungs are two very different levels of exposure with very different levels of risk. hence a mask is a good idea, but goggles are, IMO, overkill right now.

barrymanilow wrote: »

Also do you think that members of the public who have PPE should donate it to front line health care workers who might need it more once it comes down to that?

It already has come down to that in our hospitals and nursing homes. I was talking to someone today involved in worker's health in several major hospitals and was concerned for their psychological health given how angry and upset they were over the whole situation. But, it is what it is, and you go to war with the weapons and supplies you have, not what you wish you had. They were so upset they couldn't see that.

volchitsa wrote: »

Just related to this question, would normal glasses for sight be of any use?

I've been assuming that my normal glasses would be of some use there, although TBH as I don't wear a mask when I go out, it might be a moot point anyway.

I do try not to go out much though. I just can't work out whether wearing a mask is a sensible precaution or complete selfishness when anyone not directly in the front line but still exposed, like delivery men or shop workers, often seem not to be able to get as many as they need.

Well the use of goggles in a hospital vs when out shopping are in two very different environments. I'm going to reply based on joe public popping down to the shops. In that case I think your main risk would be someone sneezing into your face and literally sneezing droplets into your eyes. In that case if you are wearing glasses the glasses would act as a barrier and may prevent the droplets hitting your eyes and then passing through the mucous membranes.

Failing glasses or full on goggles one could also use swimming goggles as they have a good tight fit and are watertight... They definitely would draw more attention than just glasses though. With that said I could be wearing glasses when out and about and don't bother as I think that risk is very manageable by just not standing in crowds etc.

In terms of donating masks --- well, you have to be aware that even if donated there is no guarantee they'll be used. I have heard several cases of people in healthcare being forbidden from using their own personal masks etc in work and being instructed not to use any PPE or to use lesser PPE than their own personal equipment. I faced something similar and just ignored the individual involved. I've currently had 2 complaints/episodes of being reported to management about my preparedness/instructions to my team/department on how to protect themselves better long before the HSE enacted the sort of stuff I was instructing them to do. Over the last couple of weeks both of them have been withdrawn and apologies given as the individuals involved came to realise how serious it was. Even if they hadn't been and had been upheld I'd just emigrate to Australia next year after this is over rather than keep dealing with this sh!t.

With that said I've got to say as they've begun to understand the seriousness of this they're coming around. It is just a pity they weren't were they are now 4 weeks ago. it would have saved lives but I guess it was a big mental shift to make and it takes time for people to adjust.

This is what clinicians mean when we talk about the HSE being dysfunctional. Even just two weeks ago people were reporting doctors and nurses who could see how bad this was going to get for trying to protect themselves because we weren't following protocol 16.3, subsection c or whatever bloody protocol people who didn't understand anything had come up with. It is an Fing disgrace.

MonkieSocks wrote: »

I posted this on main thread

One reply stated

How much of a virus payload is needed for a test to be Positive?

I mean you either got it or you don't got it, if the present test is that ambiguous it very worrying going forward with diagnosing this virus

The main thread is a cesspool of ignorance and conspiracy theorists from what I can see. I don't read it because it made me think maybe the virus should win. With that said I can say that this sort of simplification of medicine - you either have it or you don't - is the sort of thing people who watch medical tv shows often come out with. Those shows make really grey, complex situations seem like they can be resolved by a single test. That just isn't how medicine is.

You can be infected by SARS-CoV2 and be on the way to developing COVID-19 and if there isn't enough viral RNA in your nose or throat ( where they swab ) to be replicated by the PCR test then you will test negative. Just because you have COVID-19 doesn't mean you have huge amounts of virus in your nose or throat all the time. Real life and medicine is so much greyer, subtle and more complex than TV shows make it appear.

Mwengwe wrote: »

You say:

"This sort of stuff is what makes virology/epidemiology and the study of pandemics so fascinating. So, bottom line, the vast majority of the world's population will be just fine and 20 to 40 years from now even if this is seasonal it will be massively attenuated and people not born now won't understand what all the fuss is about when people alive now are anxious about getting their yearly vaccine. I look forward to that day."

Sounds optimistic in isolation, but by your own reckoning earlier in the same post, we'll probably have another pandemic before then? Am i right? Do you think the next one will be worse?

Good point. Well I think that over the last 20 years we've had a potential pandemic every 5 years. I see no reason for that pattern to change over the coming 20 years. With that said I think that the next time there's an outbreak in nowheresville somewhere on the planet the WHO will be funded to send a metric f*cktonne ( that's a medical term of measurement for a lot of virologists and epidemiologists ;-) )of people down to squash it in its tracks.

Singapore got their response to SARS-CoV2 so right now because they learnt from their mistakes with SARS. We will do better next time because when we get a vaccine next year we will do a full post-mortem and put plans in place for next time... and be in a position to jump to total lockdown much, much earlier than the public would accept this time.

This one is pretty much a reasonable middle case pandemic. It therefore is probable that the next one will less severe or no worse than this with truly worse case scenarios significantly less likely. With that said it is certainly possible it could be worse. I'll outline how it could be worse ( basically longer asymptomatic infectivity and increased mortality ) ....

The ultimate nightmare is as follows:
An airborne ( via droplet AND aerosol spread + fomites ) virus with a very high rate of mutations ( causing multiple strains and thus decreasing vaccine viability ) with a high R0 of say 40 to 50 ( people who say this is the most infective thing ever annoy me. This has an R0 of maybe 2.5 to 3.5, measles has one of between 12 to 18, the infectivity could be a lot worse. ) with a prolonged incubation period ( 2 weeks or more would be ideal ) AND with a significant duration of asymptomatic spread before symptoms appear. Ideally mortality would be upward of 50% but for the process of dying/recovering to take a long time so as to overwhelm the healthcare system and for survivors to have long-term sequelae. After 1 year you'd have maybe 50% mortality, year 2 would take 50% of the remainder and so on and so forth until either some cure was developed or only those with natural immunity remained. Even if you assume 2 to 3% natural immunity you'd reduce the population to that level after only 5 to 6 years.

Is something with that potential out there? Probably. There are a lot of viruses which exist in animals which haven't yet spread to humans. Most of them will do very little harm but if even one in a thousand of these mammalian viruses in animals has this potential then we have literally hundreds of candidates out there for a pandemic which would make this look like a picnic.

On the other hand maybe it will provide the impetus for us to start treating nature better... because nature has the potential to wipe us out as a technological civilisation and if we keep prodding it that might just happen. This is one reason I agree with Musk ( who can be a bit of a nutter a lot of the time ) that we need to become a multi-planet species ASAP. The survival of a technologically advanced civilisation on earth is not guaranteed - I'm not talking extinction, just removal of the critical density of people you need to maintain technologically advanced civilisation. We'd regress technologically.

SARS-CoV2 is scary but if we had more asymptomatic spreaders and a higher mortality rate amongst the young this would be much, much worse. So, while this might be difficult to believe, what we are experiencing now is not the worst case scenario for a pandemic at all. This is much more like a reasonable middle case scenario. The pessimistic worst case scenario I outlined above, R0-50, mortality 50-90%, asymptomatic spreaders for 1 to 2 weeks before symptoms develop would wipe out technological civilisation as we know it.

This, thankfully, is not that... it isn't even close to being that. We got lucky this time but we need to learn from this cause next time we may not be as lucky. So, good news wrapped in a sh!t sandwich ;-)

66, that's the number of Italian doctors dead now. Unless we get more PPE to the places that need it in order to allow proper levels of protection we'll be letting our frontline staff ( doctors, nurses, porters, nursing assistants, people working in nursing homes ) down massively.
https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/

Pseudonym121

Hi MrMagnolia,

Yeah I noticed a few days ago that it was over 20,000 or so... I have no idea how that compares because I’m a neophyte here but at least it means some people got some benefit, hopefully, from reading my posts and got a chance to prepare properly for this/understand how serious this is and how long-term this is going to be.

Honestly I can’t give you a diagnosis over the internet but I can say that they way I’d treat that is as follows:
1. I probably had it/some strain of it
2. But that won’t mean that I assume immunity.

Various strains of this are inevitable and until it attenuated its lethality as it adapts to humans I wouldn’t assume that I’d dodged this particular bullet.

As regards the masks... what type of mask? Surgical, N95 without valve, N95 with valve, replaceable filters or not, respirator mask?

I have quite different processes for the three types I have - surgical masks, N95 with valve and replaceable filters and respirator masks. Also I’ll assume you don’t have a UV light steriliser but have disinfectant wipes, correct?

I’ll give a quick outline below depending on mask and equipment levels:

1. If you have an enclosed UV light steriliser —- i believe they are for sale on amazon UK again.

A. Surgical masks - simply put them in, run the automatic programme and they come out sterilised. Let them rest till the next day and they can be re-used. Obviously single use is best but if you only had one surgical mask I’d re-use it until it became uncomfortable to breathe through as a surgical mask is better than a scarf or nothing at all.

B. N95 mask with or without valve with replaceable filters.
Take out the filters and place them beside the mask in the UV light steriliser. Turn on, run the programme, everything is sterilised. I’d then be happy to re-use the mask the next day but would put the filters aside in a box set aside for this purpose and leave them in there until such time as I’d gone through all of my other filters. Then I’d start back on the Day 1 filters.

This assumes one cannot get resupply. When I realised this was coming back in February I ordered 6 months worth of replacement filters ( about 200 ) for my N95 masks with valves and replacement filters and 3 respirators. The N95 masks with filters give me 6 months with no re-use of filters and 1 respirator should do for a year, the other two should do for about 6 months each. So all in all I prepared for 2.5 years with no resupply. I estimated that in the worst case scenario I’d only need 1.5 years worth of filters/masks but I wanted a reserve because in the worst case scenario I could envision people with masks having them robbed by those without and so I wanted to have sufficient reserve that if I was robbed twice I’d still have a minimum of 18 months worth of usable masks/filters. I also got 4 different types of masks/filter combos so that if supply chains failed I’d be able to order multiple replacements and if even one type came through I’d be fine.

To be clear this isn’t being some insane prepper, this is just how doctors are trained. Assume everything goes to sh!t and have plans A, B, C and D to deal with all of the ramifications, include fallbacks, redundancy etc. It is simply how I think about patients’ illnesses all day so I took the same worst case scenario planning + redundancy mindset to this.

Anyways, for me that means even with the N95 masks with replaceable filters I will have 200 days of single use filters before I need to go back and use the 1st sterilised one again. Pro tip: store them in 2 separate boxes so the first box holds your first 3 months and the second box your 2nd 3 months - prevents cross-contamination and protects against other unforeseen sources of loss ( fungus etc ). With that said at present the world isn’t heading for the worst case scenario so I expect supply chains to be relatively preserved and in three months time I expect to be able to buy replacement filters easily and relatively cheaply again. In fact I’d say we’re heading for one of the three best case scenarios I envisioned in February - so that’s good news for the world.

C. Respirators
After use I simply pop them in the UV light steriliser and 11 minutes later they come out clean. I avoid any alcohol-based wipes because I don’t trust the alcohol in them not to damage the filters.

2. You only have disinfectant wipes/bleach and water and a microwave.

A, B and C. Surgical masks, N95 masks with replaceable filters and respirators.

The problem here is that alcohol-based disinfectants may break down the filters and so while it is possible to wipe down the masks with disinfectant wipes I would assume that if I wipe the filters they may become ineffective.

This would lead me to assume that surgical masks I’d wiped with alcohol-based disinfectant would no longer work while N95 masks ( with the filter removed ) and respirators ( wiping around the filters ) would be able to be cleaned just fine.

In terms of the filters - if you set them aside for a week or more I think they should be safe. The longer you can set them aside the better. One week ought to be OK but my plan of being able to put them aside for 6 months would leave me extremely confident that they’d be safe and before the price gouging I got 6 months worth of replacement filters for about 50 Euro so it was worth doing.

Heating should also break the hydroxyl bonds in the RNA and I believe if you heat something above 80 Centigrade it should be safe BUT I don’t know how that would effect the masks or filters so while that’s a reserve I just preferred to get the UV light steriliser for about 100 euro as, amortised over the next year to 18 months, I figured it would save me money and time vs disinfectant wipes. Assume two wipes at 10 cent each per day to clean the mask x 365 days x 1.5 years = 109.5 Euro. That was my maths supporting the purchase decision. Add in the cans and food packages which it allows me to sterilise and the UV light steriliser saves even more money - and as I said, I expected the Irish government to do all it could to preserve electricity production so assumed electricity would be available under even the worst case scenario... and that if the worst case was developing I’d see it coming early and just buy a battery pack and one of the small portable solar panels for backpacks which would allow me to charge my phone. I also have more faith in technology to do this cleaning than myself.

So, the key things are not to get so intense in your cleaning that you actually destroy the filters. Even without any cleaning products just putting things aside for two weeks should ensure the virus is dead.

Here’s a link to some WHO findings about virus survival on various surfaces/at various temperatures etc:
https://www.who.int/csr/sars/survival_2003_05_04/en/

ShineOn7,

1. Number of strains:
The Chinese believe they had at least two strains. I’ve heard some chatter in Europe that we’ve identified a third strain here. One should also assume that the USA will generate several different strains given how utterly Fed they are with their response and just the general numbers who will be infected there.

The bottom line is different strains are almost inevitable the longer this circulates. At this point in time I expect it to be circulating well into next year. Back over a month ago I was on record as saying we’d still be dealing with this in March 2021. I’ve seen nothing to change my opinion. By March 2021 we’ll have treatments which we know work and survival for the seriously afflicted will be much improved but it will still be circulating and I expect there will be several different strains by then. The good news is most of the strains should select for greater infectivity but less lethality... but there are no guarantees, just probabilities.

I don’t know how many strains are circulating now but once it is more than 1 that means that just because you were infected you aren’t necessarily immune. That would lead me to continue taking precautions until such time as a vaccine with proven efficacy is released. So, whether it is 2 or 22 doesn’t matter once it is more than 1... and I believe the Chinese when they say it is more than 1.... I don’t believe their death figures BUT you have to bear in mind that them saying it is more than 1 is bad news and their censorship was all about keeping bad news out of the limelight so if they say it is more than 1 strain and that got through the censors I believe it to be true.

2. Doom? Well, here’s my perspective on that...

When I first posted about this I was attacked and called a lunatic publicly and privately. I was told that I wasn’t fit to be a doctor for saying what I said. If you look at what I initially said it has largely come to pass - OR been avoided by an absolutely unprecedented worldwide reaction the likes of which we’ve never seen previously in human history. Governments wouldn’t be doing that if their internal briefings weren’t painting at least as worrying a picture as I painted.

With that said I outlined how you model scenarios as best, middle and worst case and then within each of those strata as optimistic, reasonable and pessimistic.

My reasonable middle case death toll for Ireland was 50k, my optimistic middle case was 20K. My pessimistic best case was 10K, reasonable best case was 5K and optimistic best case was 2K.

At the time we were sleep-walking into 50K or much worse death tolls over the next 12 months. Given our reactions I believe we are now in pessimistic best case territory over the next year - that’s 10,000 dead. That’s bad but it is already 80% better than we were looking at 5 weeks ago.

So what determines whether it’ll be 10k, 5k or 2K? Well I think we’re looking at 1500 to 2,000 dead in the next 2 months based on our current situation. My assumption is that we’ll follow the Spanish Flu timeline and have the largest wave of this in Q4 accounting for another 6 to 8K dead. If we get an find an effective treatment by then we’ll be able to get the death toll down to 5K, the middle best case scenario. If we get an experimental vaccine we can keep it even lower - but I don’t think we’ll have a safe one by September unfortunately.

So, is it doom or is it just reality? I take the view that I have been honest about my assessments and that honesty has helped some people prepare and hopefully not get infected and possibly saved lives. I haven’t forced anyone to read anything and have still gotten some messages privately giving out about my posting - although to be fair most have been positive.

We are currently heading for 20% of the mortality I thought was our best possible outcome just 5 weeks ago and there’s a potential that if we find a good treatment from all these trials we could reduce that to 10% of what we were looking at just 5 weeks ago. I think that’s great news and am feeling quite positive about things.

With that said I think that I have known since February that lockdown was coming and that some element of threat would remain until next March and so I am not having to come to terms with that. I think a lot of people still think this will be done and dusted in 2 months and are having to struggle with the growing realisation that it’ll be a longer term issue. I don’t feel responsible for that - that’s the virus’ fault - I’m just trying to tell those who wish to listen what is likely so they can prepare.

Preparation increases the likelihood you and those you love will make it out alive and so is, in my mind, a good thing. YOu have to also bear in mind my professional experience and training. I’m trained and habituated to be able to think about death without significant emotional response because if I have an emotional response your odds of dying have just increased. So, I look at this as another medical problem and it is my job to problem-solve it as efficiently and effectively as possible for myself and my family. I’ve done that.

I then decided I could help others by posting here and have allocated time to do that.

I’m not emotional about any of those things because being emotional isn’t helpful and so allowing myself to be emotional about those things is harmful —- and I’m trained and habituated not to allow emotions to cause patients harm. I could die and so I wrote a will and made reasonable preparations. My parents could die and if they do that’ll be sad but there’s no point worrying about it now except to make it clear that I won’t be going to their funerals etc and advising my siblings to stay at home also. Being emotional about those things isn’t helpful so I choose not to allow emotions to impinge on my decision-making.

With that said of course I’m very anti dying myself or my parents dying but Consultants only get to be Consultants if we can pack the emotions up and problem solve while our patients/families need us. As a colleague said to me recently, “We can puke afterwards” ;-).

With that said... the good news story here is that with 10,000 dead about 4,490,000 people in the Republic will not die from COVID-19 so we need to keep a sense of perspective. Life will go on and in several years time when the virus has adapted to us and we have vaccines life will largely go back to normal. I think that’s a pretty good news story.... but I can see that if you had thought “ Everything is gonna be just fine” up until a week or two ago realising this isn’t a two month problem might be very difficult to process. Nothing I can do about that though unless I’m to start not being honest... and one thing I decided before I started this Q&A was that I’d answer every question honestly - albeit only using publicly available information.

3. No I wouldn’t move. It is everywhere throughout the country. You can see that from publicly released information. I see no sense in moving anywhere in an effort to find a low penetration county.

Given my job I could actually move if I wished to. I amn’t Doing so for two reasons:
1. It is everywhere.
2. Moving would require van rental and people to move my stuff etc and those two things would hugely increase my exposure beyond the setup I have now.

Lastly, I know this is difficult but I believe it is better to just be honest about the reality of the situation than try to sugarcoat things which will lead to people being less careful and taking risks they shouldn’t. My goal here is to provide information and extrapolation so people can make informed decisions and my larger goal was hopefully to save a life or two - which is something I’ve dedicated my entire adult life to doing.

The situation is frightening but I amn’t trying to frighten people beyond the reality of the situation and the probabilities which will unfold in the future. Hell, I could definitely tell you some stuff which would terrify you all but I don’t because it is low likelihood and so I have decided I don’t need to go into low likelihood really bad news scenarios.

If asked directly I’ll answer directly but you’ll note I don’t do — “No-one asked me this but let me paint a gloom and doom scenario none of you have ever thought of” - type posts. I answer the questions asked and sometimes make a post about something which I think is helpful and hasn’t been considered ( PPE donning and doffing etc ).

So, keep a sense of perspective. The situation is not nearly as bad as it could be. It will last longer than you think, more will die than you thought even a few weeks ago BUT that number will be FAR less than I feared would die just a few weeks ago ( so overall good news ) and over the next 18 months we will develop treaments and some sort of vaccine which will really help life get back to a new normal.

Is that - Everything’ll be OK? No, but at least I’m treating you like adults and being honest with you - as opposed to the shovels of sh!t Trump is feeding Americans.

Pseudonym121

One other thing. channel 4 news is doing some really great reporting every evening on this. I’ve been recommending it to family and non-medical friends.

There’s two pieces from today which were particularly interesting.

1. An ICU Consultant in Wales talks about their situation. He is clearly trying to be positive but I think it should be eye-opening for the “its been a week, I’ll go outside if I want to brigade”
https://youtu.be/ejlbCmRJMW4

2. A piece from Italy. I have been in that doc’s situation of breaking the bad news over the phone. There’s also a hinted at subtext of the new nurse being unwarrantedly positive. I’ve had those discussions with juniors over the years. It’s great they’re so hopeful but you need to make them realistic or losing the person will just crush them and they’ll become dysfunctional and lose more/have to leave the job. Still, a really good piece, and seeing those nurses walking out in their civvies just reminded me so much of mine. Docs and nurses around the world are so similar at the basics - just people trying to do the best job as empathically as possible in the middle of a total sh!tstorm
https://youtu.be/CuKdj4TKc6M

If you’re not watching Channel 4 news already I’d highly recommend it. It regularly has the best coverage of the situation of any channel.

Pseudonym121

Gynoid wrote: »

Hi,

Having read your posts a couple of weeks ago I bought the UV light box you recommended. Question - Does the light have to fall on all parts of items inside box? So for eg if there are tins in there, do they have to be turned after the 11 minute cycle?

Well, if you look at the one I recommended the bottom of the box is crenelated.. as are the sides etc. The goal of that is to get the UV light to scatter and achieve greater coverage of areas out of the path of the direct UV light - coming from lights at the top of the box.

I personally don't turn food packaging upside down in order to ensure the bottom is thoroughly exposed for two reasons:
1. I handle packaging at the top and side, never the bottom.

2. I've moved from using individual ingredients for cooking and moved to simplified cooking - ready meals, meat + sauce in the slow cooker etc - which means that I can cook a full meal by using just 3 or 4 pieces of packaging.

let's give two examples:
a) Slow cooker: Chicken Tikka Masala with rice:
Ingredients - 2 x packages of diced chicken breast, 2 x pots of tikka masala sauce. Empty the pots into the slow cooker and then throw them into the bin. Then I wash my hands ( because I assume that even though I sterilised the packages and pots that I missed something and they are infected ) and then touch the slow cooker to set it on for 6 hours - this means I don't have do the much more time-consuming job of disinfecting the slow cooker.

Later I apportion them to containers and whenever I want one of those meals I just take the container out of the freezer, cook rice - either from a microwaveable pouch or via a rice cooker. Since I know my own containers are clean and the microwaveable pouch is clean I don't need to disinfect any of this prepped food.

b) let's say I made chilli con carne. That's pretty much the same process. Lay out a carton of mince, a can of chilli con carne sauce, a pot of kidney beans. Add them all to the slow cooker without touching it, then throw them all into the bin and then go wash my hands and then turn on the slow cooker.

It is just about thinking it through and doing it a little slowly so you maintain awareness of what you're doing and in what order. Once you form it as a habit it becomes pretty easy really.

With that said you can certainly turn things upside down to be even more certain about sterilising the bottom if you wish. I just don't think it is worth the extra hassle but part of that may be because of my training I'm very confident and quick about handwashing with soap and I have taps in my place which I can turn on and off with my elbows just like in hospitals so hand washing is very easy for me at home. For you taking double the time to sterilise with UV might be the easier solution.

Also bear in mind that I'm doing my cooking after coming home shattered from work. I've never worked as hard in my entire career as I have over the last few weeks so for me I just want to eat and crawl into bed as quickly as possible. If you're self-isolating you have a lot more time on your hands than I do.

TLDR: Turning them upside down to sterilise them is even more effective than just putting them in face up for one UV light cycle. If you have the time and find that easier than the hand washing routine then by all means do it. Better safe than sorry. I draw the line for many of these measures because some things are easy for me because of my training and setup, what is right for you will differ.

Gynoid wrote: »

Do you know any more definite things on issues like Type A blood susceptibility, why there is gender difference in susceptibility, if some people are more vulnerable like Mediterranean populations due to genetic factors, that kind of thing?

I don't think anyone KNOWS the why of those things. When we heard those conclusions from asia I think a lot of people put it down to Chinese men smoking like chimneys and the fact that they are obsessed about blood type in many parts of Asia and ascribe all sorts of things to it - it is a bit like astrology here in the West. Now that it is in Western Europe we find men dying at twice the rate of women and are no longer saying that is explained by things other than gender. Do we KNOW why? No, we have lots of theories but nothing which I'd say is proven one way or other yet.

In terms of Italy and susceptibility. I think we will find that cultural factors - living in close quarters and often in intergenerational households will turn out to be far more significant than any genetic factors due to being Mediterranean.

For this reason I think over the next few weeks we'll find the non-settled traveler and Roma gypsy communities in Ireland are EXTREMELY hard hit by this for a number of reasons including close quarter living and intergenerational living - if not within the same caravan/abode but within the same halting site etc.

Once SARS-CoV2 gets into a halting site or Roma grouping I expect it'll run riot and result in very high mortality relative to the settled population. This isn't being broken out in the figures but I think that is because a lot of morons would take the opportunity to become racist about this as opposed to realising that it is simply a medical reality/problem and that the solution to problems is to try to treat everyone well instead of dividing ourselves into US and OTHERS and beginning to let bigotry run riot. I don't hear journalists asking about this either but in any review when this is all over I strongly expect that these two groups will have been seen to come out of all of this very badly, unfortunately.

Gynoid wrote: »

Last maybe silly question, if I go out to shop, which is rare, I wear an outer layer that I take off in hall and bring to wash immediately because I have this sort of old fashioned idea about the possibility of lingering miasmas in supermarket aisles. Suspended micro particles might be the more modern description. I also wear a mask and a hat, which I wash also on return. Am I being a silly billy?

Miasmas ;-). LOL! Yeah well while I won't quite ascribe to miasma and the humours being the best way to understand this I definitely get your point.

I'll tell you my routine for that...

1. I wear simple to clean clothes with as much natural fibre as possible - a rule of thumb seems to be that the more processed the surface the longer SARS-CoV2 survives on the surface- + mask when leaving the house. I don't bother with gloves because I have good discipline about touching my face from the job and if I touch my face while wearing gloves the gloves would just transfer it anyways.

2. I assume every surface is infected - door handles, the door of my car, the steering wheel, handrails etc.

3. I assume that once I've sat in a chair or walked into a shop or shared a lift that all of my clothes are contaminated.

4. Once I'm in work I can change out of my "travel clothes" into whatever level of protection is appropriate for the task. I won't go into that since that's not relevant to people here.

5. Once I'm on way way home I change back into the "travel clothes" + mask. I now assume I'm simply covered in SARS-CoV2 and don't touch my face again until I'm home and have cleaned my hands.

6. When I get home I remove my shoes in the hall - I've heard that there are messaging circulating on social media which are trying to paint shoes as some sort of uber-vector because asphalt is thought to be some sort of sump for SARS-CoV2. This is ridiculous. I'm sure there's some SARS-CoV2 on the ground and shoes pick it up but I'm not in the habit of rubbing the soles of my shoes into my eyeballs or licking them with my tongue when I get home so I think the risk is minimal. With that said taking them off in the hall is no big deal so I do that.

7. I then take off my mask and put it aside for UV sterilisation later.

8. I then take off my coat in my "dirty room" the spare bedroom. I assume everything in that room is covered with SARS-CoV2 and never enter it unless I'm fully ready to go out and am only picking up my coat and heading out within 10 seconds.

9. Once done with that I go into the bathroom, take off my clothes and only THEN wash my hands ( I don't wash them before that since I'm assuming the clothes are riddled with SARS-CoV2 ). At this point I can go into the shower with "clean" hands and a relatively "clean" body. I then shower.

10. On my way out I pick up the clothes - infecting my hands again - and bring them to the washing machine. I put them in - in the morning I leave the door to the washing machine open so I don't have to touch it with "dirty" hands in the evening.

11. I then wash my hands again and then close throw in the washing machine pod, close the door and turn on the washing machine.

12. I then go into my actual bedroom and put on clothes for slumming it around my place.

13. I then pick up one of my C Fold Disposable Hand Towels, use that to pick up the mask and immediately put it in the UV steriliser, turn on the TV or begin preparing dinner or calling family.

14. Then I throw the C Fold Disposable Hand Towel into a bin I have set beside the UV light steriliser in order to contain “dirty” waste. I empty that bin once a week and apart from that don’t touch the bin at all. When emptying the bin I don gloves and assume that anything the bin touches is contaminated – I have chosen a small bin so that the entirety of it fits nicely inside a normal large refuse sack, this prevents spillage when emptying it.

So, this is probably a good time to talk about C fold, V fold and Z fold hand towels. Part of this is personal preference and I’m more used to C Fold ones. I also think they’re very easy to use and the flaps on both edges of the paper help prevent inadvertent side of hand contact with side of picked up object.
I dislike the lack of side flaps on the V and Z fold. You may love them, if so you do you and all that.
Back when I ordered mine from Amazon UK I got about 5,000 for less than 50 Euro and I figured that would be about an 18 month supply which would be enough to see me through to the end of this. Prices have gone up since then but they’re still reasonably priced.

For those of you who aren’t quite as up on your google-fu ( Z Nation reference there ;-) ) here’s a link to C fold 2 ply hand towels, limited to those available by prime only. Hope it helps.
https://www.amazon.co.uk/s?k=c+fold+hand+towels&rh=p_76%3A419158031&dc&qid=1586026337&rnid=419157031&ref=sr_nr_p_76_1

And thanks to Silent Running for spotting that I'd left a step out... Kudos.

The above doesn't really add more than 5 minutes to my normal coming home routine as I always would have the shower anyways. Really the only things I've changed are where I hang my coat, where I leave my shoes and the washing off my clothes every day + a bit of handwashing. I don't think that's too much to do to gain a fair bit of protection. Your mileage may, of course, vary.

It is important though to follow the process exactly every time. This means that the first few times you do it you may have to do it very slowly. I should also point out that I began trying to follow this process at the end of February because I could see what was coming and knew that it takes time to embed new habits so I started doing it then so I'd have learned this new "good habit" thoroughly by the time things became serious ( middle of April ). In the first few weeks I did find myself forgetting the shoes, or touching clothes after washing my hands etc. If that happens just stop, clean whatever part of your body you've just infected and move on from there. Mistakes will happen, it is all part of the process. Don't beat yourself up over them but just try to be aware of what you messed up last time next time. Over the course of a few weeks you'll get the new habit down and it'll just become the way you do it instinctually --- and that'll pay off over the next year.

For going out my process is as follows:
1. Put on clean clothes.

2. Put on mask. Up until this point my hands are still clean.

3. Go into "dirty room" and put on coat. At this point my hands and clothes are now "dirty".

4. Go into hallway and put on my shoes- my hands are now definitely "dirty".

5. Go out.

6. No touching of the face until I'm in work and can wash my hands properly.

7. In extremis I have a bottle of hand sanitiser in the car just in case. Pro Tip - don't leave any of these sorts of materials in sight in your car. It won't be long before people start smashing windows for bottles of hand sanitisers. Panic makes humans act like animals. It isn't a nice thing to say but, in this thread, we're about realism and not political correctness.

So that's my ingress/egress or doffing/donning routine at home. It is a lot more complex in the day job obviously.

My donning/doffing routine at home isn't airtight. I've heard of people leaving shoes in the car and walking barefoot to the house and stripping the second they're in the door. But this is where I draw the line between being safe and not having the neighbours call the cops on me for flashing them ;-). If you aim for perfect safety you will create a routine which takes up hours of your day and probably cause you to develop mental health problems. My process is pretty simple, quick and much safer than what 99% of the population does. Whatever you decide to do please do remember you will probably be doing it for a year so it NEEDS to be sustainable. Some of the routines I've heard described are just not going to be sustainable for a year.

You'll also note that my routine doesn't waste disinfectant wipes ( I think they'll be difficult to replace so I gave thought to minimising their use when I was preparing for this in February ), uses electricity for sterilisation ( i expect electricity supplies to be preserved ) and really the only daily wastage is a single washing machine pod - and I ordered enough of those to use one daily till mid July... and I don't expect they'll become scarce.

The benefit of this is that between the donning/doffing processes and the UV sterilising of food/drink coming into my place I can assume that my place is actually "clean" and just wander around in a relaxed state not worrying about touching things or my face once I'm at home. I think this is incredibly important for anyone who is out during this. I'm out 6 to 7 days a week with the day job right now and being able to have a place where I can just relax and not worry about contamination is, I believe, going to be crucially important to maintaining functionality over the next year. If you don't have a place you can relax and not have to be vigilant I think you'll have a breakdown pretty quickly.

Well, hope that has been helpful. If you have any questions you know where to go.... the questions thread ;-)

I also see a UV Steriliser question has appeared while I've been typing. Here's my best answer Cork boy 53 with the caveat that I'm no UV light specialist. I just have some experience with them from work and so decided they'd be a good solution to my problem of having to disinfect masks on a daily basis --- where alcohol-based wipes could damage the filters.

1. I don't recommend wand ones unless you have no choice because they're fiddly and time consuming and I think people will inadvertently damage their skin and eyes using them. If you know how to use them and can't find anything else then feel free obviously but I wouldn't feel safe using one personally and I definitely wouldn't trust my parents not to harm themselves with one.

2. Here's two:
a. The one I purchased and which holds everything from 3 or 4 pots of sauce/cans at a time or one full size ready meal quite easily. It will also fit 1 litre bottles of milk, but won't handily fit anything over a 1 litre liquid bottle size.
https://www.amazon.co.uk/Baby-Ultraviolet-Maintenance-Sterilisation-443853/dp/B07YB7V5QJ

I got it when it was about 30% cheaper but even at this price I think it'll pay for itself in saving disinfectant wipes over the next year. Plus, you know, if you're younger.... baby boom. My obs and gobs colleagues are all expecting January and February of next year to be very busy.

b. https://www.amazon.co.uk/PEIKUN-Professional-Ultraviolet-Disinfection-Sterilization/dp/B084JT6KK7/
This one is much smaller, isn't available via Prime BUT it is a lot cheaper. I don't expect this would be able to hold a full ready meal, or 1 litre bottle so I think it has much more limited utility.

With that said I'm sure this one would disinfect anything you could fit into it but the question is more about what you can fit in while leaving enough space on the sides for the UV light to scatter and get into all the nooks and crannies. So I think it is worth paying for the bigger one not because it would disinfect something better or multiple things at the same time but because you'll be able to use it to disinfect things the small one can't fit.

For example the small one wouldn't hold my respirator mask - the mask takes up almost all of the first UV light steriliser and that was one of my major use cases so guided my choice.

I hope that's helpful. Unfortunately in this case the more expensive option really is better IMO.

As to the strain comment. Yeah but we'll keep going till we can't go on any more and then we'll shake it off and go some more. Its simply the way we're trained and habituated. With that said --- broken record warning coming ;-) - when we're through this and ask for support for equal pay for equal work and ring-fenced mental health support for those of us who are survive this physically but are broken by it mentally please support us. We will be there for you over the coming weeks and months, please be there for us afterward. We'll need you then because the HSE management and government don't give a flying f!ck about us and will cast us aside the second it is convenient to do so.

You wouldn't believe the fights I've had to secure proper PPE for staff over the past few weeks... or even to get the PPE they have available but locked away distributed to people who need it. There's a reason so many frontline staff are out sick... they sent us into battle without the equipment we need to survive the battle... and yeah there's a certain amount of you have to go to war with the equipment you have not what you wish you had but there was time to see this coming and while we were never going to have everything we needed we should have had more than we had. You can be sure they'd find enough PPE for themselves if the politicians or HSE management had to spend an hour in any A&E in the country though. It is sickening, but not unexpected. It is the way they've always treated clinical staff. Why would they change now? This sort of thing is why so many doctors and nurses have left and are leaving. You are all only now seeing how little they give a sh!t about frontline staff in ireland. When we go abroad we are paid better, have better work life balance and are treated more fairly.... it is why so many have left.

Anyways, I'll only be accused of whining so I'll shut up now.

Pseudonym121

So, I see lots of talk about when restrictions will be lifted and the probable course and so I think it makes sense to post a reasonable middle case scenario ( not best case and not worst case ). I'll refer to best and worst case alternatives later. The key point about this post is that NO-ONE knows how this will turn out. What we can know is what is probable based on a number of assumptions.

So, what are those assumptions:
1. That this has some seasonality - there is growing evidence that this will be so. This would lead to a scenario where we could expect a Q4 resurgence.

2. That a vaccine is possible - it isn't possible for all viruses or at least isn't possible in the sort of time frame we need. Everything I've seen says that vaccines should be possible for SARS-CoV2.

3. That by the time a vaccine arrives there will be multiple strains. This isn't a huge problem as we have many vaccines for seasonal viruses which protect against multiple strains of said virus.

4. That the decision about lifting restrictions will be at least partly political and economic and not just based purely on medical advice.

5. That the decision about lifting restrictions will be based largely on medical advice, although not solely - this doesn't contradict point 4.

6. That SOME treatment currently being trialled will be found to be effective by September 2020. I don't know which one but I'm certain some reasonable treatment(s) will be found and production increased to meet demand.

7. That the majority of high risk individuals will continue to largely cocoon until such time as they can access a vaccine. If they come out before a vaccine is available, irrespective of government advice, deaths will skyrocket again.

Overall I think this is a good news story in that we aren't facing the destruction of technological society or the death of western liberal democracy but we are about to lose a lot more people than seems to be understood in the megathread. This isn't surprising as one of the defence mechanisms most people use to deal with the fragility of life is simply denial of its fragility... in spite of all evidence to the contrary.

So, first phase: Now till end of September
This will be the phase in which we will likely see 1500 to 2000 dead in Ireland by the end of May and a smaller daily number from June to September - I expect Ireland would tolerate 5 to 10 dead per day during that period in return for things largely returning to normal. So call it a low of 2100 and a high of 3200 dead by end of September. The main clusters will be in nursing homes, roma gypsies and traveller groupings because of their medical risk factors, proximity and intergenerational living setups.

Interpreting the data for Ireland is difficult because due to the lack of results from testing there is such a huge backlog that the one thing we can say is that our current numbers bear no relation to reality. Saying they might is purely a PR exercise. I understand why that is being said but that information isn't good enough for me to base decisions on the health of my loved ones on.

Anyways the normal rule for an epidemic is that you can say it is over when you've gone two 95% confidence intervals of the incubation period without a new case. This equates to about 28 days for SARS-CoV2.

Another way of looking at this is that we need to get the R0 below 1 to have fewer infections every day than the previous day. With an R0 of 3 and 90% of people obeying the lockdown/disinfecting rules 90% of the time and actually being effective with this 90% of the time you can see that we'd end up with roughly a 73% reduction in R0 from those assumptions. So R0 = 3 would become 0.813. Let's round that to 0.8 and if we had 5,000 transmissions a day to start with that'd drop as follows:
Day 0: beginning of lockdown 5000 new cases per day
Infection Cycle 1: 4,000
IC 2: 3,200
IC 3: 2560
IC 4: 2048
IC 5: 1638
IC 6: 1310
IC 7: 1049
IC 14: 220
IC 21: 46
IC 28: 10

Obviously I'm rounding and just approximating here but as you can see by IC7 you'd reduce transmission by about 80%.

A lot of people would look at IC 14 and say that by then with the number of new daily infections falling by 96% that if you lifted the restrictions then things would be fine but if we went back to the way we were behaving previously you'd be back to 5000 infections a day in 14 more ICs.

Why IC and not day? Well, the best data out there is that infections were growing at about 25% a day when we were looking at an R0 and doubling every 3 days but there's no guarantee that things will rise or fall by 20 to 25% per day. So I used IC. For ease of examples going forward lets just assume an IC is a day as that'll make it easier for people to grasp.

So what does the above tell us?
Well, it tells us that even if do a massive lockdown obeyed by 90% of the people 90% of the time with 90% effectiveness for 28 days if we go back to "life as normal" after that we'll be right back where we starting 28 days later.

And bearing in mind the death rate lags behind infection rate by somewhere between 14 to 26 days the death rate would start to fall just as new infections were really starting to rise again and we'd end up with another bad peak of deaths.

So, where to from there?
Well, it seems that the best way to play this would be to keep a really strict lockdown for about 28 days and then reduce it slightly, combined with advice for people to ALL wear masks when out and about, really strong, rapid testing and contact tracing. There would be separate advice for high risk groups who would be asked to continue cocooning as much as possible for as long as possible.

The 28 days gives the state the time to ramp up swabbing ability and test throughput ability as well as to train and man contact tracing centres and establish rapid response teams to respond once a new case is confirmed.

This would be something akin to the South Korean/Singaporean model and the goal would be to allow low risk groups to return to normal economic activity ( albeit with masks for everyone ) while cocooning those likely to die. Usage of masks by the young would be enforced by peer pressure as there would be a constant drumbeat of people in their 20s and 30s still dying and that would act to motivate them to wear masks. The goal wouldn't be to stop deaths but to keep them to a reasonable level - say 5 to 10 per day with the majority of those being the elderly obviously but probably a good 10% being young to middle-aged.

After another 28 days go by the government could look at loosening restrictions a little more if the death rate was on the lower side. Essentially they'd be balancing daily deaths vs economic activity... And before someone argues that every life is priceless. No it isn't. Your lives all have a very specific monetary value. The measure most used in the UK by NICE is called the QALY - Quality Adjusted Life Year. Most recently it was somewhere between about 15k and 20k Euro

Here's a link to explain it: https://en.wikipedia.org/wiki/Quality-adjusted_life_year

For what it is worth this is why we will always have private health insurance. Some people have a lot more than 20K discretionary income per year and if faced with death or spending 30K a year to stay alive with a discretionary income of 50K per year you can bet a rich person will spend the 30K. You can have all the ideology you want but when push comes to shove people who can afford to pay to live longer will find a way to pay for it. Perhaps not a popular thing to say but I'm all about objective reality and that's just objective reality.

I'd imagine that every 14 to 28 days restrictions will be loosened somewhat. This will be possible because even if the R0 remains above 1 we should find some treatments which reduce mortality. Statistically this will allow us to keep the same death rate for higher rates of infection than is currently possible.

So, Phase 2: October to December
I'll assume we don't even have an experimental vaccine... If that is true then we'll have a choice between accepting higher daily death rates - which we'll have become accustomed to by the next two months - for those three months or we'll go into whatever of lockdown the statisticians and PR guys have figured will result in the daily death rate which the public will tolerate versus the severity of the lockdown.

This will be when you'll really see the selfishness in society. Things happened so quickly this time there wasn't much debate. Come October there will be a very active pushback against another lockdown. There will be a very active - but they're old and will die soon anyway lobby, much more active than it is now.

Unfortunately when push comes to shove people tend to be very selfish and when they've had a taste of freedom after two months of lockdown they really won't, en masse, want to go back to lockdown. The line that those whose families are high risk can choose to behave how they want instead of forcing all of society into lockdown will be prevalent.

How many will die in Q4? Well, easily 6k to 8k but a lot of that depends on the political and economic balancing vs deaths. How many die will be a choice the public and our government will make. They'll have the information to project the death rates from various courses of action much more accurately than they had now. This is why they were so cautious this time. Come October they'll have greater confidence in balancing life vs economics.

I suspect they'll strike a balance somewhat below the peak of April/May as people will be habituated to view anything below that peak as being "good". That would argue that they won't exceed 50 daily deaths for those 3 months and would result in 4500 dead in Q4. They may draw the line differently but I don't see the government enacting a full three month lockdown. I'd be impressed if they did, but I just don't see it happening for economic reasons.

The key point is we'll have the number of dead in Q4 we choose to have politically. There's a lower bound on that number below which we probably can't go but that lower bound may be as low as 1,000... but achieving that number would really impact the economy.

Phase 3: 2021 Q1-Q3 aka waiting for the vaccine.
Well that's what it will all be about. We'll throttle economic and social activity to control death rates. As our treatments improve and the virus adapts to us and selects for greater infectivity at the cost of lethality we'll be able to have more economic and social activity for the same number of daily deaths.

Once we get a vaccine which is good for the main strains around we'll largely return to normal. I, personally, expect we'll have a vaccine which is usable for the majority of the population by March of 2021.

We will probably have an experimental one by Q4 but the risks may outweigh the benefits for all but the highest risk groups with that experimental vaccine as they just won't have had time to prove its long-term safety.

Phase 4: Q4 2021
At that point we'll really get a sense for how effective the vaccine was and whether or not we get a strain which the vaccine doesn't provide protection for. If we guess right with the vaccine then Q4 2021 will be alright and this will just become a yearly "bad flu". If we guess wrong with the vaccine then Q4 2021 will be bad and we'll just have to work harder to get the vaccine right for 2022.

This is the same process that we follow with seasonal flu. The good news is that mostly we get the seasonal flu vaccines right.

Summary:
People talking with any certainty about lockdown being done in 2 to 4 weeks or in for the whole year don't know what they're talking about. The probability is lockdown till the end of May followed by a gradual reduction in the severity of lockdown until a death rate, which is deemed the maximum level which the public will tolerate on an ongoing basis, is reached and allowed run to October. In Q4 we'll have to see a tightening of restrictions again to keep the death rate down. What death rate will they view as acceptable? I suspect 50 dead a day or less will be the level but don't know, a lot depends on what the public tells them is acceptable. In 2021 it'll all be about keeping the death rate at an acceptable daily level until we get the vaccine. As treatments improve fewer social and economic restrictions will be required to maintain a stable daily death rate which is acceptable to the public.

Pseudonym121

Stheno,

Good questions. I think that the results from the initial tranches of antibody tests are encouraging. The more people who are shown to have antibodies the better as this means they can go out and about and begin economic activity again. The one caveat to that is that having antibodies to one strain of SARS-CoV2 doesn’t necessarily confer immunity to other strains. We won’t know the impact of that until we have a large group of people who are shown to have antibodies going about normal daily life and can see just what portion of them get infected and, if infected, what portion die compared to the cohort of those who have no antibodies.

So a test to show the presence of antibodies is good but people are losing sight of the fight that presence of antibodies to Strain 1 mightn’t stop you catching Strain 2 and dying from that strain.

When will antibody tests be available? Well several countries are rolling them out already. It’ll take weeks before production can ramp up enough for us to get them in large quantities and even then initial testing will be reserved for those at high risk of exposure ( healthcare workers etc ) before becoming more widely available. This is as it should be.

With that said the fact that the more we learn about the illness the more proof we are gathering that there’s quite a lot of asymptomatic people who have been exposed is good news. It also provides more impetus to the whole - you should be wearing masks and gloves if at all possible ( and you know how to put them on and take them off properly ) whenever outside. With that said I’d say 75% of the people wearing masks I see in public are still not wearing them properly and so getting little real benefit from them.

Roanmore,
Unfortunately what you’re describing is unlikely to be viewed as an essential procedure for the next 2 or 3 months and as such unless you can source it privately it is unlikely to happen. With that said the government is being its usual jackass self with the contracts for private consultants and so they’re being advised not to sign the contracts at present. That’ll get sorted because they’ll need those 500 to 600 consultants to replace those who fall ill/run the private hospitals.

In the meantime though if I were you I’d contact your wife’s private consultant and ask if this treatment can be administered elsewhere other than the hospital under their supervision. Depending on the exact treatment it may be possible to provide it safely outside of hospital. If it is an infusion then that is less likely but the best bet would be to try to contact them directly and ask if it could be safely provided outside of a hospital setting. Depending on what it is that might be possible. If an injection then it may well be possible but if it is a surgical procedure then I don’t think it’ll be possible.

If that isn’t possible then, unfortunately, the best thing you can do is ask their advice on how best to manage in the meantime and advise everyone you know to stay indoors etc since the sooner this peak resolves the sooner the hospital system can go back to treating things like this which while really serious and impactful on people’s lives aren’t immediate matters of life and death.

Pseudonym121

Drumpot wrote: »

Thanks again for answering all questions.

I don’t understand why people are suggesting you are scaring anybody, some people really can’t face the truth. For what it’s worth I find the blunt honesty of your responses so refreshing. I also find, as an anxious person in general, that trusting what I read and understand about what’s going on is more important then being told a fairytale about how everything will be fine. I find your posts comforting and they actually relax me... So thank you again for your honesty, I for one have read every word you have posted here and have taken steps to follow your guidelines.

There are some suggestions that treating this like a pneumonia can be dangerous. That using ventilators can damage the lungs because it’s the oxygen levels that are an issue. I watched one doctors YouTube clip there say that he has patients that he thinks are starved of oxygen as if they are on top of a mountain without acclimatising to the height. I thought that was hypoxia but he didn’t use that word. Are you finding it that this may not be the kind of disease you thought? This doctor seemed to be implying every hospital was gearing up to treat this as a pneumonia but it’s not that?! Does this also explain why there are so many people in ICU with no underlying medical conditions in some hospitals or is there a chance that different countries are being hit with different strains of virus? (There were suggestions that the original strain was most potent).

Is it a case that this virus can attack in multiple ways depending on the person/strain? Is it also the case that it might also effect a person differently based on an underlying medical condition? Would this explain why smokers are not necessarily showing up as a big risk because it doesn’t necessarily attack the lungs but affects oxygen getting into the body? (Perhaps my layman understanding is off there).

Well as I’ve said several times I think we’re learning a lot about this. I believe if you read what I said a month or more ago that I said that there were things we believed were true which we would later find to be untrue and other things which we hadn’t conceived of that we’d find out. I think that medicine worldwide is learning a lot about this illness and that includes its mechanism of acting on people.

It definitely seems that this impacts the heart more than we thought it would, causes emboli which can end up in the lungs causing pulmonary emboli or in the kidneys causing kidney problems, multi-organ failure, cytokine storms which can kill those who have had mild/moderate symptoms linger for some time and superimposed bacterial infections. It is impacting younger people more than a lot of people expected.

So, we’re learning about it and at times it is surprising doctors worldwide. I think that the good news is that the more we learn about it the better our supportive treatments will get and we’ll get better at keeping more people who get it alive while we wait for an effective curative treatment and vaccine.

Drumpot wrote: »

Lastly , I bought a blood presssure monitor and oximeter to go with our digital thermometer (also got them for my mum and parents in laws). Would the oximeter in particularly help diagnose the lower oxygen levels quicker ? That is, if you were monitoring them for days and were phoning up your doctor , would this be a potential early warning tool for him to know you were deteriorating? It seems some people deteriorate quickly after looking like they were improving.

I’ve been also monitoring myself and my wife’s BLood pressure and temperatures daily. Would having these stats (along with oximeter) potentially lead to us getting medical treatment quicker because it can give a doctor or healthcare person a better idea of where we are at internally and how this has been progressing daily? (As opppsed to just phoning up a Gp and saying “I feel awful” but having no readings).

Lastly I had a temp (as did my wife) of 39oC a few weeks ago but not for long only day or two. Would it be too optimistic to think that could of been our COViD bout ? We had been battling coughs for weeks so can’t say if the cough with temp was cough that we had been battling before.

AN oximeter will give you a very good sense of any sudden change in the oxygenation of your blood which COULD be a sign of a worsening lung issue. It could also be a sign that your finger is cold, that it has dirt on it, that your posture is hunched over thus preventing full lung expansion etc. Never rely on a single reading.

But, yeah, I think pulse oximeters are a good idea for people to monitor their own oxygen saturation at home and have a set of readings they can tell their GP about if they decide to call them with a query. Same with thermometers. Objective readings are always preferred to subjective feelings.

Maybe you were lucky and only got a mild dose but there’s no way to know. If it were me I would assume I hadn’t caught it and therefore didn’t have immunity and I’d continue taking precautions. I think that’s the safest way to play it.

mountai wrote: »

What is your opinion of the latest HSE contract foisted on Doctors working in the Private sector , whereby , they MUST place their patients into the Public system , thus taking control for their ongoing treatment protocol out of their hands ? . how can this be justified when Drs who are seeing private patients in public hospitals ( which is allowed under their contract) can carry on as before ??.

Well, I think the government wanted to secure the private beds for the national good and it did so. I think they were right to do so given the potential situation we were looking at. I think that this has had consequences for private patients but I also think the government was mindful of the optics of suspending most public non-covid procedures and taking over the private hospitals and then having video of private patients going in to get their private procedures. I think those images would have damaged social cohesion and so I think they made a calculation that they could do whatever they wanted to those consultants with very little public outcry and so that’s what they did. I think they’ll get away with it also.

I’ll note that the private consultants aren’t being forced to accept the contracts. They’re free to say no and make alternative clinic arrangements. My understanding is that if they don’t accept the contracts they can occupy some of the currently unoccupied office space around and keep seeing private patients. If a procedure is safe to do in a clinic then they’re free to continue providing it. They simply won’t be able to provide treatments which can only be safely done in hospital.

So I’d expect a lot of them to rebase and re-open their rooms over coming weeks if they can’t reach an accommodation about the contract.

Anewme,
They won’t be discriminated against. They’ll get any appropriate treatment. Unfortunately as with the answer above what is now deemed appropriate and essential is different than what we would have deemed appropriate and essential 3 months ago.

With that said they won’t be abandoned and as we get more and more certainty that our ventilator capacity won’t be overwhelmed then more consideration will be given for reserving some of that capacity for the elderly. So the best thing you can do is to maintain and continue promoting social isolation and distancing so that the system doesn’t get overwhelmed and some capacity can be reserved for the elderly going forward.

Cyrus wrote: »

First off please dont take this as a criticism and i thank you and everyone working in health care for all you are doing for those touched by this virus (and the rest of our sick population)

however i would tend agree with the quoted post, my question is do you not feel it is in incumbent on you to temper your responses somewhat. my worry is that peope will assume that a consultant will know whats going to happen, when the reality is you dont. You have an opinion and a certain amount of knowledge the rest of us dont but thats it.

Any more than an accountant or economost can predict the future of the economy, they can have their opinion, but most of them will be wrong.

The factual answers that relate to the here and now are very useful, your opinion on the future is informative but id worry that people are taking it as gospel.

Ok, a couple of points in reply:
1. It isn’t my problem if people assume I’m a soothsayer. I’ve never claimed to have psychic powers to predict the future. I’ve been very clear that I am saying what i think is possible and that what I’m saying is my opinion. If people refuse to read and consider those caveats then that’s their issue not mine.

2. I’ve stated several times that when I’m extrapolating that is my own opinion. At some level if I say that isn’t enough then the only thing I can do is simply not post because some people refuse to actually read my caveats and have common sense. I think that would be worse than accepting that some people refuse to read the caveats and bear them in mind.

3. As regards tempering. No, I have decided to be honest instead of tempering things with PR. I presumed you were adults who would prefer the truth to facts massaged through a PR lens.

4. I think the days of society assuming Consultants were all-knowing and godlike is well in the past. Hell, today a patient abused one of my NCHDs so much they were in tears so, no, we’re not on a pedestal anymore.

But just to be clear - I’m not a psychic and don’t know the future. WIth that said I can say what is probable and possible and say that. I assume people are adult enough to understand that the probably and possible aren’t psychic predictions and they should bring their own judgement to bear on anything ANYONE ( including myself ) says. I’ve also very purposely said I’m just a bog standard Consultant and that people shouldn’t assume I’m the world’ leading epidemiologist/virologist etc. I’m just a Consultant ( who therefore does know more about medicine etc than the majority of you ) offering my opinions and advice for what they’re worth. I amn’t forcing anyone to listen, or believe me or anything.

I think the real problem you and others have isn;t that you think I’m setting myself up as some sort of prophet but that you wish I’d tell you nice comforting stories which you could believe whether they were true or not. Well, I’m not going to do that. I’m going to be as honest as I can for as long as I can. I’m basically going to treat you like adults. Some may prefer the comforting stories and if you do then that’s perfectly fine. Reality isn’t a comfortable place for some people... but then those people probably shouldn’t read this thread. That’s fine by me. If I survive this and when this is all over ( which it will be ) I plan to go back to asking questions about solar panels and how to make as green a house as possible which is why I initially signed up to Boards. I amn’t building any social media following or looking for anything beyond providing a resource that otherwise wouldn’t be accessible to people at this time. But pure intentions don’t mean I should be believed. With that said feel free to go back to my first posts where I was derided as a lunatic and see if what I said x weeks ago appears sensationalist now. If it does then feel free not to read anymore. I’m cool with that.

JCX BXC wrote: »

What do you make of the commentary today that we may have passed the peak? Does the larger (but arguably expected) death rate recorded today under shadow this

I wish it were true but I don’t believe it to be true. I still think we’re looking at between 1500 to 2000 dead by the end of May unfortunately. It is my fondest wish that this proves wrong and the more everyone does social distancing the lower the death rate will be and the happier I’ll be. With that said I saw a group of 7 people playing basketball in a park today, saw several full on picnics of groups of friends in the same park etc. So I don’t think 90% of people are following the rules 90% of the time with 90% accuracy.

But I hope I’m wrong as the more wrong I am the fewer people die and that’s a wonderful outcome.

Re: ShineOn7
Yeah. While I wish that the Irish government had acted sooner in instituting the lockdown and made some mistakes ( the Italians over here after the match was cancelled ) I think that overall the state has done very, very well. I think we are definitely going to come out of this significantly better than the UK and MUCH better than the USA.

I still think it is going to hurt more than many people thought or think at the moment but I think we’re going to come out of this in best case scenario territory which is not something we were heading for just 5 or 6 weeks ago.

So people who are spouting doom and gloom aren’t having a sense of perspective of what was possible 5 or 6 weeks ago and how much better things are now than they could have been. Hell, New York is talking about having so many dead that they will temporarily bury people in parks until such time as the death rate falls and they can dig them up and rebury them in cemeteries. Now look at Ireland and how far we are from such a scenario. We are doing very, very well but I think that very very well is still looking like 1500 to 2000 dead by the end of May.

The more everyone keeps observing social isolation the more likely it is we’ll do even better than 1500 dead. The great news is that this IS in the public’s (your) control. The public will determine how many die to a greater extent than any doctors. So, do your bit.

Shaunoc wrote: »

Have you been keeping in touch with UK colleagues and how they are handling within NHS as compared to HSE?
Any improvements and good collaboration with NI colleagues, sharing of resources or is that pie in the sky?
Is our country (gov, health, public etc) doing us proud in these extreme circumstances in relation to other European countries?
Some projections of UK deaths hitting nearly 3000 a day shortly are frightening.
Do you foresee any longer term positives with speed, red tape cutting and inter dept and public/private cooperation shown from the last month or we go back to status quo in a few years?
Thanks

Doctors around the world treat patients. SARS-CoV2/COVID-19 is a monster and we are all in this together. We are all just trying to keep other humans alive.

There’s a lot of information sharing going on, particularly via facebook and email. Modes that we didn’t traditionally use. Doctors are trying to get information out to other doctors worldwide as rapidly as possible to help those doctors save lives. It is utterly unprecedented, and is a sign of how serious this is.

Status quo in a few years? It won’t even take that long. It’ll be months not years before the vested interests and bureaucracy re-assert their supremacy. The government will have a VERY small window of opportunity to really make massive change as things are settling. If they don’t take that opportunity then things will settle back to normal and the foundations which are currently fluid will set like concrete again.

Do I expect the government to be so far-sighted? No, but I can hope.

One thing I do expect is that this will accelerate the adoption of slaintecare. It’ll become a national priority. I think this is great personally - although I still think there’s a role for a private sector - but I don’t expect them to go far enough in terms payment per procedure ( which would incentivise staff to work harder ) as per the Australian and Canadian models. I think if we adopted either of those models in which hard work was rewarded with additional pay combined with a modified Slaintecare system then waiting lists etc would be largely sorted due a combination of public care and the personal profit motive for clinical staff.

I think that’ll be a hard sell though so they’ll go for something easier and less effective. I’d love to be wrong though.

Pseudonym121

Metricspaces,

The design of the steriliser is such that light scatters onto the bottom of products. Do I assume that is 100% effective? No, but it is good enough for me.

I think we all draw the line in different places. I’m comfortable with this technological solution being sustainable for me and am comfortable with the bottom of the jar potentially not being 100% sterilised because I don’t touch the bottom of the jar and it takes a reasonable amount of virus to cause a successful
Infection. This isn’t a situation where a single viral organism will gain a foothold and cause illness. Hell even the N95 masks don’t stop every virus organism. They just decrease the amount you breathe in to a level that, hopefully, your body can handle. I’m comfortable that the UV light steriliser does a good enough job on the bottom of the jars.

If I have an object which is very long I often put it in slanted to ensure only a minimal area is in “shadow”. Common sense solves these sorts of things.

As to the six hours thing. Well three of those hours were to allow particulates in the air to settle. I think you’ve misunderstood how that timeline was arrived at.

With that said If you feel happier using Milton etc then you go right ahead and do that. If that’s where you need to draw the line to feel comfortable then that’s what you should do. I wish you the best with your approach.

As to what I do with items which don’t fit into the UV steriliser. I simply don’t purchase them. Or if I get the measurement wrong I’ll just wipe them with a disinfectant wipe. Easy.

Bottom line. If you have a way which you feel is safer then by all means do that. Everyone draws the line in different places with a lot of different reasons why they favour one approach over the other. I wish you the best of luck with whichever approach you feel suits you best.

And I see you’ve posted again on this issue:
I’ve decided on a solution which works for me and my elderly parents and my siblings. If you read what I have said I’ve never said it is the only way. If you prefer to take a different approach then I wish you nothing but the best. There are many ways to disinfect something. The effectiveness of Milton would rely entirely on your technique and how long you left it after before touching it again - they suggest ten minutes lay time per item. I think that, just like masks, they’re a great idea but so few wear them properly that actually they’re largely ineffective for the public. My fear would be the same with the Milton plus J cloth solution. Fine idea but the technique would matter and I fear many wouldn’t do it properly.

But you seem to be very confident with it so I’m sure your technique is good enough and so I wish you the best with your approach. I wouldn’t trust my parents’ lives to being able to replicate that though, nor mine.

Pseudonym121

metricspaces wrote: »

You give lots of fantastic information and insight which is very interesting to read so please don't take this the wrong way.

You mention a few times how you approach things in a logical manner. So when you provide a rationale for the UV sterilizer that does not seem to add up, it puzzles me. You could have easily bought enough Milton for a year or two and it's a less hassle approach as you can quickly wipe everything down; the mere fact you can get it over and done with in a few minutes as opposed to a few hours by definition is less hassle. This to me negates your rationale of wipes running out and it being more hassle to wipe everything.

From another angle. I understand you are just documenting your approach. However, as you have greater knowledge and insight than many others on here it may come across to people that this is the most effective route to follow. The gold standard. That disinfectant wipes will run out and you'll be snookered if you don't have a UV sterilizer as there's no other effective option. This may lead a lot of nervous people to buy expensive UV sterilizers or even panic if they cannot acquire one.

For the sake of balance. Would you deem wiping packaging with undiluted Milton using a throw away j cloth as effective as your approach with UV sterilizer? Or is there another approach you'd deem equally as effective as the UV sterilizer?

For the sake of balance? Are you a Milton salesperson or something?

. I have bleach as a backup but my faith in the J Cloth and Bleach approach is less than total. My use case was simply immersing whatever tins/cans etc I needed to sterilise in a small receptacle of bleach for a short time and then picking them out using plastic kitchen gloves and letting them dry on a windowsill.

I'm very used to autoclaves and UV sterilisation given the day job so that's where I sought a solution which I had high confidence in. I have much less confidence in the bleach and j cloth solution which is why it is only a fallback for me. But, you seem to be more familiar with it so I hope it works for you.

It would be very wrong of me to give advice regarding how to use a sterilising method I really don't feel qualified to comment on in detail so I hope you'll respect that I don't do so. The best I could say is that either complete immersion or washing it with a cloth in such a way that you get into every nook and cranny - but I don't have confidence in myself or my parents' ability to do that properly. Feel free to make a post in the Questions thread outlining any methodology you might have though.

Notsomindful wrote: »

Thanks for answering all the questions so far.

I tested negative for covid 19. Had and still have a lot of symptoms.
So I have a few questions.
Could you have the virus and not test positive if it took a good while (2 weeks) to get tested?

Yes you could test negative for three main reasons:
1. You cleared the virus and there wasn't enough RNA to replicate to get a positive result on the PCR test.

2. You got a false negative - there are many different tests out there with varying false negative and false positive rates. Some tests have been so bad in other countries that they've proven unusable. That doesn't seem to be as large of an issue in Ireland.

3. Poor technique by the swabber meant they didn't swab properly and get enough of a sample to replicate for the PCR test.

In your case I would assume that it was simply a case that you either didn't have it or cleared it prior to getting swabbed.

Notsomindful wrote: »

What are chances of a false negative result in test?

It depends on the test done, the lab, the technique of the swabber etc. I don't know which lab etc so can't say. But in your case I think it is safe to say you either didn't have it or cleared it. I wouldn't be overly worried about a false negative if I were in your shoes.

Notsomindful wrote: »

Is it worth getting tested for antibodies to check if you did have it?

When a reliable antibody test comes out I think that would be a very reasonable course of action on your part. I certainly intend to get an antibody test to check my status once they are reliably available. I think checking one's antibody status ( all of the issues with these tests notwithstanding ) is an eminently reasonable thing to do.

With that said I wouldn't assume that having a positive antibody test gave me carte blanche to go swanning around as though I were invincible. I'm wary about the possibility of new strains to enter Ireland.

Notsomindful wrote: »

Is there another strain going around that isnt tested for in the current test available?

Well, the longer it circulates and the more people it infects the more likely the mutations will add up and something which changes the nature of the virus significantly enough to qualify as a new strain will develop. Right now though there isn't any evidence that a new strain which would be missed by testing is circulating among the community in Ireland.

That might not be the answer I give 9 months or even 6 months from now but it is the answer as of today.

Notsomindful wrote: »

Is there another respiratory illness going around that is similar to covid 19?

No, SARS-CoV2 and the illness it causes, COVID-19 are not close to anything else going around. A lot of people are still getting ordinary flu or other respiratory viral illnesses but the pathology of those things isn't close to COVID-19. Now of course you get into what we mean by the word "similar". The flu or cold are similar to COVID-19 in a lot of ways which is why I changed to the word "close". They have similarities but I'd take the flu over COVID-19 any day. COVID-19 scares me, the flu etc never have.

voluntary wrote: »

Can a person with symptoms request to be tested avoiding the €60 GP fee?

I'm unsure of all the subsidiary pathways one might use to get around phoning a GP to inform them of your symptoms and getting tested. I think by far the best way to approach this is to simply phone the GP and follow their advice.

feargale wrote: »

The 1965 power blackout in NYC and much of the East Coast reputedly resulted in an overload of the maternity hospitals nine months later. In a worst case scenario, given the lockdown, if the virus is still prevalent here around Christmas could we witness a similar scenario exacerbating already stretched resources?

P.S. As a septuagenarian I assure you my concern is purely altruistic.

Yeah I've joked about that with colleagues. This lockdown is going to cause a spike in relationship breakdowns but also a baby boom starting around Christmas time ;-). Humans are resilient and birth rates often rise for a period of time during and/or after a disaster situation.

Geuze wrote: »

It is the immune system response that kills, i.e the cytokine storm.

This is not entirely correct. The cytokine storm is one of the ways it kills but it also kills through cardiac complications, emboli/strokes, general multi-organ failure, pneumonia etc.

auspicious wrote: »

If you've caught it and recovered, isn't there the chance you can still pick it up and spread it for a limited time?

When you are recovered there appears to be evidence that you still shed virus particles for some time. Our best sense at the moment is that after a few days you aren't shedding enough to infect other people. You have to bear in mind that there's a difference between us being able to detect particles of virus in your stool and that being a viable way for you to continue infecting people.

As to "picking it up" again. No, once infected you will have immunity to that strain of the virus for some time - potentially for years or decades. The problem occurs if other strains which are sufficiently different develop over time and then you may be at risk of reinfection by a different strain. The probability is that such strains will become more infectious and less lethal over time but that's just probability. Hopefully we'll be lucky but there's no guarantee.

chka wrote: »

Today is a particularly bad day for Ireland having 33 new deaths due to coronavirus and 320 in total. If I compare the same day with my home country, Greece, we only had 1 today and 93 deaths in total. What confuses me is that Greece has virtually destroyed economy, the health system is in seriously bad shape after so many years of austerity: for example, if you have an accident, you need to bring your own bed sheets, gauze and toilet paper because hospitals have none. In addition, Greece has one of the oldest population (#5 in the world) and Ireland has one of the youngest. Finally, Greece has twice the population of Ireland, and not only that but it's also packed with Roma and migrands that have no respect of the lockdown or interest in hygiene. How do you explain that Ireland has more than 3 times the amount of deceased compared to Greece? Also, why we don't hear any medical research or ideas coming from Irish doctors when almost every day, I hear on the news of new, more successful treatment protocols and reports for huge amount of research happening inside Greece's medical system?

Greece enacted social distancing measures earlier than Ireland. My understanding is festivals and parades were being cancelled in February and Greece closed schools on March 10th and then rapidly progressed with the shutting down of other social venues over the next few days. Greece is now reaping the rewards of moving early with social isolation measures. Ireland moved more slowly - although still more rapidly than the UK - and so has a worse outbreak than Greece but better than the UK.

As to the future: Well, let's see what happens with the refugee camps and Roma communities. This is a long haul till at least the middle of next year. Greece is doing well so far in the first wave. The first wave isn't even over yet nevermind additional waves over the next 12 to 18 months.

As to the news about research. I wouldn't pay too much attention to PR designed to give the populace a sense of hope about the future. Greek research institutes have been gutted by austerity. I don't expect this PR to be reflected in real-world outcomes over the next year.... I'd love if it were but there's a difference between spin and substance.

Shaunoc wrote: »

With such a huge pressure on PPE, what of used PPE can be reused now that was not before - after being sterilized

Re-usability is a function of scarcity and resupply. If there were no more gloves coming into the country we'd be dipping used gloves into agents which can kill RNA viruses, sterilising them and re-using them. We have enough gloves so we aren't doing that.

The same applies to the other gear. Generally speaking pretty much anything could be sterilised and re-used if you couldn't get resupply but since we can get resupply and are getting resupply we don't have to re-use most things anymore.

With that said I'm aware PPE supply difficulties still exist in certain hospitals, GP hubs and in nursing homes etc. I think that it will take some more time for sufficient supply to become available in every healthcare setting. It is a process but we're doing pretty well with that process actually.

Satturnfalls wrote: »

Ive read somewhere that the virus can be mostly found in the floor and that peoples shoes are a source of contamination. Would you advise a sort of foot bath for entering and leaving the house for messages? And if so what would be a good chemical(s)

Hmm, a key word these is "mostly". SARS-CoV2 is not mostly found on the floor. It is mostly found in the air or on things people have touched after getting it on their own hands.

I think it is reasonable to have a single set of outdoor shoes at the moment and to keep them outside of your main house - I keep mine in a certain area in the hall. I only ever touch them when putting them on going out or taking them off coming home and immediately assume my hands are now "dirty".

I don't disinfect them with a bleach foot bath although I could easily make one using a shallow plastic bucket filled with slightly diluted bleach. I don't go around touching the floor with my hands or mucous membranes and so don't see the need for a bleach foot bath. I think the much easier step of just taking the shoes off before you enter the main house is good enough. But if you want a disinfectant bucket for shoes then you do you. I think it is unnecessary overkill driven by internet rumour and a failure to understand how the virus is really transmitted.

It is akin to why I am fine going out with just a mask but no goggles or gloves ( even though I have them available ). That's because I'm not about to go near someone coughing in public but am concerned about droplet spread in shops, lifts, stairwells and other enclosed, poorly ventilated spaces. I also amn't concerned about fomite spread from my hands because I simply don't touch my face when out until I arrive home or at work and have disinfected them.

But you may differ and you should suit your planning to your situation. I've never presented what I do as the "only" way to do anything. I've just offered advice regarding what I felt were reasonable precautions. You have to be safe but you have to balance that with practicality.

padser wrote: »

I'm interested in your assessment of your own mortality rate if you get it and in particular whether its changed since you first posted about it.

Originally, you gave yourself a 15% to 20% mortality rate if you caught the disease. I'm wondering if anything has changed your mind on that?

Given that roughly half of our deaths come from nursing home patients that leaves us with something like a 1.5% mortality rate for the rest of the population from the reported cases.

I assume this is grossly inflated due to
- significant gaps in testing
- testing concentrated on the most severe cases

Given that, I imagine you are assessing yourself as being maybe almost 2 orders of magnitude more at risk than the general population excluding nursing home residents.

Does your original assessment still hold?

Well, you're making a major mistake in looking at population level data and then assuming that has any applicability at the personal level.

Let's imagine a disease which kills only the Taoiseach of Ireland. On a population level the risk is 1 in 5 million BUT if you're the Taoiseach and you catch it you're guaranteed to die, a 100% mortality.

So, using population level risk to discuss individual risk is not valid in the slightest. As to my risk... Yes, if anything the risk of mortality if I catch it is even higher than I initially estimated. It really is worse for those under 65 than I think most of us thought a month ago.

zippy84 wrote: »

Thank you for all your efforts. You have been an invaluable source of information on here.

I have some disposable gloves, but haven't yet used them as in my own situation, I don't feel confident wearing them with any positive effect on my routine. I have seen your linked video on how to remove them effectively etc. When I go out, I carry a small bottle of 70% sanitizer. It pokes out of the back pocket, so I don't even have to touch clothes to grab it. Some examples of when I use it... before entering a shop, before and after using a card machine, before putting stuff in a boot, before getting back into car. Then when I get home everything either gets left to disinfect naturally, or it gets wiped down with disinfectant before getting put away. Clothes off and into a wash.

I absolutely will not touch my face when out and about. My thoughts are that gloves would complicate my situation, and potentially even aid the spread through infected surfaces as I wouldn't be sanitizing as much. Or should I wear gloves and continue to sanitize? I bought a few litres of isopropyl alcohol so there's no shortage of sanitizer for now.

I could see the value in wearing a mask (although I don't have any proper masks), but I'm at odds with gloves. Is there a point at which we could start looking to purchase proper protective masks? I know there is probably a shortage so I wouldn't have been on the lookout online.

Just to add... I didn't mention all the precautions I take and know they will never be perfect, but I do my best.

Well, I think you have to do you. Personally I wear a mask whenever I go out but I don't wear gloves or use hand sanitiser until I'm at work or at home. My reasoning is that I have the discipline built up over time of not touching my face for prolonged periods when wearing masks and so there's no benefit to hand sanitising when I assume that anything I touch is "dirty", including the door handles of my car etc.

If I were to use hand sanitiser on leaving a shop I'd simply assume my hands were "dirty" again the second they touched the car door so, to me, that seems like a waste of hand sanitiser. With that said the first thing I do when I arrive home or go into work is doff my mask, coat etc and then disinfect my hands.

With that said your approach is certainly not unsafe and if you have enough hand sanitiser to hand sanitise all the time then more power to you. Different people are comfortable with different approaches.

I think masks are hugely useful ONLY IF WORN PROPERLY because I'm much more concerned about some random stranger having coughed in a shop or stairwell a few minutes before I walk through that space than I am about me touching my own mucous membranes with "dirty" hands or having poor doffing technique at home or at work.

With that said IF you can get a good mask with replaceable filters and have the means to sterilise said mask then I would do so. I think we are ALL going to be wearing masks when out and about a few months from now. In fact once sufficient supply becomes available I'd expect that to be a requirement to enter a lot of shops.

Over the next few days I'll be editing the mask/PPE post with some additional tips and links to cheap gear on Amazon which will help make masks much more effective.

How are we doing?
Penultimately, there's been a lot of discussion on various threads about how well or how badly Ireland is doing with this and I thought it useful to address this. Several weeks ago I said that we'd peak at somewhere between 40 and 60 deaths a day. We have, now, unfortunately, reached the lower bound of this range. With that said Ireland is very much in best case scenario territory. I still think we'll end up with 1500 to 2,000 dead by the end of May but given what we were heading looking at in early March if we didn't take radical steps 1500 to 2,000 dead by end of May is testament to how well Ireland is doing. Sure, if we'd started taking steps in February we could be doing even better but this is a crisis and we're doing pretty well - certainly a lot better than the UK.

Honestly though I'm more positive about this whole situation every week as I see the measures having an effect and most people doing their best, however imperfectly, to socially distance. We really have avoided the worse scenarios. Hell, even HSE management mostly gets a a thumbs up from me and I'm normally VERY jaded and cynical about them. People have really pulled together and done what needed doing when it needed doing.

Masks
The other thing to note is that this is a marathon not a sprint. COVID-19 will be killing people in Ireland next April and May and will continue to do so, even if it doesn't mutate sufficiently to cause a new strain for which a vaccine is ineffective, until a safe vaccine is available next year. So, even if you are looking at a two month wait for a mask to be shipped from China go ahead and order it. You'll be glad to have it three months from now.

I would strongly urge everyone who has seen the videos of how to put a mask on and take a mask off and so will benefit from wearing one to go out and buy one - even if it'll take a month or two to get here. Yes, do gloves and hand sanitiser etc also if you wish when out but there's a reason why the only piece of PPE I think is essential when out is an airtight mask. All of the rest is nice but can be compensated for by awareness and good routine on entering and leaving your house/work. But without a mask you are at the mercy of whoever passed through space you are now passing through over the last hour or so. If they were sick and coughed you are defenceless without a mask.

With that said, if you don't fit it properly then it'll do more harm than good so look at the videos I posted about taking on and off. I'll post some tips about fitting them properly over the next couple of days.

I hope this was helpful. Stay safe.

P.s. I see someone posted while I was writing...
Locohobo. Thanks, I'm fine. I was just working and then shattered and sleeping. I feel human again today though, hence the post. Thankfully my department dodged a couple of bullets with negative tests among colleagues over the past week - just got the last result back today - so that was great news too.

Pseudonym121

Cork Boy 53 wrote: »

With the death toll in the USA rising virtually every day what do you think the total mortality rate will be there if things continue as they are with no change in restrictions?

Thanks for the question. Unfortunately it is impossible to give a definitive answer to this because of the Trump Factor. As I've outlined previously you can model the probably outcomes of any scenario as Best, Middle and Worst case and then within each of these cases you can have Optimistic, Reasonable and Pessimistic outcomes.

A few countries in the world are heading for Optimistic Best Case Scenario ( Taiwan, possibly Vietnam - I wouldn't include Greece here as I think that their lack of action re: refugee camps will cause their numbers of cases and death rates to spike over time ), others like Ireland are heading for Reasonable Best Case Scenarios. The UK, Italy and Spain are, I think, heading for Pessimistic Best Case Scenarios. Italy and Spain are heading for that because they had community spread before they realised what was happening and so while they've done a good job since they were on a bad trajectory before they realised what they were facing. The UK is on a different trajectory with, probably ( officially it is only double but this is more of an artefact of their inclusion criteria for COVID deaths than an objective reflection of reality ), triple the per capita death rate, than Ireland due to their week-long experiment with herd immunity.

The point about all of the above is that in all cases:
a) the governments are listening to doctors and epidemiologists albeit acting more rapidly or more slowly and
b) each country's government is reasonably efficient - some more so than others obviously and
c) each country's response is reasonably united - one can see this even in federal states like Germany or Belgium.

None of these three factors apply in America. You've got pockets of knowledge and excellence warring with pockets of anti-scientific, populist demagoguery within the government at different levels ( federal vs state vs local ) and within the same level and department.

I think what we are seeing is a scenario in which the federal response is more concerned with creating a scenario in which Trump can lay the blame for deaths at the State/Governor level - I refer here to his new position that the Federal Government shouldn't be responsible for testing, procurement of ventilators etc. He has basically just admitted these things are hard and so he thinks other people should do them, a hellish abrogation of his responsibility - than it is with effectively addressing the issue.

So, America had the potential to come out of this like Ireland with an equivalent of our 1500 to 2000 dead by the end of May ( which would be roughly 90,000 to 120,000 dead ). I think they will do significantly worse than that. Now it is necessary to state that the official numbers will NOT reflect the true death toll. I expect the official numbers will be under 100,000 dead by the end of May BUT:
a) I expect a lot of states will put pressure on doctors to record the primary cause of death as something other than COVID - e.g. if the person dies from a cardiac arrest and has COVID the state will create rules whereby the death is attributed to heart disease. I'm sure people will be say this couldn't happen but doctors work within systems and those systems generate procedures. In America the heads of many of those systems are political appointees and I find it very easy to imagine Republican appointees in Republican-dominated states coming under pressure to ensure their medical organisations issue guidelines which keep the number of COVID deaths low through administrative means.

b) the current figures in the US are basically correct for hospital deaths ( although even there see above ), partially correct for nursing home deaths ( albeit still missing quite a few cases there ) and, in most states, seem to be missing almost all COVID-related deaths taking place in people's homes - which seems to be a large portion of deaths in America. I refer you to the excellent Day Diary of a Paramedic the BBC posted about a week ago in which they had 12 deaths in a single shift, 11 of which were COVID related but none of which were included in that day's number of dead.... and that is ONE paramedic in ONE day.

So, in Ireland I think we are probably undercounting by about 15 to 25%, in the UK I think they're undercounting by closer to 50% and in America I think you could safely double the number of dead given by the "official numbers".

I've written previously, about a month ago, about the need to look at "excess mortality" in order to figure out the real number of deaths caused by COVID. I think that in six to twelve months time when these excess mortality numbers start becoming available we'll see that a lot more people died in America than the current numbers show. At present they are showing roughly 35,000 dead which I'm taking to mean 70,000 dead already.

So what will the total mortality be with no change in restrictions? There's no point answering that since restrictions will change. Already you can see Trump trying to ease the restrictions and states resisting him. This will enable him to blame them for any economic fallout - which is all he appears to care about. What I feel is safe to say is that America will suffer a multiple of the number of dead it had to suffer if it had an effective leader. If Trump is re-elected I think they will easily exceed 1 million dead over the next year - assuming there is no vaccine available until next year, that there's a Q4 spike a la Spanish flu and the Federal Government continues to fight reasonable restrictions and science ( as it currently does ). The real determinant will be whether or not there is a Q4 spike. If there isn't then even with woeful management you'll have only 25% of the number of deaths as if you have a Q4 spike. So that's the difference between 375000 dead and 1.5 Million dead. And right now no-one knows for certain whether we will see a Q4 spike or not. The way to bet in terms of preparation is that there will be a Q4 spike. It is a very sad state of affairs.

Purple Mountain wrote: »

Good to hear you sound rested today and positive. I just want to know.. Today we saw 40+ people die.
I just can't get my head around why our death numbers are creeping up slowly every day when we have had huge restrictions on our movements for 2 weeks.
What I mean is, I know the figures for new results are not in real time because of the backlog with test times etc but reported deaths are in real time.
I would have thought that given how less human interaction there is especially in the last 2 weeks and even since schools and universities closed the death cases would be down?

Well, the first thing to say is that a death rate of 40+ per day is no surprise. I can't find the post where I said it but by my recollection about 2 to 3 weeks ago when we were having far fewer dead a day I was on the record here as saying I expected us to plateau somewhere between 40 and 60 dead per day - this is implicit in the prediction of 1500 to 2,000 dead by the end of May. One other consideration is that I think you could safely add 15 to 25% to our recorded daily deaths by dint of people passing away in nursing homes and at home of COVID 19 but not having been tested or not having the results of the test back yet and so it not being notified. So I think 40 reported as dying in the daily press conference actually means 50 died from COVID19 that day.

So, firstly, it is no surprise, the number we are at is the number we were always going to get by locking down when we did. What you need to remember is that if we had delayed lockdown by, perhaps, 10 days we would be looking at four times this number of dead daily ten days from now. That's the nature of exponentiality.

Secondly, if you say that it takes 5 to 10 days for most people to become symptomatic and another 12 to 18 days for those who will die to die then you can see that if you lock down on the 1st of the month you will still see the number of dead rise for 17 to 28 days but clustering around 21 to 24 days ( call it 3 to 3.5 weeks on average ).

So what you're missing in your thought process is the length of time taken to incubate the virus and the length of time from onset of symptoms until you die. You should expect rising death rates for 21 to 24 days after the date of lockdown and I think that is precisely what we will see.

So, best case scenario I think we are looking at another week of rising cases and then a plateauing of cases in week 4 with a gradual fall in cases in week 5, accelerating as we go into weeks 6, 7 and 8. This is why I've been on record as stating that April and May will be very bad months but by the beginning of June things will very much be looking up. We should see some slight loosening of restrictions in May but in June I would expect that to accelerate significantly. Ideally I'd avoid any lifting of restrictions in June on medical grounds but politically and socially I think that may prove unavoidable - which will risk a an increase in infections and a yo-yoing of easing and strictening of restrictions and death rates.

Honestly, the daily deaths we are having now are pretty much right on track for where we should be for a Reasonable Best Case Scenario and not at all surprising. That I can say we are doing well when up to 50 citizens are dying daily is horrendous but these are horrendous times. That doesn't change the fact that we are doing well. The hospitals haven't been overwhelmed, ICUs which were looking a bit touch and go around the Easter Weekend made it through fine and a lot of our justified preparation in increasing bed capacity, taking over private hospitals etc is going to not be needed ( although it was ABSOLUTELY right to make those preparations ). We are solidly in best case scenario territory right now and that is NOT where we were 6 weeks ago so that needs to be recognised. Yes that we've gone from 90 deaths a day on average to about 140 is horrendous but we aren't at 280, which was eminently possible if we'd just delayed another week or been a bit less strict with the lockdown.

We'll know by the end of the month if the lockdown has worked. I think everything is looking good at the moment and I think we'll finish the month at about 1,000 dead officially ( so about 1250 in reality and even more by the time you look back and count excess mortality figures as others will have died by not coming in to hospital when they've had a heart attack/ delayed cancer treatment etc ) but with a clear plateau and the first signs of falling numbers. But I won't call that a trend until we have at least 5 days of plateau followed by 5 days of generally falling numbers ( the 5 days is based on mean incubation period ).

Then it all depends on us not loosening restrictions too quickly and us keeping the R0 down. If it spikes again we may need to lock down again. Otherwise deaths will fall to a socially acceptable number per day ( I bet somewhere between 10 and 20 ) and the economy will get going again - more slowly than some think - and we'll muddle through. We do absolutely need to prepare ourselves for a major depression and not just a recession or, even more wishfully, a V shaped recovery. We will be dealing with this till next year and that will depress the world economy until pretty much everyone is vaccinated - which will take till the end of 2022. So, 2 years of depressed economic activity. I think that will lead to a significant recession worldwide, especially when combined with a strategic move away from the production of strategic materials globally and a focus on more local manufacture of a lot of those goods.

Anyways, that is economics, a subject which I'm much less of an expert on so take that with a pinch of salt... I just think a lot of economists who are predicting a bounce back just don't understand the timeline of this illness. Reasonably speaking even if they have a vaccine in April 2021 it will be the end of the year before enough has been made to vaccinate everyone, so that's two years of economic activity negatively impacted by SARS-CoV2. I don't think they're taking that into account.

makeandcreate wrote: »

Hi - a question regarding masks - having followed your posts for a while, I realise you are advocating best practise/personal ideal solution.
Specifically regarding masks, I often had to wear one in the oncology out patients - no one advised us how to wear it, put it on etc - simply - in this room we wear a mask. For yourself, for others.
Going forward as a society; does in your opinion - using a layere cotton face mask have any benefit to us? I am not looking at this as "face masks make us invincible" or that is prevents infection from Covid-19 but if it reduced droplet spread in all users by 30% even, is that not beneficial?
And thanks for all the time, energy and sleepless nights you are putting in - there are not enough words to thank you.

I think that, as masks become available they will become mandatory in society. Whether that mandatory nature is through legislation or peer pressure I'm unsure of but I would, personally, be in favour of the following:
a) behavioural approach: Exempt people wearing masks from limits on numbers of people in shops. People who don't want to wait in queues to get in will get a mask and wear it in order to be allowed straight in.

b) behavioural: limit access to certain areas to people wearing masks - eg you can't go into a nursing home or hospital UNLESS you wear a mask. People will want to visit relatives so they'll buy and wear masks.

c) legislative: just make it a law that you need to wear a mask if you go into ANY establishment other than your own home.

I think that any masks is better than no mask. So a cotton mask with no filter is still better than no mask... and then a surgical mask is better yet and an N95 better again. I use an N99 respirator mask when out but they're contra-indicated for people with significant respiratory pathology and even then I find it significantly more difficult/tiring to move around much with it on.

So, yeah, if everyone wore a mask - even a cotton one - it would help reduce spread. Obviously the ideal would be everyone having a reusable N95 mask ( not even a respirator ) with replaceable filters and they're pretty cheap. I got two for like 30 Euro before this started and replacement filters are about 25 cents per day. So, a year's worth of protection with daily travel and filter replacement would come to about 120 Euro. At that level it'd be the sort of thing which would make economic sense for the government to provide ( a day in hospital costs about 1,000 Euros per day and an ICU bed about 5,000 a day ) so avoiding admissions ( and taxes lost due to those ill but not hospitalised ) very quickly pays for itself.

makeandcreate wrote: »

And thanks for all the time, energy and sleepless nights you are putting in - there are not enough words to thank you.

Thanks, we're all just doing our bit. I'm no different in that way, just trying to do my bit.

ZX7R wrote: »

Hello pseudonym 121.

For example your child is special needs and you needed to fly.
If the child was unable to wear a mask how would you see them been able to travel if a repatriation flight was needed for them and the family.

I think that is a very difficult situation. I think there are three possible solutions which vary in terms of feasability depending on the individual circumstances - which I'm obviously not privy to....
1. Innoculate the child to mask wearing using behavioural techniques - treats etc in the days prior to the flight - so that they'd be able to tolerate the mask by the flight. This may not be possible depending on the severity of the impairment.

2. A mild level of sedation could be considered such that a mask could be worn while the child basically sleeps through the flight. This would have to be discussed with their treating team though and could be risky.

3. Probably the simplest solution which might work is for the family simply to bring a lot of extra masks and pass them out to other passengers sitting nearby and explaining that the child is vulnerable, cannot wear a mask and just asking the other passengers to be decent human beings.

5 or 6 rows should be 2.5 to 3 metres and with 6 seats a row that'd be 30 to 36 people requiring masks. That relies on the understanding of others but:
a) most people are decent.
b) most people on any repatriation flight should be delighted to be coming home and scared of the virus so hopefully even a bit more understanding.

4. I'd also highlight this issue to the airline beforehand so that, if the flight wasn't full, some sort of buffer zone where people who didn't want to wear a mask weren't seated close to your child and were moved to empty seats elsewhere in the plane. I'd be willing to bet that if you offered free masks to people you'd have a lot of volunteers to swap seats and move into that buffer zone. Fear is a great motivator.

I think points 3 and 4 are probably most feasible. I want to be clear that the above is just my initial best thoughts on the subject and not medical advice... but I'd be surprised if 3 + 4 plus a chat with the airline didn't solve the problem... plus a bit of habituation a la point 1.

I hope that helps.

Pseudonym121

s1ippy wrote: »

Our neighbours along the road all have this virus, nine other houses. As they spend a lot of time out their back gardens, we are keeping our cat inside because we're worried he'll bring coronavirus into our house.

For context he is very upset, I'm worried it'll give him bowel troubles as he only really goes out to poop and doesn't do any socialising with people or other cats etc. He's pooping at his regular times in the litter box but only after about an hour of wailing at the door.

Are we being overly cautious? I feel cruel. There is only evidence of three pets and those lions having the weak positive but when we're so cautious it would be a shame for all our efforts to be subverted because our cat wants to take A dump somewhere exotic.

Well, I think it is important to treat pets well BUT my view is that if I were to die my pet is going to end up in a shelter and if not adopted euthanised. So, it is, I believe, a far greater kindness to keep healthy and give the pet a secure home for years to come than to take a risk.

This is a virus which infects mammals so jumping from human to cat and back again is not impossible. I, personally, am not taking that risk but I do accept that I’m being very cautious about this sort of thing. With that said I remember six weeks ago when I was talking about needing to treat everyone else as though they’re infected whether they show symptoms or not that I was called a lunatic for saying this. Now the growing consensus is that at least 50% of spreaders are asymptomatic. So, just because the evidence isn’t there at the moment of pet to human spread doesn’t mean it won’t be there six months from now.

I assume it can happen and work off that basis. Better safe than sorry IMO.

volchitsa wrote: »

Hi Pseudonym121

Glad to see you're still doing okay. I have two (more) questions:

I heard on the BBC about a woman who had been saved beyond expectations - her family had been called in because she was dying, but after discussion and as a last resort they agreed to try a technique called "proning" which is basically just putting her on her stomach (still on the ventilator obv). It seems just putting her on her stomach was likely to kill her, so it wasn't something they intended to try without the family's express request.

Now I missed if this was because just moving her could kill her or whether it was something else to do with being left in that position, but I wanted to know what you thought about this - and also how quickly "new" information like this is transmitted to other medical teams around the world?

Do you all wait until proper studies have been run before adopting new procedures, or do you tend to try these things out if, say, a mate in a London hospital tells you that his team has been having success with it?

I read that piece myself. It seemed very exaggerated. Proning isn’t some “last gasp, experimental, this kills half of all people we try it on but without it everyone dies” treatment. Proning is a well recognised treatment which has multiple randomised controlled trials backing it up. The way it was presented in that article was very sensationalist.

Here’s a good link which is easy to read if you want to find out more about it.
https://m.oxfordmedicine.com/mobile/view/10.1093/med/9780199600830.001.0001/med-9780199600830-chapter-99

Normally one of two things happens:
1. Ideally you wait for studies to be carried out in specialist centres. Ideally you wait for multiple randomised controlled trials which are methodologically sound and then you change your practice when the proof is there that it will do more good than harm.

2. Sometimes you have a patient where the situation is such that you take a chance on something which isn’t quite as clearly proven because this patient is in such a dire situation that the benefits of trying this new treatment - which seems to work but hasn’t been fully proven yet - far outweigh the risks. Where you draw this line varies from clinician to clinician and on the individual situation of the patient.

I have certainly done off-label prescribing and tried things which aren’t fully proven when I’ve had patients who I felt were going to die otherwise. Some of the time they still die and some of the time it makes a difference.

With COVID-19 there is a lot of chatter between doctors about what seems to be working in a given hospital or region or country which is being shared. We recognise that this doesn’t have the same level of authority as an RCT BUT this virus has moved so fast that we don’t have time to wait for this research before trying things which seem like they help. This is where 20+ years of experience with patients etc helps and why so much internet opinion about these treatments is useless.

So you’re getting quite a lot of “compassionate use” of drugs which people think might help because if you do nothing then the person will almost certainly die. We then record which drugs seem to help and then if one seems to help a lot we move it into actual studies so we can begin to be confident that it is a good treatment. This is what is happening with Remdesivir. It went from “hey it might help” to “anecdotally it helps” and now it seems it might be moving into “ we’ve proven the benefits out weight the risks” This would be great news if it comes to pass. We’d finally have a treatment.

But yeah I’ve seen stuff from the US and UK and elsewhere where people are reporting what they’ve seen work in order to help other doctors elsewhere save more of their patients. We are all, after all, humans just trying to save other humans. Borders etc are artificial constructs compared to that reality.

Lisha wrote: »

Hello OP,

Thanks for doing this I find it very interesting and informative .

I’ve tested positive for Covid19.

I had high temps for 16days, then I did 5 days post fever before I came out of isolation. (Difficult enough with 10&12year old children.) neither husband nor children have shown symptoms. So I’m hoping that’s it. Gp told husband not to work since I showed symptoms and he didn’t do we hopeful we didn’t spread it. But who knows. I’ve no idea where I picked it up..

When can I be considered no longer infectious...? Work are slow about bringing me back, would prefer if I was tested again and negative. But I know that’s not possible here..

Date I first showed symptoms was 21st March.

I think that’s a really difficult question. I think that the research on that is changing all the time and that a few months from now we’ll know the correct answer but right now the best I can say is that once symptoms are gone the level of virus you shed falls rapidly at first but persists for quite some time ( up to three weeks in some studies so far ) at low levels. Are these low levels enough to infect others? Well, we are certain you’re far less likely to infect them with these low levels but can we say that you certainly won’t infect them? Not with 100% certainty.

So I’d say that to be cautious I’d give it a minimum of one week and a maximum of three weeks after symptom resolution at this stage. That is probably excessively cautious but excessive caution is, I believe, the way to treat this illness on both a personal and population level.

Sorry there isn’t a definite answer but the best the research can really support right now is a range with an assurance that even in week 2 and 3 the amount of virus you shed is much, much lower than when you were symptomatic or during week 1. I think That you should be guided by your GP/Occupational Health and shoudldn’t sweat it if they ask you to wait a couple more weeks. They are probably just being cautious like I am. That’s not a bad thing.

Pseudonym121

GaryByrne wrote: »

Hi I have a fairly difficult question to answer

My grandmother who is 93 is in a hse community hospital. There are more than a few confirmed cases within the hospital including 7 staff in isolation.

We get updates daily from the hospital and my Granny has a mobile and rings us upto 5 times a day asking when she can see us as she isn't sick but just needs constant care because of her age and frailty.

Last night her next door neighbour (from her street) passed away, in the same hospital from complications due to coronavirus, we can't even tell her of this as it would break her heart and she has nobody to comfort her.

My question is, with the word that restrictions will be eased gradually and people will be let back to work without a vaccine, this will obviously raises the risk of my Granny getting infected through staff coming in contact with her. Would we be better to take her out while she is fit and healthy now rather than leave her to eventually get infected as most probably will if it is to continue to go the way it is going.

I don't want to not see my grandmother for another year or at all as her neighbours relatives are now going through

Our local doctor said she is in the best possible place but it is so hard to actually believe that at the minute

And thank you for doing so much

Thanks for the question. I don't think the answer to that question is a strictly medical answer. The answer to that question is a balance between medicine and your feelings.

What I can say is that even if you were to bring her home:
a) it would likely be difficult to provide the care she needs and
b) it isn't as though you and your family will be immune to this over the next 18 months so if she comes home someone in the family could bring it into the house - and infect her.

Generally speaking you could be damned if you do and damned if you don't. Your local doctor is probably the person to follow with this but even following the best of advice there is no guarantee of a good outcome here.

One thing though: i expect that when restrictions are lifted some form of visiting within nursing homes will be allowed again but it will be of the, "You can visit but you must wear a mask and go straight to your relative's room and then leave immediately once the visit is over" type. The majority of Irish people won't tolerate a year of not seeing their relatives face to face. Ideally we would tolerate that but we won't. With that said it is the safest way to play this and while I drop supplies over to my parents I don't go inside and just wave through a window.

On a human level the next 18 months are going to be very tough for those with aged relatives. Sorry I cannot give you a definitive do this or that answer except to say that your local doctor is likely to give you good advice.

What Username Guidelines wrote: »

Any thoughts, or experience, on this?

https://www.today.com/today/amp/tdna178991#click=https://t.co/3vlCF2fWgn

Noticed by doctors treating covid patients in Spain, Italy, and US, along with dermatologists noting a spike in cases/reports.

My 4yo daughter developed a slight cough a week to ten days after schools closed. We thought it odd as she was cocooned with us (she’s a transplant recipient) but it was mild and only here and there through the day. Only just stopped in the last few days.

Middle to end of March I developed the exact symptoms shown in above article. All toes quite sensitive, swollen, itchy and felt “hot”. Similar to a fungal infection but on all toes equally and daktacort did nothing for it. Went away by itself after a about a week, pain went first, then swelling, skin still a little red but all fine now.

Are you noticing any similar symptoms or a pattern of patients displaying non-classical symptoms alongside the usual fever/breathlessness/etc?

Well I think a lot of unusual symptoms and signs are being seen. When I heard about this I immediately thought of micro-emboli and/or generalised inflammation, both of which can occur with COVID-19. With that said lots of people are ascribing lots of symptoms to COVID-19 and when they get tested they don't have it. I've had doctors and nurses around me have all sorts of symptoms, loss of sense of smell, taste, generalised malaise, shortness of breath, cough, generalised aches and pains and so far the vast majority have tested negative. I've also known a number of general members of the public who have been tested and so far none of them have tested positive.

I think that we'll just have to wait for antibody testing. Even then though it is questionable just what a positive antibody reaction will mean functionally in terms of being able to go back to life as normal... You may have antibodies but for how long does that mean you're immune? Probably months to a year or two but we can't be sure... and much will depend on your antibody titre. Lower will probably mean low or no protection, higher will likely mean more protection. I'm not sure the publicly available kits will give you a titre.

Purple Mountain wrote: »

I just have 2 more questions for you.

Are you aware of what Dr Phil (doctor of psychology in the US) said about reopening the economy?
Basically he says look at the figures for people who die in swimming pool accidents etc and the economy still goes on. He can't see the justification of an economic shutdowns.
How do you argue with his mentality?

Also, there's hints in the media, even from our leaders, that schools may return for one day a week.
But yet, I've heard that there are still some test centres or the proposed UL field hospital that hasn't even opened yet.
I just don't understand how we're near opening schools if that's the case.

Thanks.

Well Dr Phil says what his network wants him to say. He's not a medical doctor, and neither does he hold a licence to practice psychology. He voluntarily surrendered that in 2006 - and voluntary surrender is not a thing to inspire confidence. He has also had numerous ethical violations including breaching patient confidentiality and hiring a patient to work with him which resulted in the Texas board putting limitations on his practice in the 1980s.

So he has, to say the least, a checkered past, questionable morals and ethics and isn't the sort of person I'd refer a family member to.

So how would I argue with his mentality? I'd simply say that a lot of people with no real scientific or medical background have suddenly discovered that they're world-class statisticians, epidemiologists, virologists, research scientists and doctors all rolled into one person. You can either believe them or you can believe people who have spent 20 or 30 years doing one or more of those things.

If someone showed up to my place saying they had never had formal training but were a world-class plumber, electrician and carpenter and were much better than the trained, accredited plumber, carpenters and electricians I'd hired I'd have no hesitation in calling BS on their claim. Yet when people do this with science people seem to be much more accepting.

As to the specifics of Phil McGraw's claim. I have NO DOUBT that he is willing to open up America at the cost of many others dying. He certainly doesn't think he'll be among the dead. I think that says a lot about his morals. Certainly we have to strike a balance between death rate and economic catastrophe. I accept that. I do not think that what he is advocating is a very moral balance. I have no doubt that Ireland will strike a much more moral balance. Will many still die? Yes. Could we have reduced this toll if we'd acted earlier? yes, but in a crisis mistakes are made and hindsight is 20/20. Does any of the previous mean we should throw caution to the wind now and throw a 2 to 5% of the population to the wolves over the next year? No. We're better than that.

Purple Mountain wrote: »

Also, there's hints in the media, even from our leaders, that schools may return for one day a week. But yet, I've heard that there are still some test centres or the proposed UL field hospital that hasn't even opened yet.
I just don't understand how we're near opening schools if that's the case.
Thanks.

Well, talking about opening schools in the future could be viewed as an attempt to convince people that normal life will return. Talking about it now doesn't mean it'll happen in a couple of weeks. I think the government is trying to give people hope that a new normal which is livable will come within a reasonable timeframe. That is certainly the prism through which I view those pronouncements.

You only have to read the main COVID-19 thread here to see how many people are unable to put the needs of society above their own desires. To me this shows that they need to be given some hope that the lockdown will end and life will return to a new normal. Of course doing this will result in more deaths over the next year but, to be blunt, unless it is their deaths these people don't seem to care.

Oh and lastly... about masks.
1. If you can get the masks which don't use ear straps. They'll chafe and become uncomfortable and will lead you not to use the masks. Far better to use ones which tie around the back of your head/neck.

2. If you do have a mask strap which is chafing behind your ears or your neck you can wrap some adhesive tape around it which should go a long way to reducing the chafing.

3. So, which tape should you get. Well I've always found the 3M transparent hypoallergenic 2.5cm wide tape to be very good. A bonus is that it is really easy to tear when wearing gloves and is designed to stick well to skin and has reasonable water resistance. I've always had a few rolls of this at home ever since I first came across it almost 30 years ago in hospital.
https://www.amazon.co.uk/Transpore-Surgical-Hypoallergenic-Transparent-2-5cm/dp/B0741B3S4P

The 1.25cm wide version is just too narrow IMO but your mileage may well differ.

4. I've seen a LOT of people with very poorly fitting masks out and about. I've also seen a lot of masks which don't have good nasal bridges to allow shaping to the nose. So, pro tip... Use the tape to stick the facemask to your nose ( and if you wish under your eyes ). The hypoallergenic tape will greatly improve the quality of seal you get.

This won't apply so much to you guys but it'll also prevent hot air escaping upwards and fogging up goggles etc. You can do the same on the bottom and sides if you wish but you'll never fully prevent air leakage where the straps are. I've known some people to remove the straps and just tape the masks on but I wouldn't go so far.... Even if you just tape the top and bottom of the mask you will vastly reduce air leakage.

Word of caution: Hypoallergenic doesn't mean no-one will react to it so just use common sense.

5. If you find the mask chaffing along your nose you can always put a plaster over the bridge of your nose. Normally that would make the mask fit less securely but use a plaster to stop chaffing and use the hypoallergenic tape to create the seal again and you should be good to go. That's what I've been doing recently anyways after I had skin irritation from masks.

Pseudonym121

Lochobo, re: migrant workers.

I don't think the issue is migrant workers. The issue is that once a country ( defined as a geographical national polity with the ability to control ingress and egress ) has controlled the infection rate within its borders to whatever the populace within that country is willing to tolerate then allowing people in from outside without a strict, externally monitored/enforced 14 day quarantine ( as opposed to a relatively useless voluntary quarantine ) will become a source of new infections. I don't think people will tolerate that.

You have to bear in mind that in recent history ( the last 100 years or so ) pandemics and other major shocks to society have usually been followed by shifts to the right in terms of politics. For example, I would expect that support for Trump's wall will increase now that it can be painted as more than just an anti-immigrant measure. Now it'll be an anti-COVID measure also. That'll garner more support.

This will have to be balanced against the reality of our food production which, in many sectors, relies on people being paid below the minimum wage. One should expect food prices etc to increase as the friction caused by COVID on the economy is reflected in increased prices generally.

Will it cause inflation? Probably not because of the massive deflationary effect of many of the other measures that will have to be taken to combat COVID and the massive job losses which will follow over the next year.

zippy84 wrote: »

Any chance of a link to buy masks or are you still working on this? I've seen some for sale on Amazon, but I'm not sure on the quality and wouldn't be relying on reviews on there.

I have one at home that fits nicely, bought it in Woodies a year ago for spraying weeds... cost about 10eu... ffp2 according to the stamp on the side, Can I assume that this is the same effectiveness as a normal n95?

Would like to source a few more online all the same.

If you can source an N95/FFP2 mask on Amazon from a reputable manufacturer (3M etc ) then I would do so. My respirator masks (N99/FFP3) are both from 3M, I have some N95 from other sources. I got all of them from Amazon in late February/early March. Prices are higher now but if what you order doesn't look like what arrived then Amazon's return policy should cover you.

I would definitely invest in masks because as part of the opening up of society again I'd say masks will become de rigeur in any crowded situation.

There may be an issue with masks with valves not protecting others if you're infected - as the valve allows exhaled air out - and so in certain situations you may be forced to go for a valveless mask instead but even then I think valved masks are still worth purchasing... as well as non-valved ones... because they're much more comfortable and I doubt Ireland will tolerate legislation about mask type when masks are in such short supply.

Conelan wrote: »

Hi and thanks for your time,
I know a vaccine will be the longer term hope as a solution to this virus but could I just ask your opinion on the anti viral drugs being used/ being trialed at the moment? Is there any pattern of success emerging with one over another?? Hydroxychloroquine is getting alot of the media attention, less so Remdesivir. Are Irish hospitals using these or do you think is there anything out there that can help? I saw an Australian lab managed to kill the virus "in vitro" with Ivermectin. Is there a big difference in terms of success rate moving from "in vitro" into the human body??
Thanks.

When lecturing about these sorts of things there was a quote I found useful... "In theory there's no difference between theory and practice. In practice there is."

I've seen endless treatments look great in theory and in initial studies and prove worthless or actively harmful in the real world. With that said it seems that Remdesivir cuts down the duration of hospital stay which is useful BUT that is quite different than saying it reduces mortality. So even with Remdesivir it looks useful in a certain cohort but the jury is still out with respect to whether and how much it reduces mortality in those who may end up in ICU.

Still, even a partial treatment is welcome because reducing the duration of hospital stay by 25% reduces the strain on hospitals and that'll be useful to cope with the resurgence in infections when the lockdown ends / Q4 hits.

voluntary wrote: »

The Polish embassy in Dublin just announced the presidential election to take place in Dublin on May 10th. A personal vote in the Dublin 4 embassy itself. Tens of thousands of Polish living in Ireland. Will this be let run?

I'm not a politician just a doctor but my understanding is that the Polish Embassy is viewed as polish territory and so they can do whatever they want on their grounds.

I would expect that if the election goes ahead in Poland then voting will be allowed in the Polish Embassy in Ireland. How many people show up in person to vote is another matter though... but I expect that the vote will go ahead, yes. I, personally, think this is the right thing to do as otherwise various autocratic leaders would seize on these sorts of things as precedent to delay their elections in many countries.

Will going ahead with the election result in increased infections and deaths vs staying at home? Yes, but so long as voting isn't mandatory then those who don't want to risk it can stay at home and those who feel the risk is warranted can vote. It is a tough call but you have to remember many millions of people around the world have died to give this generation the right to vote. If there was another election in Ireland during a winter peak I'd go and vote - albeit with gloves and a respirator mask on. It really is an important thing to preserve....

With that said, that's just my personal opinion.

zippy84 wrote: »

Do you foresee a time-frame or any kind of guidance in relation to children with grandparents going forward? I am happy to keep things the way they are, but I fear in the future siblings may not stay the course, or my parents either.

Well, this has to be a personal decision. There's going to be a new baby in my family in the next few months and I can guarantee you that my parents won't be making a trip to see the baby or hold the baby etc until there's a vaccine. I'm sure there'll be a presentation of the baby through the front window etc but they don't want to see the baby enough to risk dying over it.

Different families and sets of grandparents will draw the line in a different place but that's where my parents are going to draw it. If people visit them then each visit will increase the risk of transmitting COVID - especially since we are now clear that at least half of people transmitting it are asymptomatic --- possibly significantly more.

I also won't be having anyone visit me in my place until such time as I've gotten vaccinated are have proof via an antibody test ( neutralising antibodies NOT binding antibodies ) that I have a sufficient titre to be immune to the prevalent strain in Ireland. I expect healthcare workers to have access to a vaccine during Q4 this year with it rolling out to others over the course of the next year as efficacy and safety are more rigorously proven and production ramps up.

So, I don't expect to visit my parents or family for at least 6 more months and I don't expect them to be able to visit eachother until the middle of next year - roughly 12 months time.

I'm sure many people will visit eachother freely and take the risk and most of them will be lucky and only get an asymptomatic or mild infection but I don't want to be the person who gives my parents something they have a 5 to 10% chance of dying from and so for myself and my family we'll hew to the more careful route. With that said even within my family some people are being noticeably less cautious than others. Even then I'd say they're being more cautious than most of the public but less cautious than I'd like. With that said I'm 100% certain my parents won't allow those individuals into their house until l say it is safe - and I won't be giving that imprimatur until they are vaccinated and/or have a proven neutralising antibody titre.

JoChervil,

I have no problem with complementary therapies per se. I do have an issue with the leaps of logic and evidence which these therapies and those promoting them often make.

Let us examine some of your thinking/supposition.

JoChervil wrote: »

If it was so, the remedy then should be the reduction of Fe3+ to Fe2+ and preferably removal of free iron ions from the blood.

Ok, well firstly we don't know if it IS so. We don't know that Fe3+ and Fe2+ are a central component of the pathology here. Lots of illnesses result in the breakdown of Haemoglobin and the release of its constituent compounds into the blood. There's no evidence that I'm aware of which says that the harm that COVID-19 causes is mediated by "free iron ions".

Secondly, since we don't know that the presence of free iron ions is a central component of the pathological process here - as opposed to just a byproduct of other ways in which the illness causes harm - then there's no reason to suspect that removing these "free iron ions" is "the remedy".

JoChervil wrote: »

I am not a physician but I suspect that BLACK SPOTS LEFT ON THE SKIN BY THE GLASS BUBBLES CONTAIN IRON (that is why they are black)

And here we get into opinion backed by statement transforming into fact. You suspect the black spots contain iron... and then you say that iron-containing spots would be black.

Firstly iron-containing spots wouldn't necessarily be black.
Secondly, the reason these spots are black isn't, as I understand it, due to any iron content. As I understand the colour of the spots it is a combination of suction and the rupturing of capillaries.

But, really, this is a case of making a guess and then a statement and then that somehow becoming a fact. This simply isn't how science and validated treatment works.

JoChervil wrote: »

What if “cupping-glasses” treatment is a method of "sucking off" a significant portion of toxic iron ions from the blood into the skin and thus reducing oxidative stress caused by toxic iron overload?

Ok, I'll counter with... And what is "cupping-glasses" treatment is a method of using the placebo effect to harness the power of the mind and suggestion to make people feel better. My statement has a lot more scientific veracity than yours.

JoChervil wrote: »

Now in hospitals there are a lot of patients with toxic iron ions in their blood causing damage to their vital organs.

Please quote the research which has proven this.

JoChervil wrote: »

I believe in therapeutic power of this method as the “cupping-glasses” helped my sister recover from severe pneumonia when she was a child.

And you are entitled to your belief. You are not entitled to place your belief on the same basis as facts proven by years and decades of research.

With that said, conduct the years and decades of research to put your belief on the same scientific basis as our current understanding of disease pathology and then I'll have no problem incorporating it into my treatment plans. Cupping isn't there yet and I strongly doubt it will ever be there - except insofar as it has a placebo effect similar to many complementary therapies... and let's be clear, placebo effects are real and welcome.

JoChervil wrote: »

The “cupping glasses” are not acknowledged by modern medicine, but has anyone ever tested their effectiveness of eliminating free iron ions (Fe3+) from the blood? Maybe the extravasated blood contains also some virus proteins transferred simultaneously to the skin, which tissue gives probably the strongest immune response in the body. So even, if the spots were only simple bruises with no iron but some virus, they could prod our immune system.

That isn't how immune system sensitisation works. It all sounds pseudo-scientific and I can see how it could persuade people who don't understand medicine or immunology properly but it simply isn't how the immune system works in the human body.

Also I'd love to see the research behind your claim that the skin "gives probably the strongest immune response in the body". It seems you really misunderstand the function of the skin.

JoChervil wrote: »

Why this kind of method can’t be tried and ruled out for good, if not working? Or approved and used, if working?

Probably because no doctor believes it would work given the lack of scientific basis and therefore isn't willing to condemn the intervention arm of the study ( those who get cupping ) to far worse outcomes vs the control arm ( those who are treated using 21st Century medicine ).

Cupping would have to have a LOT more scientific support before it would be ethical to use it instead of treatments which have been shown to have some benefit.

JoChervil wrote: »

It is only a question of applying cups (bubbles) and then analyzing the content of these spots. The advantage of the “cupping-glasses” method is that the therapy is very cheap. Much cheaper and safer than ventilators.

No, it wouldn't. This shows your lack of familiarity with medical research. Proving that the spots contained Iron Ions wouldn't be the end point of the study. The end point would be patient survival or duration of hospitalisation.

So, to test cupping properly you'd have to risk people's lives. We're willing to do that with antivirals and other medicines which we know or suspect will have efficacy against coronaviruses. We're not willing to do that with cupping. You, of course, are free to try it yourself if and when you are infected with SARS-CoV2. No-one will force you to avail of 21st Century Medicine.

And here's a debunking article about what appears to be the basis of your post and putative treatment:
https://medium.com/@amdahl/covid-19-debunking-the-hemoglobin-story-ce27773d1096

As to Phelps... I'm sure he believed it would help him. That doesn't mean it did. Also, we don't know whether it helped or hindered his performance as we don't have a "Control Phelps" who didn't undergo cupping to compare his performance to. And just because he's an Olympian doesn't mean his opinion on this is correct. Just because I'm a doctor doesn't my opinion on this is right but at least my opinion is backed by a lot of research, a lot more than his and yours.

I know which way I'd bet and which way I'd like any doctors treating me to lean.

auspicious wrote: »

Thank-you for all your work and that of your colleagues.

Going forward, should a conversation on diets which have strong scientific evidence of reducing the risk of developing comorbidities associated with Covid-19 be a priority to ease the burden of this disease on the healthcare system and increase the chances of ones ease of recovery?

Well, we've been trying to have that discussion with limited success for the last 60 years. I'm sure attempts will continue and some will listen, some won't.

Hmmzis wrote: »

Hi,
The short version of my question is: "Asymptomatic cases, what's the story there, why are they asymptomatic?"

Well it is becoming increasingly clear that there are a lot of asymptomatic cases. At present it is a safe bet that at least 50% of cases are asymptomatic, quite probably more. This is important because it does lower the case fatality rate significantly since up until recently we were only testing people with symptoms. I'm aware, over the last two weeks, of many colleagues who were asymptomatic testing positive.

One problem with this is that we don't yet know whether an asymptomatic infection results in a high titre of neutralising antibodies which may lead to immunity for a prolonged period of time - 1 year+. Or it may not lead to immunity but the likelihood is a high titre of neutralising antibodies would lead to immunity TO THE STRAIN YOU GOT but not other strains.

If asymptomatic infection doesn't lead to a high titre of neutralising antibodies then even though those individuals technically had the virus they won't be immune and so can get re-infected by the same strain again.

Generally speaking the more severe an infection you get the more likely you are to come out the other end with a high titre of neutralising antibodies which should confer some level of immunity for some period of time.

SARS-CoV2 hasn't been around long enough for us to know for certain but if it behaves like other viruses then there is a decent chance that those who had signficant symptoms will mostly have high titres of neutralising antibodies ( and some level of immunity for some period of time to be determined) while those who had asymptomatic infections will have mounted a lesser response and have lower titres of neutralisiing antibodies and a lesser level of immunity to no immunity for a lesser period of time. This is the way I'd bet it'll turn out BUT I must stress that we do not know this for certain yet. It won't become clear for several more months.

For example, I'm fairly sure I had COVID-19 back in late February after exposure to a probably case who didn't meet the testing criteria at the time. I had what we now know to be a number of symptoms of COVID-19 but which we didn't realise were related to it at the time (rigors x 2/7, no fever, no dyspnoea, abdominal pain x 2/7, intermittent chest pain x 2/52, dry cough once or twice a day on most days for 2 weeks, massive fatigue worse now at 2 months remove than in the immediate aftermath) and so I never met the testing criteria even though I asked to be tested. I'm assuming I have no immunity because that's the safe way to play it... although when a neutralising antibody titre test comes along I'll be first in line to do it.

locohobo wrote: »

Hello again!!..
Noticed you've not posted since 20/04//Hope all is ok and that the HSE have'nt nobbled you...
Just reading today that investigators in China noted, and now the French have noted also that there seems to be surprisingly a lot less smokers affected by coronavirus than non-smokers.. They are to conduct trials using nicotine parches to see if nicotine may be an inhibitor of the infection..
Am just wondering here that maybe its not the nicotine itself but rather the deposit from smoking that is built up in the lungs that may be causing this inhibition. As in that the virus cannot connect with the receptor in the lungs because of this coating..
Would like to hear you're thoughts on this....

No, they haven't nobbled me yet ;-). To be fair with how significantly the country has been locked down I think they'd be hard pressed at this stage to paint anything I said as unprofessional etc etc. It has mostly been just fatigue, massive fatigue which I think is probably a post-viral thing.

Yeah the nicotine findings really surprised us. We were expecting smokers to be particularly hard-hit and yet that isn't what seems to have happened. This virus is weird - largely because it has only just jumped to humans and so hasn't adapted to us yet so it kills us in lots of unusual ways.

I wouldn't think it is anything to do with any deposit from smoking. You have to bear in mind that these receptors are on individual cells and even in a heavy smoker the deposits in their lungs don't coat ever single cell in the lungs. I'd imagine that what we'll find is that the presence of nicotine competes with the virus for receptors and acts in that or some similar way. I really doubt it'll be something on the macroscopic level like deposits.

Tails142 wrote: »

Are you seeing many complications arising for people with asthma contracting covid-19, is it affecting them more severely? Are patients with covid-19 and asthma at much higher risk?

I wasn't overly concerned at the start as asthmatics are generally used to their condition being overhyped, a blast of ventolin and you're normally good to go. But I suppose
I've been dwelling on it the past few weeks - I have psoriasis too and caught cocksackie virus (hand food and mouth) last year from one of my kids, it really took hold in the skin affected by my psoriasis, I.e. My lower legs and arms and gave me a real good doing. It's unusual for adults to get it so I had been wondering if the psorisasis was an opening in my body for that virus to take hold. And likewise, now I'm wondering the same thing about covid-19 and my lungs, could my asthma be an opening for that virus to take hold in me and hit me severely.

Would be interested in your opinion or recent experiences or if you knew of any papers that have looked at this.

Well this is getting perilously close to individualised medical advice which is something I want to avoid. What I would say is that if you have severe asthma then, yes, COVID-19 could impact you more severely if you get it. With that said everyone is different and the best way to figure out the risk to yourself is to contact the respiratory specialist dealing with your asthma and inform them of your particular situation and what they would recommend.

They're going to be far more au fait with your particular illness and medication regimen than I could ever be and will be able to give you good advice. With that said I know several friends who have pretty severe asthma and I've certainly advised them to be extra-cautious. At worst they're now being overly cautious and will be a bit slower to go out again and mix freely as restrictions are lifted. At best they could avoid catching a really serious dose of SARS-CoV2. So, if I were you, I'd play it safe. It doesn't mean you couldn't return to work etc but it might mean that your specialist might advise you to maximise working from home and back it with a letter or advise you to be very diligent about wearing a mask even if others aren't etc.

eeeee wrote: »

Hoping you're alright at the moment, and getting rest in what must be an insanely busy time.

I was just wondering what you think of how the virus has progressed, in terms of your predictions, where do you see things heading now that there's an exit plan? Are the measures premature? Are ye run off your feet in hospital? Do you believe we have seen a rounded peak of sorts or is this level of infection and hospital stress the new normal until a vaccine comes in?

Well, I suggested that as restrictions came in we were looking at a reasonable best case scenario in the short-term ( to the end of May ) of 1500 to 2,000 dead. I think that has, unfortunately, been borne out.

I also suggested in a post earlier in this thread that what would determine our death toll over the next year would be the balance that would have to be struck between acceptable casualties and economic/social activity. At the time I said that everyone was backing the lockdown but, unfortunately, as I expected, human nature, short-sightedness and selfishness are presenting themselves again and already a significant minority of people are openly admitted they're happy to return to normal so long as they're only killing other peoples' parents/grandparents.

I suggested in that post that somewhere between 10 to 20 daily dead ( which would suggest that roughly 50 to 100 hospital admissions would occur daily, with an average treatment time of 2 weeks - so about 1,000 to 1500 hospitalised at any one time or 6 - 10% of the bed capacity) would be the acceptable figure to society. I think that is still so.

We have about 26,000 people in nursing homes in Ireland and when it gets into a nursing home/residential facility it seems the death rate is roughly 1/3rd of residents. I think that is in keeping with a mortality of about 10,000 dead up to March next year and another 300 to 500 per month after that until a vaccine becomes widely available.

So, I think we're still well on track for 10,000 dead in the year to March 2021 as a reasonable best case scenario and approximately about 13,000 till September 2021 IF we get the experimental vaccine in Q4 2020 and people continue to socially distance etc for the next 18 months.

IF we get a very safe and effective vaccine in September 2020 that situation will improve but while the vaccine will be effective I don't think they'll have proven safety by September 2020. There just isn't enough time to prove that and I expect stocks will be limited so I don't think there will be enough vaccine available to vaccinate healthcare staff and the elderly. In that situation healthcare staff should be prioritised as the best protection for the elderly then will be that the healthcare staff can't transmit it to them.

So, where are we. Pretty much on track for the reasonable best case scenario. The two things which will most impact this are:
1. Positively - a safer vaccine earlier. This could hugely reduce the death rate but while I think we'll have an experimental vaccine which is safe enough for high risk groups in Q4 2020 that won't solve the societal problem and I don't think we'll have the population vaccinated until Q4 2021.

2. Negatively - people being idiots once lockdown is lifted. I think this will absolutely happen. It won't be long before people are agitating to be able to go to pubs, soccer matches and to take advantage of all the cheap holidays in Spain, Croatia etc. If people behave in this way then we'll suffer significantly more dead and I think it would bump us up to the Pessimistic Best Case Scenario which would be 20,000 dead in the year to March 2021 and approximately 26,000 dead to September 2021.

I think though that the most likely outcome is somewhere between the two as people won't maintain social distancing and the government will find itself having to dial up and down restrictions at it seeks to balance economic activity with death rate.

So, if I had to bet money I'd say that from 1st March 2020 to 1st March 2021 we're probably looking at 15,000 dead, just splitting the difference, and with roughly 19,500 dead by the end of September 2021.

To put it into perspective we would normally have about 31,000 dead in a 12 month period so that 15,000 would mean 46,000 dead in the 12 month period which is a roughly 50% spike in deaths. That is very significant.

Are we lifting restrictions too soon? Yes, I think so but as I've said from the beginning, the lifting of restrictions will be based on a balancing of death rate and economic and social needs. Given the economic and social backlash the government's hand has been forced. As a society we can't blame the government for this, it is our fault.

@Barrymanilow,
It is certainly possible but it could have been a number of other things also. I think you're in the same boat as myself... We may have had it but we have to assume we didn't have it and should maintain all the precautions until a NEUTRALISING ANTIBODY TITRE test is available. At that point in time we can begin making informed decisions about whether or not we had it AND have some level of immunity.

After all I'm sure you don't care whether you had it or not if it gives you no immunity. You want to know whether you had it AND are now immune. A neutralising antibody titre should answer that. A binding antibody titre won't.

PMBC wrote: »

I see from one of your replies you expected the deaths to peak between 40 and 60 which looks to be what happened.

Where do you think Ireland's numbers are now heading and I appreciate that there are a lot of unknowns and variables?

Also, without being over critical of the decision makers, what mistakes were made regarding treatment of the nursing and care home sectors?

My own opinion is that mistakes have been made but decisions were made with the best of intentions

Thanks for the time you have taken and the information you have given here and wishing you well.

I've answered above. Basically we missed out on closing our borders and ramping up testing and tracing very early on. That meant that we missed the opportunity to be like New Zealand. That would have led to the Optimistic Best Case Scenario of maybe 2,000 dead in a year with less than 200 dead up until May.

By the time we entered lockdown etc we had enough spread within the population that it was highly unlikely we would eradicate this without a very long lockdown. We are now exiting lockdown far too early to have eradication, instead we're entering lockdown because of economic and social pressures and are accepting a certain death toll in order to do that. Hence why I think we would have 10K dead to March next year. The problem is I don't think the public will be sensible and so we will get peaks and then troughs as restrictions are ratcheted up again and we'll go through that cycle a few times over the next year. This will yield about 15K dead by March next year IMO - barring a much more successful treatment/vaccine - and about 19.5K by September 2021 when I expect us to have enough safe vaccine to conduct mass vaccinations at a national level.

Unfortunately it has become clear to me from seeing people out and about that people simply won't socially distance sufficiently when restrictions are lifted and so we will get significant spread again.

With respect to the nursing home and care sectors... Well, I think the original error was in not closing things down in late February/early March. If we'd done that we'd have had fewer deaths and could open everything up much more rapidly now. As it is by the time we started locking things down everyone was gearing up for a tsunami in the hospitals and it was right to focus on that since if that had happened we could have had many thousands of dead by the end of May.

There weren't enough resources to do everything and so, correctly, the nursing homes weren't prioritised, the hospitals were. To be honest we're all a bit surprised how well the lockdown worked and while things were close over the Easter Weekend we got through it without being swamped and have been pretty fine, overall, in the hospitals ever since.

You could argue that after that attention should have shifted to nursing homes more rapidly but I think that's a 20/20 hindsight argument to make.

So, I don't buy into the blame of the government for the nursing home situation. Nursing homes were always going to be hit hard and once the government didn't shut things down when they could have in late February/early March we missed the opportunity to have a New Zealand-like outcome. Right now my rule of thumb is that before this is over we'll lose 1/3rd of the current nursing home population of roughly 26,000 over the next year. So that's about 8,000 to 9,000 dead in the nursing homes absent a safeish vaccine in Q4 2020. I simply don't see how we are going to avoid that and no amount of switching resources a week or two earlier in April would have avoided that. We missed our chance to avoid that in late February/early March. That's the original, costly mistake.

The next really costly mistake will be allowing visitors into nursing homes again. If I were in charge we wouldn't allow any visitors into nursing homes for the next year but, again, people won't tolerate that so they'll all go in and visit and a few weeks to months later 1/3rd of the residents there will die because of it.

The crazy thing with SARS-CoV2 is that a 50% increase in year on year mortality is still a great outcome. Even if you assume complete immunity once infected and a 0.78% case fatality rate and 70% infections over the next year that yields 38 million dead. We won't get anywhere near that because of the actions we've taken. Sure we'll definitely lose a few million to it but I doubt we'll exceed 10 million dead worldwide before Q4 2021 even though I suspect we've already exceeded 500,000 dead (measured by excess mortality) by now rather than 250,000 as measured by officially. 10 million dead while an awful lot is significantly less than we were looking at just 2 months ago. And to be clear I'm certain the official toll won't be 10 million, it probably won't exceed 5 million but you have to bear in mind that in many African countries there isn't even a reliable central register of deaths so that in those countries they'll do well to record 25% of the COVID-related deaths officially.

So, overall, as a planet we've done really well. As a country we've done very well also but we definitely missed the opportunity to have a great outcome ( medically and economically ) in later February. I think the nursing home stuff has been blown out of all proportion given the nature of the crisis and the fact that once it gets into a nursing home you can expect to lose up to 1/3rd of the residents in short order and that it getting in is almost inevitable when you extrapolate this out for another 16 months before a vaccine becomes readily available.

But a lot of people don't want to hear logic and reality. This crisis has shown that. They just want to hear things which support what they want to happen, not what the reality is.

Pseudonym121

JoChervil,

With all due respect debating vaccines with someone who thinks injections are given “into the skin” rather than through it into deeper structures is rather pointless. You opine about complicated things without understanding the very basics. In addition while I respect your right to do whatever you want to yourself I don’t intend to respond further to your posts as I don’t want the Questions or Answers thread to become a haven for quackery which could harm people at this time.

As to others:
Yeah I did rather avoid this because I didn’t want to get drawn into a quackery vs science debate where you end up having to give parity of esteem to things which have no basis in our understanding of physiology and biochemistry beyond that appended by wishful and magical thinking.

I didn’t want to post because I didn’t want to have to deal with these sorts of posts and I had taken the policy of trying to answer anything. In the end I’m squaring this circle by just not responding to JoChervil again - which I’m sure will be misrepresented. Essentially cupping isn’t a treatment for COVID and debating it here isn’t the purpose of the thread. I support him/her discussing cupping wherever else they wish.

Saturnfalls,
Well, “under control” is a wide-ranging statement. It is under control now but most of us expect it to roar back in winter time, especially with America, India, South Africa and Brazil largely losing containment in recent weeks.

But basically my plan is to treat this as though it is still prevalent until Q1 2021. No-one knows for certain if it will have a resurgence in Q4 2020 but the cautious approach is to plan that it will and so I amn’t planning anything involving travel or large gatherings until 2021, and that includes moving home.

As I’ve said before I expect to be have the option of being vaccinated in Q4 2020 and will do so and so come Q1 2021 I’ll have a window of about 3 to 6 months to meet family and friends without putting them at risk and to move. I intend to use that window.

It might be longer but I won’t bet on it. I think things will get back to pretty much normal for everyone with a vaccine throughout 2021 but even then COVID will be a significant issue for years to come. It is a good lesson to us not to be so cavalier with the planet, it is far more powerful than us and bites back occasionally.

Re: mask sanitation... I’d recommend a UV light sanitiser. Heat could break down the plastic microfibres which create the protection/filtration in a mask and I don’t know how Milton could react with masks but figure it could damage them too. This is one of the reasons I bought a UV light steriliser back when I saw this coming.

I have multiple re-usable masks (N99, N95 and surgical types ) and sterilise them after each use without any trouble.

Locohobo,
We still aren’t sure about why some things seem to protect people so the answer is who knows? We are still learning so much about this.

Padser,

Where are we now?
Well, you have to bear in mind that we’ve just gotten through the first 3 months of this. We probably have another 18 months to go before we are largely out of the woods - through having a vaccine which provides some level of immunity to infection/reduction in severity of infection.

The same goes for other countries. You can see that America is going to lose control of its COVID numbers, Brazil is seeing rapid spread and South Africa and India are seeing significant rates of increase of numbers after initially baffling us as to why it wasn’t running rampant there. China is also experiencing another significant outbreak that hopefully they’ll be able to contain.

So, until we get a vaccine, once travel is re-instituted without mandatory quarantine we should expect to see countries re-infecting each other and multiple waves of infection, especially in non-island countries.

Our current pathway to restrictions... I support the easing of restrictions because it is inevitable. People won’t tolerate those restrictions. Way back I stated we would have between 1500 and 2,000 deaths by the end of May. We did so, thankfully on the lower end of that. I also said that as we opened up we’d likely see 10 to 20 deaths per day being tolerated by society. I see no reason to change that number. We will open up and accept an increase in infection and death rate.

If we have good track and trace and can institute local measures ( closing a factory for two weeks if there is an outbreak there etc ) then we will do fine. If we don’t we run the risk of it circulating freely in the community with a much higher death rate and the need for more aggressive and wide-ranging lockdowns.

But, basically, I think we will see a low level of deaths each day for the next 18 months with, potentially, a large peak in winter time. A lot now depends on luck ( will we get a winter peak ), the vaccine ( just how quickly is a working vaccine approved, how quickly can production be ramped up ( they’re already producing potential vaccines so whichever ones work will have supply ) and whether or not we find a treatment which can prevent the disease progressing to its severe presentation. I’m confident we will find useful treatments and a vaccine ( although less confident that it will provide meaningful protection beyond 6 months to possible a year ) but I don’t think we will avoid a winter resurgence.

Any promising therapies? Yes, quite a few but most of them are about keeping people who are severely ill alive to recover rather than being able to prevent them progressing to that stage. It is early days yet. Very early on I said that falling ill with this in April and falling ill with it in September would yield very different likelihood’s of survival. I stand by that. Even if you are going to get it the longer you can put that off the greater your chance of surviving as we get better at treating it and more prepared to do so.

What about treatment for non-COVID issues. Yes, we need to get back to that. It won’t be treatment as normal as capacities will be down and investment will be required. Costs will also escalate as improvements in ventilation and cleaning will be absolutely essential and restrictions will be put in place on how many patients can be passed through a single room in a day ( in out-patient’s etc ).

But yeah, we have to get back to normal... If you read some of my early posts I argued for a focus on “excess mortality” rather than deaths from COVID because I knew that the true impact of COVID would be both those who died from it and those who died from other things because services were curtailed.

We can expect a major increase in waiting lists, significant capital expenditure to bring existing buildings up to the spec necessary to be safe for COVID, significant costs on COVID testing and cleaning and also changes in the structure of services. Hospitals will not return to the way they were before, they will transition trying to provide the same services in new ways consistent with the new reality of COVID circulating in the community. I think we’ll also see a strain on services from COVID survivors who have lost significant lung and renal function as well as suffering significant strokes and that’ll be an added burden on the state and waiting lists for non-COVID cases.

I think psychiatry is going to see a massive increase in numbers after Winter. People generally can survive the first shock fairly well but it is follow-on shocks that cause them to shatter. Some have shattered already but if Winter is bad then I expect there will be a large increase in mental health problems with spikes in suicides, PTSD, anxiety disorders etc - including in those under 18.

Over the next year I think people who frequent OPDs and hospitals will see huge change, very little of which is appreciated outside of those working on these issues within the health service.

I’ll try to check in more regularly now that I’ve decided to break the “I’ll try to answer everything” policy I’d set for myself.

Bottom line though the lockdown worked very well, better even than I had expected but this was the first wave of a few over the 2 years that we can expect this to be a pressing issue for the country. The nation will survive, it isn’t the apocalypse but I don’t think people understand just how long-term and impactful this is going to be.

august12

Boards.ie: Niamh wrote: »

Answers from our AMA guest to questions asked in the Questions thread.

Please only post your questions in the dedicated thread here.

Any update from our HSE Consultant?

Boards.ie: Niamh

He has assured me he will get back to the thread in his own time which is why I have left it open this long.

Let's leave this thread for his answers only now

thegetawaycar

Boards.ie: Niamh wrote: »

He has assured me he will get back to the thread in his own time which is why I have left it open this long.

Let's leave this thread for his answers only now

7 and a half months after the last post from our AMA guest it might be time to close this, I check regularly for any update but it seems safe to say that the thread is dead.

Chuck Noland

Be great to get an insight should the poster be able to return