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

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.

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.

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.

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/

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.

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.

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.

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.

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.

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.

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 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.