🤡@COVID19Up: Since COVID-19 broke out in 2020, radical non-pharmaceutical interventions (NPIs) have been used in many countries to supposedly limit transmission. These were undertaken quickly and in a panic after scenes of overwhelmed Italian hospitals scared governments.
Whilst over reaction could be somewhat excused in this phase, the measures were not stopped even when it became apparent that the risk profile of the disease is highly stratified by age. This means the majority of the population was at low risk of mortality. An immediate shift to protection of the vulnerable was clearly warranted. This never happened. 18 months have passed and some form of lockdown measures remain the preferred method in many places. Why?
It’s because this is now very much a politically driven phenomenon. Policy is not being driven by evidence. Governments are trapped and find it difficult to reverse out of the policies without admitting that the measures were not needed. Unfortunately public health officials and some high profile scientists are fuelling this narrative without thought to the consequences. In this regard it is worth reading Martin Kulldorffs’ Twelve Forgotten Principles of Public Health and ask how many of these principles have been violated.
Below, in no particular order, are six facts that now appear quite clear yet continued to be ignored in forming policy.
1. Lockdowns Have Serious Costs
Widespread and draconian NPIs are sometimes treated as if they have few side effects. There is now much evidence that these NPIs have little effect on disease outcome except possibly to delay it somewhat (the ‘flattening the curve’ conception, now virtually forgotten). After a short time the measures begin to become very costly to many groups in society, though critically less so for some.
It is for this reason that such things have never been recommended to deal with such a pandemic. Previous reviews 1, 2 of NPIs do not make any mention of societal wide lockdowns as a means to control the spread of influenza or other respiratory infections. A more recent review 3 by Ioannidis found no evidence of an effect on cases growth of NPIs like stay-at-home orders.
Some of the most obvious negative effects of NPIs include:
- delays to cancer treatment
- missed or delayed cancer diagnoses
- lack of access to, or unwillingness to seek, medical treatment
- loss of employment
- missed education and impaired childhood development
These are all quantifiable but some will not become apparent for several years.
There will undoubtedly be much hand wringing over such things later on.
2. Lockdowns in Low Income Countries Are a Disaster
Despite NPI measures not having been proven effective even in Europe, they have been copied almost wholesale in many African countries. This is despite their very different economic resources and population age profiles.
A study by two professors at the Karolinska Instituet, have used data from UNICEF and UNAIDS, and come to the conclusion that least as many people have died as a result of the restrictions as have died of COVID-19 directly. Lockdowns are a perfect excuse for authorities to exert unwarranted control over the population.
In Zimbabwe for example, the measures were cynically used to curtail the right to protest throughout 2020 to silence journalists and opposition politicians. The state of the country’s economy has already caused misery for a generation. Now many children have not gone to school for over a year with no possibility of even online learning. The government can simply state they are following WHO guidelines in response to criticism.
In India excess all cause mortality has increased by an astonishing 4.2 million according to a recent report by the Center for Global Development, as reported here. When the government imposed lockdowns in 2020, millions of migrant workers in India’s cities were thrown out of work and essentially left destitute. Restricted access to clinics left hundreds of thousands of tuberculosis, HIV, cancer and malaria patients with no treatment.
In Peru, with one of the strictest lockdowns, mortality increased by 96% over the running 3-year average. This list could go on.
In low income countries the damage done to health programs is almost incalculable. An additional 400,000 people may die from inadequate tuberculosis treatment as a consequence of these measures.
3. Pre-Existing Immunity Was Already Considerable
This has been self evident from almost the beginning because of the simple fact that most people don’t get seriously ill or even notice they have been infected. Children are hardly susceptible at all. This does not mean the pathogen is not dangerous to the elderly and to a subset of the vulnerable just as with other endemic coronaviruses and influenza. Part of the reason for this existing immunity to a relatively new virus is likely due to cross reactive immunity from exposure to the similar common coronaviruses that are already circulating.
This has now been shown in numerous studies 6 that measure T cell reactivity to virus specific antigens in unexposed controls. So SARS-Cov-2 is novel but only in a relative sense. This information was not integrated into pandemic modelling at the start (which was understandable then) but it certainly should have been since.
It also means that it is quite unlikely that a variant will arise that will completely escape this natural cell mediated immunity in the population. This was indicated in a study in Science from May 2021 7 that showed changes in the spike protein of SARS-CoV-2 variants of concern do not impact T cell reactivity. So a variant may appear that escapes humoral immunity (antibodies) but is less likely to affect T cell immunity. A brief and sensible discussion of escape variants is given here.
4. Natural Infection Provides Robust Immunity
Infection against a viral infection generally provides immunity, sometimes lifelong. The reason we aren’t forever immune to colds and flus is that they make new strains different enough to evade the memory immune response.
There have been numerous confusing and conflicting media reports on this subject in relation to COVID-19, such as this one from the Irish Times and then another in the Guardian that contradicts it. However a recent article in Nature points out that those infected will probably make antibodies against the virus for most of their lives. This is due to the ability of our body to retain memory B cells that can produce the required antibodies when needed. The study quoted found these cells present 8 months after infection. The process is complementary to the T cell immunity mentioned above.
This subject is now a factor in the strange debate over whether those previously infected need to be vaccinated. If you have had a disease you generally don’t need to be vaccinated against it.
Most recently a retrospective cohort study of the 52,238 employees of the Cleveland Clinic 4. was carried out. It is described here by Sebastian Rushworth in more detail. The outcome showed that prior infection is highly effective at protecting against COVID-19.
5. Mass Testing in a Respiratory Disease Outbreak is Counter Productive
The sensitivity of PCR testing makes it a great laboratory tool in molecular biology. The same cannot be said for it’s widespread use in community testing. The likelihood of a large percentage of positives being false increases dramatically as the specificity of the test reduces, especially in situation of low prevalence (which most countries have been in for a long time).
This is not to mention the fact the PCR positives are merely an indication of viral RNA detection. Many with positives are not symptomatic or infected. Or they may have already cleared the infection. They are not clinical cases. The positives are called ‘cases’ which is very misleading and has fed the constant panic in the media about the presence of the virus. Though less sensitive, the same is essentially true of antigen tests whose only saving grace is that they are at least quick and cheap.
Remember that we have never before mass tested for the presence of respiratory virus. The UK is still doing millions of tests per week. The result is a constant stream of test positives per day in each country that is loosely coupled to the true rate of serious infections particularly after a large vaccination campaign has been rolled out.
As corollary to this, contact tracing, which depends on testing, is largely futile. This is both because the disease is already so widespread and that testing errors substantially raise the human costs of contact tracing with little return, i.e. many cases are missed so the effect is minimal with great cost to society.
Testing has a role in certain settings, used in a targeted manner, not as a mass screen.
6. Mask Mandates Are Very Likely Useless
Despite everything we hear and see around us, no robust randomized controlled trial has yet shown masks protect from infection against a respiratory disease. The only such trial performed for COVID-19 was in Denmark 5. This is the only kind of evidence that really will give us a good answer. It found no statistically significant benefit. Other evidence is scant and it is unwise to infer causation based on regional differences in mask wearing. One can argue about mask types on a mechanistic level. Some are probably superior to others. Cloth masks, as used by most people, are particularly bad for instance.
The fact is that the virus spreads through aerosols which can easily penetrate these masks. The main effect appears to be psychological. Many people simply feel safer using them. Interestingly mask wearing in Japan was investigated in a 2013 BBC news report entitled “A Comfort Blanket?”.
Mask wearing has now become so in-grained in the community and organisations that reversing the requirements will prove hard in some quarters.
- Smith SM, Sonego S, Wallen GR, Waterer G, Cheng AC, Thompson P. Use of non-pharmaceutical interventions to reduce the transmission of influenza in adults: A systematic review. Respirology. 2015;20(6):896-903. doi:10.1111/resp.12541
- CDC. Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017, Recommendations and Reports / April 21, 2017 / 66(1);1–34
- Bendavid E, Oh C, Bhattacharya J, Ioannidis JPA. Assessing mandatory stay-at-home and business closure effects on the spread of COVID-19. Eur J Clin Invest. 2021 Apr;51(4):e13484. doi: 10.1111/eci.13484. Epub 2021 Feb 1. PMID: 33400268; PMCID: PMC7883103.
- Nabin K. Shrestha et al. Necessity of COVID-19 vaccination in previously infected individuals. Medrxiv. https://doi.org/10.1101/2021.06.01.21258176
- Henning Bundgaard et al. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers. Annals of Internal Medicine. https://doi.org/10.7326/M20-6817
- Gustavo Echeverría et al. Pre-existing T-cell immunity to SARS-CoV-2 in unexposed healthy controls in Ecuador, as detected with a COVID-19 Interferon-Gamma Release Assay, International Journal of Infectious Diseases, 2021, https://doi.org/10.1016/j.ijid.2021.02.034.
- Geers at al. SARS-CoV-2 variants of concern partially escape humoral but not T cell responses in COVID-19 convalescent donors and vaccine recipients. Science Immunology. 25 May 2021. DOI: 10.1126/sciimmunol.abj1750