## Consequences of actions

I have read an interesting and challenging post by Robin Phillips who asks two very important questions:

(1) How will the coronavirus eventually end? (2) Is it possible that the damage caused by the containment measures and shutdowns could end up doing more harm than the virus itself?

so here is my personal perspective on these two challenges, particularly as both involve the type of mathematical modelling I am very interested in.

The questions are challenging because they involve predicting the future in which our current actions in reaction to these predictions change the course of action. They also involve our limited understanding of how very complex epidemiological, economic, social and psychological systems work.

We now have a reasonably good understanding of how fast the virus spreads which makes short term predictions possible – assuming the way it all works does not change. As for long-term predictions, they are notoriously difficult to make.

There is a worst-case scenario which assumes that everybody or nearly everybody will become infected leading to massive casualties. This is based on the current estimates of the rate of spread plus realisation that what we see as reported cases is a tip of an iceberg – in other words, that there are actually many individuals who spread the disease but somehow escape the attention of the health authorities – perhaps because they have very mild symptoms. This is known as under-reporting and judging from other outbreaks (going back to measles in 1960s) can be as high as 90% (i.e. we only see 10% of cases). This case is worrying because it means we are already past the stage when we can actually do something to stop the disease from spreading and so the only thing we can do is to flatten the epidemic curve i.e. to slow down the spread so that the health system is not overwhelmed.

There is another factor that worries the authorities, that the virus might become endemic. This means that we will never be able to eradicate it completely and so it will keep coming back in the years to come. I do not know exactly the thinking behind what emerges as the UK strategy centred on reaching herd immunity, but I suspect it is the combination of three factors: (i) the conviction that we are past the point when we can stop the disease, (ii) the assumption it will keep coming back, and (iii) the estimation that costs of a massive lock-down are immense and the outcome uncertain.

I am personally not fully convinced about these assumptions. As for (i), China and South Korea examples show that it is possible to stop the disease from spreading. The implementation of various control measures, some very drastic, reduces the rate at which infection spreads and leads to local eradication of the disease. This is becoming known as the continental strategy as it has been implemented by Italy and most other EU countries.

I am even more suspicious about (ii). This is a very infectious virus with a high rate of spread and so is likely to go through the population quickly and to burn-out. Evidence from past epidemics (like measles or flu) and modelling suggests that for such virus to persist it would require a massive population well exceeding the size of the world (what we call critical population size). The closest analogy is flu, but it is a flawed analogy as each year flu comes and goes and disappears, but what comes back next year is a genetically different virus (so really, a new epidemic); thus, technically speaking flu does not persist in humans.

The only possible explanation supporting point (ii) is that unlike flu, the coronavirus might not make people immune. I do not know the current state of knowledge in this area, so it is possible that the UK government scientists know something I do not.

As for (iii), it is really a matter for the governments – and people – to decide what is the balance of costs and benefits. Science can only assist by presenting different scenarios and estimating – very broadly – the costs and benefits of each strategy. I suspect that the governments in the continental Europe countries feel the EU will help financially if needed (as it already does) and the UK government feels that it cannot afford to spend billions on helping the businesses to survive the lock-down. But, it is only my own opinion.

I believe there is actually an even worse scenario in which the governments go part-way, so impose a partial lock-down which causes massive (but not extreme) economic losses but fails to stop the epidemic. Something like this was apparently happening in the late stages of the 2001 foot-and-mouth epidemic which resulted in huge losses and a very long tail of cases, as seen below in figures (c) and (d) (another example of whack-a-mole strategy) [from Science  26 Oct 2001:Vol. 294, Issue 5543, pp. 813-817; DOI: 10.1126/science.1065973 ]:

I think the next couple of weeks will tell which strategy works (or whether both fail) and what is the future of the coronavirus outbreak. As an epidemiological modeller, I find the emergence of the two control strategies fascinating (see my earlier posts), but as a human being taking immuno-suppressing drugs and hence at high risk from coronavirus, I find it a bit disturbing.

Finally, Robin asks about the long-term political outcomes. A slightly cynical view is that, actually, not much will have changed. There is a possibility that this will strengthen the shift towards more concentration in power for the governments. Judging from the long-term consequences of the 2008 crisis, the economic and social effects of the lock-down will be harsh, but again, it is too early to say which direction this will all go.

However, there is one often overlooked aspect. Hopefully, the outbreak and the lock-down will actually result in us feeling more responsibility towards other people, to suffer gladly inconvenience because we actually care to protect those at risk, to go out and help the elderly with shopping, to share toilet paper rolls with those who are unable to go out and shop, to become more united as families, neighbourhoods, and countries. Perhaps in years to come, we will see it as a positive thing.

As usual, if you have comments, please send them to me at info@statisticallyinsignificant.uk

## Some interesting links

A couple of interesting links on COVID-2019.

Up to date maps and number of cases (updated daily):

https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

A very good article on herd immunity, so related to my yesterday post:

https://theconversation.com/coronavirus-can-herd-immunity-really-protect-us-133583

As usual, if you have comments, please send them to me at info@statisticallyinsignificant.uk

## Coronavirus: when and how to act

There is now a lot of discussion on when and how governments should act to stop the coronavirus from spreading further and causing more damage. These discussions and arguments will continue for a long time, even well after the epidemic finishes and we know the results of the actions.

The problem of which strategy to choose is actually not a trivial one. The decisions are taken under very limited knowledge of how fast the disease spreads, how many infectious but non-symptomatic individuals already are in the country and what the economic and social effects of both the disease and the actions to control them will be.

Fortunately, there are some lessons we can draw from previous epidemics, not only human viruses, but also animal and plant epidemics.

If we were simply looking to control the infection without counting economic and social costs, arguably the best strategy would be to clamp on the spread as quickly as we can, to lock down the whole world and stop any long-distance travel for as long as the infectious period is. If a vaccine was available, we could have relaxed some of the regulations and instead introduced a mass vaccination policy. The measures would be tough, the costs horrendous, but the whole thing probably quickly over. The Netherlands followed this course in 2001 when faced with a spill-over of an animal foot-and-mouth disease from the UK. This was in contrast with the UK which in the first stages of the epidemic allowed the animals to be moved around, took a long time to act, and then implemented a very harsh strategy of preventive killing resulting in millions of healthy animals to be culled.

The big problem with the very quick ‘lock-down and smash’ approach is that at the start of the epidemic we actually know very little about it. As the governments by their nature are cautious and tend to sweep bad news under the carpet, they are not likely to react to a small outbreak of what looks like another flu. The reaction only comes later when the number of notified cases goes up, some people die, and others actually start making a fuss. By which time it is already too late.

To understand why, we need to look a bit at how diseases like coronavirus spread. It all starts with ‘patient zero’ (or several ‘patients zero’) who somehow drew a short straw in a mixing bowl of animal and human viruses (most recent human diseases have animal origins or, as we call them, ‘zoonotic’). There could be several such events, most of which would not spread further, as the ‘patient zero’ recovers or dies without the new disease being recognised. As this often happens in places with limited health services, such animal-human transmissions often go unnoticed.

Such a phase, called ‘stuttering’, can actually last a long time, resulting in a number of cases which die or recover without causing a large outbreak. It is only when we start seeing significant ‘human-to-human transmission’, things become problematic.

Thus, once in a while one of the ‘patients zero’ will infect a few other patients and start the avalanche. At the start, it is usually local, so limited to a family, a village or a region. It is also still relatively easy to stop, but nobody knows about it or realises the potential to spread.

MERS (Middle-East Respiratory Syndrome) is a good example of a virus that never actually made it; it is causing problems, people become ill and some die, but it does not spread very fast between people and hence is (still) quite localised.

There is another ‘ace in the sleeve’ that viruses use to spread. A person who contracts the infection usually does not notice this until the first symptoms appear. But even then, if the symptoms are relatively mild, we might go about not noticing anything unusual. Have you ever gone to work or school or shop or cinema not feeling very well, with a bit of a cough and maybe a running nose? The author actually sat an important exam while showing the first symptoms of chickenpox, including a very high fever. I am not sure about the quality of my answers (it was an oral exam in philosophy and we talked about Plato and chaos theory), but I managed to pass the exam only to spend the next two weeks in bed.

The effect of this ‘pre-symptomatic’ (or as we often call ‘latent’) phase is that people can travel quite considerable distances and meet a lot of people while being highly infectious but without showing symptoms. In today’s world, flights can take the disease from one end of the world to another within hours (the shortest China to Italy flight is only 9 hours 55 minutes; we call this property a ‘small world’). So, by the time the authorities notice something is going on, there might already be quite a few ‘infectious but pre-symptomatic’ individuals on their territory.

So we end up with a ‘whack a mole’ situation in which we are trying to control something in one place, for it to reappear in another.

There are also other considerations to be taken into account, like psychological, social and economic aspects of disease control. People might start to panic which can lead to political perturbations and food and petrol shortages. The cost of closing down schools can be huge as people will need to stay off work to look after children. Closing down restaurants and music halls can bankrupt owners and musicians. In addition, not knowing exactly how fast the disease spreads and for how long people are infectious, means that it is not clear how long the closures need to last. At the moment we think 2 weeks is enough, but we simply are not sure. And what politician would want to be telling people after horrendous 2 weeks that they need to do it again for another 2 weeks?

There is good evidence in both modelling and controlling other diseases that the earlier and the harder we act, the more effective and hence the shorter the outbreak will be. But even more important is that the government is very clear and open with the public why the particular decision is taken and when. One of the lasting problems of the foot-and-mouth disease in the UK in 2001 was the loss of trust between the government (and mathematical modellers) and farmers. As a result, bad feelings continue even after 19 years. We can only hope that the coronavirus outbreak will not leave such problems in its wake, although there are very good indications that the world will not be the same after the 2020 outbreak.

One thing for sure, we as epidemiologists will have even more work to do…

As usual, if you have comments, please send them to me at info@statisticallyinsignificant.uk