Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com

Introduction

Last weekend involved a journey to visit family in East Yorkshire and, in particular, an elderly relative. This is one of the reasons why this blog is later and shorter than usual. We were able to do this as there is no longer a blanket ban on travelling and visiting people. It was a learning experience. It made me aware it was time to focus on some of the more vulnerable groups in our society.

Back in Norwich, the nuts are falling from the walnut tree in the garden. There will be an exceptional crop this year, enough so the squirrel has not been able to steal them all. They drive us wild by planting them around the garden, so we end up with walnut tree saplings. I don’t mind sharing, but I do object to being taken for granted so have invested in a powerful water gun!

I spent a happy hour or so shucking the green exterior off the nuts. The problem is that I was not wearing gloves, so my fingers are now stained a very dark brown. Google was not helpful. My first question: ‘how does one harvest walnuts?’, the answer ‘hit and shake the branches’. The second, ‘how to get walnut stains off your hands?’. The answer: ‘Wash your hands thoroughly, using a good quality soap and warm water. Apply lemon juice. Follow up with a round of cooking oil. Wash up.’ Well… not really! Gloves are going to be needed in the future!

The Numbers

There have been 25,761,430 Covid-19 cases globally. The peak was on 14th August with 304,449 new cases and the global curve appears to have flattened, with a possible downward trend. This will become clearer over the next two weeks. The key question will be what happens in the northern hemisphere in the impending winter months! The USA accounts for about a quarter of cases, at just under 6 million. Next are Brazil, India, Russia, Peru, South Africa, Columbia, Mexico, Spain, Argentina, Chile, Iran, and the UK. Table 1 shows selected countries by number of cases.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order every 2 weeks)^{1, 2, 3}

Date	Global cases	Brazil	Chile∞	India∞	Mexico∞	Peru∞	Russia	South Africa	UK	USA
15 Feb	69,000	0					2	0	9	43
4 Mar	93,000	4					3	0	86	149
18 Mar	201,500	372					147	116	2,600	7,800
1 Apr	861,000	6,836					2,777	1,400	29,900	213,400
15 Apr	1,982,552	28,280					24,490	2,415	94,845	609,422
29 Apr	3,117,756	79,685					93,399	4,996	162,350	1,012,583
13 May	4,262,799	180,000*					232,243	11,350	227,741	1,369,964
27 May	5,594,175	291,222					362,342	24,264	241,408β	1,681,418
10 Jun	7,250,909	739,503					493,023	52,991	262,098	1,979,893
24 Jun	9,264,569	1,145,906	264,689	456,183	196,847	264,689	598,878	106,108	277,200	2,347,022
8 Jul	11,830,885	1,668,539	312,911	742,417	261,750	312,911	693,215	215,885	286,979	2,996,098
29 Jul	16,741,049	2,483,191	349,800	1,531,669	402,697	395,005	827,509	459,761	302,295	4,352,083
17 Aug	22,145,643	3,407,354	388,855	2,767,253	531,239	549,321	930,276	592,144	322,177	5,482,602
26 Aug	23,901,014	3,669,995	400,985	3,234,474	568,621	600,438	963,655	613,017	329,822	5,779,028
3 Sep	25,761,430	3,950,931	413,145	3,769,523	606,036	657,129	997,972	628,259	339,415	6,075,652

As well as absolute numbers we need to look at rates. Belgium has the highest rate 865 deaths per million. The UK is second. The US leads the number of cases per million. The daily death toll has fallen significantly. While South Africa may be fifth in cumulative cases, by the measure of deaths per million people it is ranked 31st – ‘so nowhere near the podium’.⁴

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)⁵

	Belgium	France	Italy	Russia	South Korea	South Africa	Spain	UK	USA
Deaths (19 May)		421.07	529.64	18.84	5.13	5.26	593.04*	523.33	275.8
Total cases (20 May)		2,189	3,736	1,991	216	277	4,953	3,629	4,557
Deaths (3 June)		429.83	533.93	33.56	5.27	13.35	580.58	587.24	320.93
Total cases (2 or 3 June)		2,320	3,856	2,905	225	579	5,125	4,070	5,472
Deaths (17 June)		438.73	568.76	49.01	5.38	27.14	580.78	627.71	354.46
Total cases (16 or 17 June)		2,410	3,924	3,681	237	1,239	5,221	4,372	6,386
Deaths (1 July)		444	574	63	5	43	606	655	385
Total cases (30 June or 1 July)		2,516	3,976	4,393	249	2,432	5,140	4,595	7,826
Deaths (8 July)		444	575	64	5	46	606	657	388
Total cases (7 or 8 July)		2,759*	3,999	4,713	257	3,317	5,400	4,209	8,877
Deaths (22 July)		449	581	93	5.7	122	608	688	451
Total cases (21 July)		2,804	4,073	5,606	277	7,630	5,693	4,420	12,961
Deaths (12 August)		451	582	104	5.9	186	611	699	501
Total cases (13 August)		3,127	4,155	6,150	287	9,545	7,214	4,607	15,532
Deaths (26 August)	865	453	586	113	6	227	617	623	540
Total cases (25 August)	7,075	3,751	4,305	6,588	350	10,309	8,257	4,811	17,344
Deaths (2 September)	866	455	587	118	6	244	622	624	559
Total cases (1 September)	7,346	4,305	4,452	6,820	393	10,572	°	4,947	18,220

*misread these data °data missing

Special Groups

The Elderly

The data show that older people are more likely to experience symptomatic Covid-19 infection, fall ill and die. Men are at a greater risk than women,

“older men are up to twice as likely to become severely sick and to die as women of the same age. Why? The first study to look at immune response to the coronavirus by sex has turned up a clue: Men produce a weaker immune response to the virus than do women, the researchers concluded.”

This means, according a paper in Nature,⁷ the treatment of males and females should be different, and it has implications for the development and administration of vaccines. “Men, particularly those over age 60, may need to depend more on vaccines to protect against the infection,” as their immune responses are weaker than those of women of the same age.⁸

Apart from the risk of infection, illness and possibly death we are learning that this pandemic has caused extensive collateral damage particularly for the elderly and the young. Currently there is a push in England to get children back to school. The message is that being out of education is very damaging, not only are children missing out on schooling, but they are isolated and face psychological problems. The poorest children, it is suggested, may never properly catch up.

There are major problems at the other end of the age spectrum for the elderly. On the 21st March the English government released guidance for people at the highest risk of contracting the virus. This group was the

“1.5 million people in England (who) currently live with conditions, or are taking medication or receiving treatment, which health experts have identified puts them at a much greater risk of developing serious complications if they get the virus.”⁹

Specific groups included organ transplant recipients, those with severe respiratory conditions and specific cancers and patients receiving certain drug treatments. It should be noted that the elderly were not specifically included as a ‘blanket’ group although there are detailed guidelines for care homes.

The three relevant statements in the guidance were:

• ‘People identified as belonging to one or more of the at-risk groups will be contacted by their GP practice, specialist or both strongly advising them to stay at home for a period of at least 12 weeks’.
• Dr Paul Johnstone, Director at Public Health England, said: ‘The NHS are contacting the people who are most vulnerable to developing a very serious illness as a result of COVID-19 with specific advice to stay at home for at least 12 weeks’; and
• Do not leave your house for at least 12 weeks starting on Monday 22 March.

It went on:

‘Do not attend any gatherings. … Do not go out for shopping, leisure or travel and, when arranging food or medication deliveries, these should be left at the door … Keep in touch using remote technology such as phone, internet, and social media’.¹⁰

I was confused by this. Thank heavens for “Full Fact”, the UK’s independent fact checking charity.¹¹ They have waded through the masses of contradictory advice and, in June, explained shielding.¹² The government identified

‘two levels of higher risk—the “clinically vulnerable” which includes, amongst others, all over 70s, and the “clinically extremely vulnerable” people with certain conditions (see above) who were contacted by the NHS.’

The clinically extremely vulnerable group were told to shield, the clinically vulnerable group were not. The difference between the groups was not well communicated.

The latest advice (August) from Public Health England is people who are clinically extremely vulnerable and who were advised to shield,

‘do not need to shield at the moment. … because the rates of transmission … in the community have fallen significantly. There is specific guidance on what will happen if there is a local lockdown in your area. This guidance is government advice and it’s your personal choice whether to follow it. … guidance for the clinically extremely vulnerable is that shielding has been paused. … you do not need to follow previous shielding advice; you can go to work (if) the workplace is Covid-secure, but should carry on working from home wherever possible; clinically extremely vulnerable children should attend education settings in line with … guidance … ; you can go outside (but) … try to keep your overall social interactions low; you can visit businesses, … while keeping 2 metres away from others … or 1 metre, plus other precautions; … continue to wash your hands carefully and; … you will no longer receive free food parcels, medicine deliveries and basic care from the National Shielding Service.”¹³

What does this pandemic mean for the elderly? The answer, sadly, is that we don’t really know yet, the full impact will take time to become apparent. I will talk, without citation, about what I have seen and think.

The first consequence was increased isolation. Events, support groups and gatherings were cancelled, the elderly were advised to remain indoors and avoid all contact with others. They could no longer have visitors other than carers, and the carers wore full protective personal equipment (PPE). This combined with the 24/7, somewhat hysterical, coronavirus coverage on television, increased fear, and anxiety. This has resulted in an acceleration of dementia for some.

Globally, care homes bore the brunt of the first wave of the epidemic. Indeed, the cruise ship Diamond Princess, with its major epidemic in February could be regarded as a floating old age/care home, although this is not how the operators would see it. Of the passengers 58% were over 60 and 33% over 70.¹⁴ In the USA the ‘Nursing home residents were among the first known cases of Covid-19 in the US. In mid-February in suburban Kirkland, Washington, 80 of 130 residents in one facility were sickened by an unknown respiratory illness, later identified as Covid-19’.¹⁵ The appalling situation in Canada, especially Quebec, has been documented in previous issues of this communique.¹⁶ In the UK, care homes were initially excluded from the data.

Practically if you want to organise care for a loved one, the first step is to find a suitable home. This is problematic as you are unable to visit, see the homes, or even talk to the residents. There are few facilities with websites, some may have Facebook pages. In England you only have the full range of choices if you can afford to pay the fees for the home, and if you do not the local council places the individual. If the person has assets exceeding £23,250 (and this includes their property) they are expected to be self-funding. What does it cost? There is some variation, but it seems that between £600 to £1200 per week is a ballpark. This will depend on the needs of the prospective resident and the activities organised for them (there are very few activities in the time of coronavirus).

To be admitted the applicant needs to have a clear Covid-19 test, from no less than four days previously. They are placed in quarantine for a week on admission. Most homes allow residents no more than one visit, by one person, for 15 minutes per day. Both the resident and visitor must wear PPE and maintain the requisite social distance. There is the possibility of prearranged Skype and other social media calls, but usually staff will have to be involved to manage the technology. The government has guidelines, and these are available on the web and are updated.¹⁷ Leaving a loved one in care is a bit like leaving a child at boarding school, but without the prospect – at the moment – of exeat weekends or indeed any time out. This pandemic has shown differential vulnerability but also how poor we are at caring for the elderly.

Travellers

Last week I talked about how hard it would be to get people travelling again. The English government keeps changing the list of countries from which travellers must self-isolate. The Financial Times notes

“The criteria used in assessing whether travellers returning to Britain should self-isolate have not been published, but government officials say a number of tests are applied. As well as considering rates of infections and deaths, scientists look at the rate of acceleration of cases, the quality of monitoring and the measures in place in each country.”¹⁸

The Telegraph warns that England could remove Greece from its quarantine-exempt list whilst Scotland and Wales have imposed new restriction. Scotland required all holidaymakers from Greece to enter self-isolation for 14 days as of 4am on 3rd September. Wales applied the rule but only to arrivals from the island of Zante.

This may be a way forward – travellers from specific holiday destinations isolating rather than the whole country. The Telegraph notes:

‘In terms of overall infections, however, Greece remains below England’s threshold of 20 cases per 100,000 people over seven days, the metric it uses to keep a country off the ‘red list’. Greece’s number yesterday stood at 14. The Department for Transport stated last night: “The JBC [Joint Biosecurity Centre] has not changed the risk rating for Greece and we won’t be removing it for now.” Portugal, on the other hand, now looks likely to gain red status, only two weeks after the mandatory quarantine was dropped, with a rate of 22.5 as of yesterday’.¹⁹

I have not been able to find the ‘specific criteria’ anywhere on government websites.

Conclusion

Every aspect of life is being affected. Elderly people are vulnerable and isolated and it must be deeply depressing to not see loved ones. The young need to be in school and their parents, for the most part, want to be back at work. There is a realisation that we are social animals and actually going to work and mixing with others is important.

New rules of engagement need to be developed, and they will have to recognise the existence of some risk. The decisions made early in the epidemic made sense, but now they need to be revisited and revised. Everyone makes decisions about what risks and trade-offs they will accept. When I get on my bicycle there is a chance I will fall off or be hit by a vehicle, as a result I wear a helmet (something I scoffed at for years) and try to stick to cycle trails and quiet roads. I will carry on cycling despite the risks.

Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: awhiteside@balsillieschool.ca

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1. These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html
2. The UK data from 27th May is taken from Worldometers.info.coronavirus/country/uk
3. *estimate ∞ these countries were added, early data is not included. β Data for the UK from Worldometer
4. https://www.groundup.org.za/article/how-well-has-south-africa-done-reducing-covid-deaths/
5. Deaths http://www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/
   Case per million ourworldindata.org/grapher/total-confirmed-cases-of-covid-19-per-million-people
6. https://www.nytimes.com/2020/08/26/health/coronavirus-men-immune.html
7. Takahashi, T., Ellingson, M.K., Wong, P. et al. Sex differences in immune responses that underlie COVID-19 disease outcomes. Nature (2020). https://doi.org/10.1038/s41586-020-2700-3
8. ibid
9. https://www.gov.uk/government/news/major-new-measures-to-protect-people-at-highest-risk-from-coronavirus 21st March 2020
10. Ibid.
11. https://fullfact.org/about/
12. https://fullfact.org/health/coronavirus-shielding-social-distancing/
13. https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 update 18th August 2020
14. https://cmmid.github.io/topics/covid19/diamond_cruise_cfr_estimates.html
15. https://www.theguardian.com/us-news/2020/may/11/nursing-homes-us-data-coronavirus
16. Covid-19 Watch: The Epidemic Curve starts to change 15th April 2020, https://alan-whiteside.com/2020/04/15/covid-19-watch-the-epidemic-curve-starts-to-change/
17. https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes/coronavirus-covid-19-admission-and-care-of-people-in-care-homes
18. UK quarantine measures: where are the Covid hotspots?, The Financial Times 7th August 2020 https://www.ft.com/content/9bcb0a65-0cc3-4b35-a9b7-c5199576a981
19. The Telegraph, Travel news: Greece holidays at risk as Portugal heads for the ‘red list, 2nd September 2020 http://www.telegraph.co.uk/news/2020/09/02/travel-news-greece-scotland-portugal-quarantine-list-latest/