Daily numbers, graphs, analysis thread 4

[Barracker]

Welcome to thread 4 of the daily updates.

Resource links:
Worldometer UK page
Financial Times Daily updates and graphs
HSJ Coronavirus updates
Johns Hopkins Coronavirus Resource Centre
NHS England stats, including breakdown by Hospital Trust
Covidly.com to filter graphs using selected data filters
ONS statistics for CV related deaths outside hospitals, released weekly each Tuesday

Thank you to all contributors for their factual, data driven, and civil discussions.

I am trying to reassure myself, 2 of my kids and 2 of their partners are frontline, 3 NHS plus 1, and all the talk of NHS staff dying is obviously worrying.

On the news this morning they said 19 NHS staff had died, how does that look statistically? I mean the NHS is a big employer so if thousands are dead do 19 NHS staff stand out?

I know it is pointless to try and rationalise it all but I can't help it.

The updates on COVID-19 in Korea as of 10 April

There can sometimes be multiple negative tests before a positive
That should not indicate people being re-infected, but the need for better testing

https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030&act=view&list_no=366806&tag=&nPage=1

KCDC is investigating the epidemiological and/or clinical characteristics
of 91 cases that have re-tested positive after being discharged from isolation.

re herd immunity - it does not look imminent and that Oxford study looks ever more optimistic

Less than 1% of Austrians infected with coronavirus, study shows

https://www.theguardian.com/world/2020/apr/10/less-than-1-of-austria-infected-with-coronavirus-new-study-shows

Re: obesity

There's a good article here www.aljazeera.com/indepth/features/doctor-note-obesity-risk-factor-coronavirus-200406065716658.html

Its introduction says:
"We already know that patients with obesity-related conditions such as cardiovascular disease are at higher risk of diabetes, which can mean a higher risk of developing complications if you catch COVID-19. But can obesity itself be a risk factor for developing complications and, if so, why?"

Its answer:
"During the influenza A (H1N1) - or swine flu - viral pandemic of 2009, studies showed that obesity was an independent risk factor for increased morbidity and mortality following infection.

Those studies found that people with a Body Mass Index (BMI) - a calculation taking into account height and weight - of 30 or above fared much worse after being infected by the flu virus than those with a "normal" BMI of 24.9 or below, with more cases of pneumonia reported in this cohort.

But is the same true for coronavirus?

A Chinese study published last month looked at 112 COVID-19 patients and their outcomes. Sadly, 17 of these patients died. Fifteen of the deceased (88 percent) were classed as being overweight or more on the BMI scale. By comparison, only 18 of the 95 survivors (19 percent) were classed as overweight or above on the BMI scale.

This study prompted experts to question what it was about obesity that might make it a risk factor when it comes to coronavirus."

Then there is the question of what problems obesity can cause:
"Obesity is defined as a disruption of energy balance that leads to weight gain and metabolic disturbances that cause tissue stress and dysfunction. This means that obesity is not just being overweight but also the adverse effect that being overweight has on your body's health.

One of these adverse effects is a disruption in a function of the immune system called the lymphoid and neutrophil line. These are cells that can tell infection from normal tissue and that need to be kept in careful balance in order to maintain a healthy immune system.

Obesity can disrupt this balance and lead to a low level of chronic inflammation of normal tissue, caused by these cells. This places the body under a constant low level of physical stress on a microscopic scale.

This imbalance in the immune system and chronic inflammation of normal tissue has put people with obesity at increased risk of complications of infections and higher rates of chronic diseases generally.

This is true of common infections such as skin or wound infections. Their immune systems are already working hard, even at rest. It comes as no surprise, then, that if people who are obese are struck down with the COVID-19 virus, they will also be at increased risk of its complications, including breathing difficulties and pneumonia."

Looking at the UK table for deaths, there does seem an increasing death rate with BMI class,

although it is only BMI 40+ that is in the govt list of more vulnerable people

Spain's figure for the last 24 hours is 510 deaths. Probably particularly low because of the holiday, more things shut even than normal, there might be an uptick on Tuesday, but still encouraging.

Obesity is also a risk factor for Vit D deficiency

Looking at the UK table for deaths, there does seem an increasing death rate with BMI class

I think to confidently state this we would have to know the proportions of overweight/obese people within the most at risk demographics. There is likely to be a correlation with diabetes and hypertension and CVD. Are lots (relatively) of otherwise healthy younger people with BMI over 25 dying? That's the question.

Good point Chaz.

Lymphocytes and neutrophils are white blood cells (immune system cells).

Low levels of lymphocytes are one of the features of HLH (Haemophagocytic lympohistiocytosis, one of the ‘cytokine storm syndromes’ which are off the chart episodes of inflammation). HLH is considered a rare condition (but may actually be chronically under diagnosed, especially in adults). it’s not a disease, it’s a dysfunction of the body that can be triggered by lots of diseases including viruses and lymphomas and leukemias, and some rheumatological conditions, such as stills disease. It’s sometimes caused by one of the ‘in born errors of metabolism’. These are all things on the government extremely vulnerable list. Low neutrophils are a common side effect of chemotherapy. Cancer patients of all types in active treatment are also on the list

HLH is usually observed in the paediatric population, I don’t think it’s associated with obesity (lots of HLH patients end up on high doses of steroids so put on weight as part of the treatment, but that doesn’t mean they started that way!) however, if obese adults already have a poor balance of lymphocytes and neutrophils, it would make sense that a disordered inflammatory response might occur.

Perhaps the white cell imbalance only happens/increases dramatically at the 40plus BMI point? Worth looking into.
Obviously extra weight makes it harder for our hearts and lungs to work effectively and hypertension and prediabetes may also be playing a part, but beyond the obvious and approaching is systemically is how answers will be found. Very challenging in an emergency, of course!

Here’s a recent shorthand release of international data from the university of Birmingham. The medications that look promising are used in treatment for HLH and MAS (‘macrophage activation syndrome’ which is essentially HLH with a rheumatological trigger).

The immune system is still very mysterious (and full of variation from person to person) lots for even world experts to learn. The one silver lining in this very dark cloud is the potential for greater understanding, multi-discipline clinicians and researchers from all over the globe sharing data and celebrating each other’s breakthroughs.

medium.com/@juliovincent/prepare-for-the-ultimate-gaslighting-6a8ce3f0a0e0

"Are lots (relatively) of otherwise healthy younger people with BMI over 25 dying? That's the question."

I think the point may be that increasing BMI class seriously increases the risk of having those other conditions

• many of them brought about by the increased likelihood of inflammation & reduction in immunity discussed upthread.

If we look at those of BMI 30+, BMI 40+ without any of them, then we are not looking at the average in those weight classes

The reported risk factors generally seem to be anything that reduces the working of the immune system, or reduces the working of vital internal organs

With increasing obesity, there also usually comes increasing amounts of fat in and around internal organs,
such as heart, panceas, liver, kidneys which reduce their efficiency

The ability to take in air and inflate lungs is reduced by excessive internal fat
and when lying down, the lungs are more squashed than would otherwise be the case

On the news this morning they said 19 NHS staff had died, how does that look statistically? I mean the NHS is a big employer so if thousands are dead do 19 NHS staff stand out?

I don’t think the percentage of deaths to NHS employees working with infected/ potentially infected patients will be particularly high, hopefully most NHS workers who get this will get a mild illness and a nice dose of antibodies to enable them to work safely in future.

There were 14 deaths among Transport for London workers announced this week. And 3 in the prison service iirc (and two prisoners).

People in these jobs cannot work from home, they are in close proximity with others, all-day-everyday.

I think the surprise about the NHS staff is that they are young enough and fit enough to be working on the wards, in a crisis. Even the doctors who have returned from early retirement appear fitter than average in their age cohort. Their deaths cannot be explained away with the awful ‘well, most people who die of this would’ve died within a year’

(I’m really not convinced of this, personally. Many of the people on the extremely vulnerable list would be expected to have long life spans, and people in the late stages of terminal illness are invited not to follow the ‘shielding’ guidelines if they would rather prioritise quality of life over remaining duration, so the majority of the 1.5 million are surely not expected to die within a year?)

Of course, we don’t really know anything about the 19s clinical presentation or health history, there may well have been something underlying that put them at bigger risk, that’s why the data is so important and why we are all asking questions relating to sex/ethnicity/age/BMI. Hopefully someone is also recording info such as profession, living situations/cultural & religious risk factors (such as attending football matches or places of worship). At the very least we need to learn who the most at-risk are and how we can protect others like them in future.

I’m sorry I cannot give you any real statistical comfort - I will certainly be pressing my MP to demand an enquiry into the deaths of any essential workers who may have been put at unnecessary risk due to poor governmental planning/lack of adequate PPE.

The reported risk factors generally seem to be anything that reduces the working of the immune system, or reduces the working of vital internal organs

A large proportion of the population have a BMI over 25. But still the risk is greater with age. Minimal numbers (relatively) of younger people are being admitted to critical care.

It would be useful to see a general age breakdown for BMI in the U.K. That would help us work out how much of a risk it was, absent any other conditions.

I will certainly be pressing my MP to demand an enquiry into the deaths of any essential workers who may have been put at unnecessary risk due to poor governmental planning/lack of adequate PPE. Yes contacting MPs is probably a good idea. It is criminal to leave these people exposed, I didn't like Matt Hancock's talk yesterday, sounded like he was blaming HCP for using too much protection. I'm sure most of them would say, "fat chance."

They keep saying the issue has been sorted but it hasn't.

This is one serous concern within the NHS, mentioned on last thread:

UK government urged to investigate coronavirus deaths of BAME doctors

www.theguardian.com/society/2020/apr/10/uk-coronavirus-deaths-bame-doctors-bma

Doctors’ organisation concerned at ‘disproportionate severity of infection’

"It would be useful to see a general age breakdown for BMI in the U.K. That would help us work out how much of a risk it was, absent any other conditions."

We would need to compare the % in the UK with each BMI class vs the % deaths in each BMI class

We cannot exclude those with comorbidities from higher BMI classes in the comparison,
because those comorbidities are often a consequence of that excess weight

@1forsorrow, the NHS employs 1.5 million people. I'm not sure how many of those are clinicians and how many are admin, but in my little bit of the NHS I'd make a stab that clinicians are about 50%.

So, that's 750,000 clinicians, of whom 19 have died. Obviously, every single one of those 19 is a tragedy, but it puts the death-rate for clinicians at around 1 in 40,000.

If we shift guesstimate of clinicians to one third of staff (half a million), then the risk of death goes up to 1 in 26,000.

For comparison, the fatality rate for the population as a whole in the UK at the moment is (from Worldometers) is about 1 in 7500.

So this back-of-envelope calculation suggests that NHS clinicians are at much lower risk than the rest of the population. Perhaps, in part, it's because NHS staff are going to be younger, on average, than the population as a whole (although you'd be surprised - the average age of staff in my trust is almost 50).

Anyway, I hope that sets your mind at rest a bit.

I thought that was very offensive from matt Hancock, to describe PPE equipment as precious, the precious thing is the people that are being protected by the PPE.

It was a disgraceful slur, implying that NHS staff were wasting PPE,
when in fact they don't have enough PPE and have still been risking their lives to treat patients

Yeah. It was as if he momentarily forgot that the precious Personal Protective Equipment has just one purpose... to protect people, the people who are risking their own health to try and maintain or restore ours.

a disgraceful slur
I agree, he was implying that in wanting to protect themselves they were being profligate!🤨
a desperate emergency situation where people are having to risk their lives and make very difficult decisions and and he wants to remind them to be frugal with the protective equipment🤨
Shows exactly where his priorities lie.... the frontline workers, they are our precious resource, they should not be treated like 'virus fodder'

Name changed for this, but I don't think he's said anything very out of line tbh. In the Trust where I work a month's worth of PPE was 'used' in a week. Management believe that this was largely down to staff creating their own stockpiles of PPE and possibly theft after reports of members of staff being seen out in public wearing ffp3 masks. Amnesty stations had to be set up for staff to return ppe they had taken without sanction, followed by searches of lockers and random bag searches by security when leaving the site. PPE was indeed found in staff lockers etc. Yes, this is because staff are really scared, but this particular hospital does not have a shortage of PPE if it is used in the way it was intended. I would imagine this behaviour has been seen in other hospitals too and I think it's fair enough for Matt Hancock to say what he did.

@BirdandSparrow that is good news again for Spain.