Saturday, May 23, 2020

Resolving the issue of day trips in the pandemic (and beyond)

We have a growing storm of controversy about people visiting the countryside as lock-down is lifted.

Locals are justifiably concerned that visitors will bring the virus to communities that have up to now been unaffected. So should all trips to beaches and beauty spots be banned, or how should it be managed?

Let's analyse the problem. There is no virus transmission risk if a household drives to a beach, parks at a car park observing social distancing rules, walks to the beach, bathes and sunbathes (the latter boosting immunity through Vitamin D production in the skin), eats its home-prepared picnic and then drives home again. The only risk comes from filling up with fuel without wiping the filler handle, giving cash to the cashier and buying ice-creams and sweets. At their destination, the risk again is buying in local shops, sitting down for a meal in a restaurant or cafe, and through simple overcrowding. 

Locals face a dilemma here: they do not want Covid, but they do want an income, which normally comes from selling goods and services to tourists.

There is a way to resolve this conflict in many localities. Take the case of a small seaside town that has only two roads leading to it. Traffic flow into the town can be controlled so that a safe number of cars in the town is never exceeded. It is necessary to take a spot check of the number of cars and vans in the town early in the morning of one day, and match that number against a safe maximum that can be accommodated in the town's car parks. That number of can now be let in. As cars leave the town, more can be allowed in. Digital communications can enable the numbers to be balanced. A toll must be paid on entry to make up for the community's loss from their inability to trade. 

Local vehicles would be identified with a windscreen sticker, and waved through.

This method of traffic control will also be useful when the pandemic is over. Many small seaside towns are overburdened with traffic, and a significant part of it is just driving around looking for somewhere to park. Many cars drive into a town, find that all the car parks are full, and drive out again - a totally wasted journey that makes local congestion worse. The cars are often inching along through streets filled with walkers, blasting exhaust fumes into the crowd. By controlling ingress into the town, these frustrating trips can be avoided. People could still enjoy a trip into the town by parking in a designated field at the entrance, and taking a small courtesy bus down to the town.

This is a sensible and rational solution to a problem that applies not just to the pandemic, but to ordinary life. 

Thursday, May 21, 2020

Covid-19 hand hygiene upgrade



There's an awful lot we don't know about Covid-19, but the one thing we do know, even total idiots like Donald Trump and Iain Duncan Smith, is that we have to wash our hands frequently. Very frequently, as often as possible, and thoroughly, front, back, between all the fingers and both of the thumbs, while singing Happy Birthday to Me twice. And we know that we do this because the SARS-CoV-2 virus that causes Covid can live on surfaces (or fomites as we in the medical profession like to call them) for many hours, and can transfer to our hands and thence to our mouths if we do not wash frequently.

The only problem is that if we are in a supermarket picking things off the shelf that was put there by someone who is carrying Covid without knowing it, we cannot wash our hands between each item. We could find the lavvy at the end of our shopping spree, but that place is probably a hotbed of virus, and the tap needs to be turned off, and the door needs to be opened, and can we be arsed?

So the advice to wash for 20 seconds is excellent, but a bit impractical.

For this reason some have taken to wearing gloves while out and about. Some shop assistants wear them too.  Gloves mean no virus on skin, which is great, but instead we get plenty virus on gloves, which is not so great. Signs are beginning to appear: TAKE YOUR BLOODY GLOVES OFF. Which is also not so great.

So here is the solution: Shops can provide, at accessible places, glove cleansing sponges soaked in 0.1% sodium hypochlorite (=dilute bleach) which kills the virus within a minute. One squeeze (front and back is enough to dampen the gloves in deadly bleach, and anything you touch thereafter will leave a trace of viricidal bleach, not a trace of virus. The bleach will not harm the gloves - I've tried it.

This makes perfect sense. You can sterilise your hands every few minutes, with a quick squeeze. You can even carry your own sponge about with you in a polythene bag. No more trips to the loo, no more more 20 second hand wash routines, no more sore red hands, no more fomite anxieties. And if everyone does it, we get a smaller R number. What's not to like?

The only thing not to like is that the suggestion is coming from a retired GP with an inventive streak, and therefore the Government scientists have no replicated double blind crossover clinical trial on this procedure, no comparison of Covid incidence in 10,000 hand washers as compared to 10,000 glove sterilisers. Therefore there is NO EVIDENCE and therefore Government scientists will find reasons to pour cold water on the proposal. In fact, they will wash their hands of the idea.

But it is still a great step forward in the battle against this deeply unpleasant disease. Look for it to be taken up in other countries, and in this country once we are well and truly desperate.

Tuesday, April 21, 2020

VOLUNTEER COVID-19 CONTACT TRACING PROTOCOL



21/4/2020
Volunteer Contact Tracers (VCTs) will work to shield their local community from transmission of Covid-19, and speed the lifting of the lockdown and return to normality. They will work in cooperation with regional Public Health England (PHE) teams and Local Authority (LA) Directors of Public Health. If possible, they will receive supervision from, and report back to, the local Director of Public Health (DPH).

VCTs will maintain absolute confidentiality regarding clients’ identities, except when the client gives permission for information to be shared with agencies that need to know, e.g. care workers.

VCTs will work exclusively by phone, messaging, and email.

The client will be invited to make the initial telephone approach to the VCT in order to avoid any complexities regarding patient confidentiality and agreement. Clients will get information about the existence of the VCT from PHE, doctors, care workers, social workers, or through informal communications such as social media or word of mouth.

 The VCT will introduce themselves by name, explaining that they are a volunteer, and asking if the client is well enough to speak at present. In the case of people where the fever is intermittent, it may be better to speak at a time when the client is more able to speak.

VCTs will explain that there is no obligation to talk, but that contact tracing may help others to avoid getting ill, and get the country out of lockdown more quickly. We will explain that the aim is not to punish anyone, but to help to suppress the spread of the virus.

VCTs will ask about symptoms, to confirm that the picture is of Covid-19. [symptom list to be added] This enquiry will take place whether or not the case has been confirmed by testing, as it will increase the engagement between client and VCT, and also because it has proved impossible to provide adequate testing for Covid-19 in the UK.

We will allow the client to speak freely at first, as people often want to tell their story in their own way. Take notes as the story unfolds, and come back to salient points.

VCTs will ask how the client is managing,  and if there is someone looking after them. They can provide a leaflet on how to Nurse a Covid patient at home.  [version for self-care is needed for people without carer]. Contact numbers with appropriate agencies will be provided.

Having made sure that all needs are provided for, the VCT will now enquire about any contacts that the client may have had in the last 3-5 days. Although the incubation period may extend to 14 days or longer, viral shedding is at its most intense in the 3-5 days before symptoms appear, and asking people to retrace their movements over 2 weeks may be too challenging. The client or the carer may be able to supply other names after consideration.

Shops and supermarkets visited by the client in the five days before symptom onset will be identified.

An attempt will be made to discover where it is most likely that the client picked up the infection. Names of shops or supermarkets will be taken.

Contact emails, telephone numbers and addresses will be requested.

At the conclusion, an undertaking will be made to follow up in one week to log progress. The client should be made aware of red flag symptoms that would mean a 999 call for hospital.

The second phase of the operation is to call all people and places that may have been infected by the client and warn them that they are at risk of developing the illness. They will be asked about their state of health, and asked to test their sense of smell. They will be advised to self-isolate for 14 days from the date of their meeting with the client. They will be asked about their household, and especially if it contains a vulnerable person. They will be provided with information about nursing a Covid patient, and a list of useful items to prepare.

At the end of the process, the volunteer will complete a case form and send it to the DPH,with a brief summary to be sent to the patient‘s GP.


Draft 1.00

Richard Lawson



Saturday, April 18, 2020

How do we get a swift recovery from the pandemic?



It looks as if the Coronavirus is peaking in the UK, with a bit of luck.
Neil Ferguson, the epidemiological computer modeller at Imperial College predicted a couple of weeks ago that we would peak between the 9-16th April, and he was just about right.

What happens next? Hopefully, we will be on a downward slope. The question is, will our path be like China, or like Iran? If we are to follow China to victory, without using Chinese methods (everyone quotes the welding up of doors, but we need to check that actually happened) we will have to up our game.

If we do not up our game, we will be more like Iran, staggering along on a painfully shallow downward slope, still in lock-down while more progressive nations are opening up their economies.

So what do we need to do, over and above staying home, maintaining social distance, and washing our hands for 20 seconds as often as we can?

Here's what we need to do:

  1. Mask Up. It is very clear: Masks greatly reduce the range of the droplets leaving our mouth as we sneeze, cough, speak or breathe. It stops us infecting others. We must not wait for Government to give the go-ahead on masks, we the people must just do it.
  2. Check history and temperature of all incoming airline (and ship) travellers. All incomers should be asked to self-isolate for 2 weeks. Compliance must be ensured with random checks.
  3. Remote temperature checks can be applied to all queues and entrances to large buildings
  4. Widespread testing for presence of virus in nose, throat and faeces.
  5. Widespread testing for immunity. Immune people might be given a certificate that will help them to get work in situations that would otherwise need PPE. We do not yet know how antibodies in the blood correlate with resistance to infection. This is one way to find out.
     
  6. Contact tracing, especially for  cases in regions (for example Cornwall) where the incidence of Covid-19 is at very low levels.
  7. Digital Contact tracing using software that has a barrier between the essential requirements of contact tracing and data relating to the person who is being followed. Yes, the civil liberties aspect of this technology needs careful consideration and debate, but it must not be dismissed out of hand.
  8. Shops and supermarkets are now major places where transmission can happen. There are a number of measures that can be brought in to prevent transmission, starting with masks and frequently-sterilised gloves for shop workers.
  9. Large organisations in necessary businesses that still put people in close contact with each other must be given detailed advice about lowering the risk of transmission, and organised into small cells, where there is more restricted numbers that can be infected by a carrier.
  10. Unnecessary large building work must be closed down.
There are more, but this is a good list to begin with. This gives us a chance of getting a strong downward slope on the graph.  The sooner we can get that downward slope, the sooner we can get out of our houses and down to the (still socially distant) pub.