A few weeks ago @ClareCraigPath, @RealJoelSmalley and I wrote a short piece on endemic Covid, and what it might look like.

It seems particularly relevant to current observations.

Consider the possibility that all our naso-pharynxes together make up a single ecosystem, in which only one predator can be completely dominant.

We are not saying that this has definitely happened with Covid - but it would explain the disappearance of flu this year.
Every winter, we see "excess deaths" in the sense that more (mainly elderly) people die in the winter than in the summer.

This is a worldwide phenomenon.
It is now thought that all or nearly all of the extra deaths in Winter are due to infection with winter respiratory viruses, mainly influenza:

However, we do not - and never have - extensively tested for the presence of such viruses in the critically ill elderly population, so we really have no idea how frequently infection is present, or in fact what its contribution to death is.
In 2017, researchers at 2 morgues in Spain swab-tested a series of recently deceased elderly individuals and found respiratory viruses in 47% of them. In only 15% of these had a diagnosis been made prior to death.

The death certificates for all these individuals featured the usual wide range of pathologies that would be expected in this age group, but viruses were detected (post-mortem) across all categories of causes of death.
For this cohort - presumably representative of similar cohorts of subjects across Europe - what would the mortality picture have looked like had we applied a policy of recording the detected respiratory virus as the cause of death, irrespective of other pathologies?
That is, in effect, what we might be doing now, to some extent - Covid taking the place of other viruses (particularly influenza).

In other words, might some of the Covid deaths we are now seeing be those that would have sadly died in a normal winter anyway?
As is usually the case, the picture is more complex and there are probably a number of other factors contributing to the current mortality picture.
Firstly, there will of course be some additional "pure Covid" deaths as the virus moves into its endemic rather than pandemic stage.

This was seen in the year following the Swine flu pandemic:

Secondly, there is increasing evidence of deaths being caused by nearly a year of restricted access to healthcare.

In fact, given the nation's state of health and presence of multiple diseases, it would be more surprising if there was no such effect.
That attendances at A&E departments making up the Syndromic Surveillance System (currently covering 82 hospitals in England) are running below the same period last year is consistent with this: Image
Ambulance calls for cardiac/respiratory arrest calls are high, yet calls for chest pain appear to be lower than average.

This is worryingly consistent with a picture of reluctance to seek help in time. Image
This would be highly unlikely to result in no excess deaths.

The numbers involved are not small, the arrest calls appear to be ~50-75 more than expected (daily), but chest pain calls ~250 per day fewer than expected.
Surprisingly, attendances for acute respiratory infections are well below average for the entire Autumn and Winter so far; although rising recently they are still below average.

This is consistent with the point made above - ie could Covid be replacing flu this year? Image
Some have previously claimed that this category does not include Covid, but the notes in the report seem quite clear that it does. Image
Finally, it must be acknowledged that the emergence of Covid is currently causing significant strain on our NHS, although it is worthwhile acknowledging that several reasons must contribute to this.
Firstly, it appears that treating Covid patients is more complex and onerous than treating those who would previously have been patients with a variety of other
- mainly undiagnosed - respiratory viruses.
Secondly, the reduction in beds available for a growing and ageing population is a major problem; they fell from 240,000 in 2000 to under 165,000 in 2019.

The figure fell by a further 10,000 beds to allow for social distancing between patients in hospital. Image
The need to segregate suspected Covid from confirmed Covid and non-Covid patients has a detrimental effect of bed management, as does the need for smaller bay sizes to accommodate distancing.

A&E departments can easily become clogged up by delays in finding beds for patients.
In some hospitals patients are not being discharged until their Covid test returns as negative.

Clearly returning patients to care homes during the window of infectivity would be a bad idea.

Beyond that this policy is surely inadvisable.
It should be recalled that some patients continue to test PCR positive for weeks or even months after infection, as experienced by the unfortunate British students stuck in Italy last summer:

PCR testing has led to a staffing crisis, as asymptomatic staff - even those who must be immune through known prior exposure - are made to self-isolate for two weeks.

50,000 NHS staff are absent for Covid reasons, out of 100,000 total absences.

Finally, it should be acknowledged that staff are having to work in PPE and change it frequently, adding a significant additional burden to an already heavy workload.

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More from @jengleruk

11 Jan
Interesting thanks, but can we really comment on misunderstandings relating to comparisons between vaccines while ignoring the elephant in the room:

Relative v Absolute risk reduction?

The vaccines are being pushed on the former while apparently nobody dare speak of the latter.
Pre-2020, it would have been unarguable that consenting to a medical treatment should always be on the basis that the individual gives fully informed consent.

Fully informed involves describing risks v benefits.

I am not commenting in this thread on risks, only on benefits.
Effects on infection rates and transmissibility have not been demonstrated in these trials - only symptom reduction.

Hence any societal benefit via herd immunity is purely speculative, and ethically unjustifiable as the basis of coercion (which is unjustifiable anyway).
Read 17 tweets
10 Jan
To complete the picture, the AZ vaccine.

The pertinent data is at page 7 of: assets.publishing.service.gov.uk/government/upl…
In this table:
There were some dosing issues in relation to this trial, but the data for any dose (ie all data combined) shows that:

So, in terms of any Covid the results are that:

227 / 10k on placebo developed any Covid


108 / 10k on active vaccine

Hence the 52% overall efficacy.
Read 7 tweets
10 Jan
A number of people have thanked me profusely for explaining the below.

But I want to stress: it's really not complicated, it's all ascertainable from 5 mins of reading the FDA report.
So anyway, thought I'd do the same with the Moderna vaccine.

These aren't my opinions.

I am saying nothing about safey.

Just extracting the top level data on efficacy.
The relevant document can be found at:


Page 23 is the start of the efficacy data.
Read 8 tweets
9 Jan
Genuine question:

At fda.gov/media/144245/d… it can be seen that in relation to the Pfizer vaccine:

The 95% effectiveness is based on:

162 cases / 22k receiving placebo with mild symptomatic Covid


8 cases / 22k on active vaccine.

8 is ~5% of 162 so yes: 95% reduction.
But 99.4% of the 22k in the placebo group didn't even develop mild symptomatic Covid.

This is despite the locations chosen being supposed hotspots to accelerate recruitment.

Severe Covid numbers were: 4 placebo: 1 active

One of these was hospitalised.
Is the reason why this is being touted as a significant exit strategy because:

- governments don't understand trial data

- they do, but realise the fear is so ingrained they are happy to let people think it's more significant than it is.
Read 7 tweets
7 Jan
There are some interesting, but not conclusive, observations to be drawn from looking at the proportion of people who have SARS-CoV-2 antibodies in different regions. Image
According to PHE, in the 10 weeks up to week 49 (the last date with data) SARS-CoV-2 antibody prevalence changed as follows:

- in the NW it increased from ~5.5 to ~10.3 %
- in London it was roughly flat, at around 9%
I have estimated these by eye from the graph at page 68 of:

Read 13 tweets
7 Jan
As can be seen on p 61 of assets.publishing.service.gov.uk/government/upl…

....the extra Covid deaths do not at present appear to be feeding through to excess mortality. Image
Caution should be exercised as PHE use some modeling in the below to estimate deaths by occurrence from the registration data and this may not work as well over the holiday period.
Nevertheless, I do find it hard to reconcile the above with reported Covid deaths: Image
Read 4 tweets

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