Desperate measures
Century old pandemics and kids in gyms - truly a firm foundation for wide reaching policies impacting millions.
How did our political masters get the idea that all the drones had to stay home, wear masks, stay six feet apart, not travel anywhere and obsessively wipe down every surface of the planet?
Who decided that prohibiting crowds (at least at events that aren’t politically advantageous to the current administration) was a good way to limit the impact of an infectious respiratory disease?
These measures (non-pharmaceutical interventions, or NPI) were all detailed in a thick report published in 2019 by the World Health Organization.
Pandemic preparedness
Pandemics don’t come along often, and it’s important to take advantage be prepared when they do. Pandemics of new, previously unknown human coronaviruses are hard to anticipate (unless you’re using those viruses to experiment with gain-of-function research, of course). But influenza comes around every year, and once in a great while there’s a big, scary pandemic.
If you read my article about the 1918 flu pandemic you already know that most fatalities were due to secondary infections of bacterial pneumonia rather than the influenza virus itself. Penicillin wasn’t discovered until 1928 and wasn’t used successfully as a drug until the 1940s. But thanks to antibiotics the next two flu pandemics, in 1957 and 1968, were far less deadly.
This table comes from that thick WHO report, titled Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza1. The goal of the report is to detail things we can do when there are no drugs available yet for a new flu strain, if that strain results in another pandemic.
[Note, by the way, how low the bar is today for something to be a “pandemic.” Apparently 123,000 deaths (worldwide) is now enough to qualify.]
It seems unlikely, given the use of modern antibiotics and other treatments, that we will ever see another influenza pandemic on the scale of 1918, but this same report obviously has relevance for today’s COVID-19 hysteria because it details the reasons and justification for all the different NPIs like masking, social distancing, avoiding crowds, etc.
Let’s talk about the big huge WHO report that nobody read but everybody somehow still misinterpreted
This report covers lots of subjects, and later we’re going to review one section (Avoiding Crowding) in detail to get a feel for the type and quality of the available information about NPIs. But first let’s hear why they created this monster-sized report.
Influenza pandemics occur at unpredictable intervals, and cause considerable morbidity and mortality. Influenza virus is readily transmissible from person to person, mainly during close contact, and is challenging to control.
Okay, influenza is a recurring problem, and the WHO is concerned that despite modern antibiotics and other medical aid, another global pandemic is still possible.
In the early stage of influenza epidemics and pandemics, there may be delay in the availability of specific vaccines and limited supply of antiviral drugs. Non-pharmaceutical interventions (NPIs) are the only set of pandemic countermeasures that are readily available at all times and in all countries.
It normally takes time to develop drugs for new diseases (or new strains of existing viruses) so what can we try when these are not yet available?
The evidence base for this guideline included systematic reviews of 18 NPIs, covering:
personal protective measures (e.g. hand hygiene, respiratory etiquette and face masks);
environmental measures (e.g. surface and object cleaning, and other environmental measures);
social distancing measures (e.g. contact tracing, isolation of sick individuals, quarantine of exposed individuals, school measures and closures, workplace measures and closures, and avoiding crowding); and
travel-related measures (e.g. travel advice, entry and exit screening, internal travel restrictions and border closure).
The report tells us what the expected impact is of these interventions. It’s not exactly earth-shattering.
These community mitigation measures may be able to slow the spread of infections in the community, delaying the peak in infections, reducing the size of the peak and spreading infections over a longer period of time (Fig. 1).
Oh goody, they may be able to slow the spread of infections. Let’s take a quick look at figure 1 - it looks very familiar. Many people used this same figure in early discussions of COVID-19. Notice that the overall height of the peak in cases per day is lower, but is also spread out over a longer period of time.
This is the important part of today’s post. If you only read one part, please read this.
Not many people seem to appreciate the implications of this graph:
Given that in some locations there could be limited surge capacity in hospitals (and particularly in intensive care beds), spreading infections over a longer time period could save lives, even if the total number of infections remained the same.
Understand what they’re saying: all of these measures are not expected to reduce the total number of infections, just to spread them out over a longer period of time.
Why? Their fear is that hospitals could see so many cases at once that they are unable to give each patient proper treatment, which would result in more deaths than would have occurred if the infections were more spread out.
The idea here not to save lives directly via the use of these non-pharmaceutical interventions. This is not what the authors are suggesting.
Wearing a mask, for example, does not make you less sick than you would have been without a mask, nor does it mean you’ll never get sick. Their hope is that you won’t be sick at the same time as all your neighbors (although you will eventually get sick). As a result, you may get better care and therefore have a better outcome.
Is all the emphasis on hospital capacity early in the pandemic starting to make sense? If hospitals aren’t full and they can still treat all their COVID patients properly, then slowing the spread of infections doesn’t actually do us much good and maybe we don’t need these interventions.
They (local health officials) need everyone to believe hospitals are about to be overrun, or a lot of the justification for these interventions falls apart.
One more time for the stupid people (CDC Directors, Governors of Oregon, etc.)
No one claims NPIs keep people from ever getting infected. They might delay it - the attack rate is in theory slower, but it’s never zero.
If everyone is sick at the same time, hospitals get overrun. This could lead to more deaths.
If hospitals aren’t at capacity, then using NPIs does nothing to reduce the number of deaths, they just lengthen the pandemic.
The only other reason for the NPIs is to delay infections while pharmaceuticals (antivirals, vaccines) are developed.
Are some of those news reports about overcrowded hospitals making more sense? How about those government policies? Do some political leaders benefit from lengthening the pandemic?
Yes, I’m looking at you, Dear Leader Justin Trudeau. Did we enjoy our emergency powers? Yes we did, who’s a good little dictator? Have a cookie. Do we feel better now?
Done ranting. Time to get back to the report.
So this report covers all known NPIs. How good is the available data? How much confidence do we have these measures will actually slow the spread of infectious disease? Because if they don’t, then this was all just Kabuki theater2.
The evidence base on the effectiveness of NPIs in community settings is limited, and the overall quality of evidence was very low for most interventions.
So for most of these things, we have very little data. These are simply not subjects scientists spend a lot of time researching. Only two areas had significant research available.
There have been a number of high-quality randomized controlled trials (RCTs) demonstrating that personal protective measures
such as hand hygiene and face masks have, at best, a small effect on influenza transmission, although higher compliance in a severe pandemic might improve effectiveness.
Although it’s not the subject of this post, I can’t resist a little side trip. Hand hygiene and face masks have, at best, a small effect on influenza transmission. In fact, the report actually says the balance of the available evidence is that they don’t work.
So these masks that everyone has been trying to force muzzle our toddlers with probably don’t do anything at all, per a huge non-governmental organization that just spent a bunch of time and money to research that exact question.
And those are the two things with some reasonable evidence - the other NPIs rely on computer models and observational studies.
However, there are few RCTs for other NPIs, and much of the evidence base is from observational studies and computer simulations.
To get a feel for what “limited” means we’re going to take a more detailed look at an example of one of those NPIs with limited evidence.
The running of the bulls (and other crowded events)
The picture at the top of the post is from the festival of San Fermin in Pamplona, Spain. One of the possible interventions is to limit the size of crowded events like this, on the theory that infectious diseases spread more rapidly when six hundred people are in close proximity because they’re all running from the same bull.
From the section of the WHO report titled Avoiding Crowding:
Three epidemiological journal articles were included in our systematic review.
Okay… three whole articles. Do they know there are over 7 billion people here?
One of those studies concerned World Youth Day 2008 pilgrims; it found that sleeping in a small group reduced the transmission of influenza compared with sleeping in one large hall.
Kids in a gym. Great.
Another two articles were based on the 1918–1919 pandemic; both articles found that timely bans on public gatherings and closure of public places appeared to reduce the excess death rate (Spearman ρ=0.31 and 0.46). However, it is impossible to determine the individual effects of measures to avoid crowding in these studies.
And two articles about a flu pandemic from so long ago we didn’t have MTV or antibiotics. It was like the Dark Ages. Was this all they could find? How hard did they look?
We identified three studies for the systematic review after reviewing 815 titles and 121 abstracts identified from databases and other sources.
Well, three papers isn’t much but they thought the other 812 were less useful. What was their assessment of the strength of the evidence?
There is a very low overall quality of evidence on whether avoiding crowding can reduce transmission of influenza.
Keep in mind they admitted right up front that they couldn’t determine the effect of avoiding crowding by itself. Multiple measures were in place in 1918, as we’ll see below.
We’ve been cancelling weddings, concerts, trips to Chuck E. Cheese, and grandma’s funeral based on very low overall quality of evidence?
Just for the hell of it, let’s take a quick look at those papers
We’ll start with the two about the 1918 pandemic. Medical science should always be about events that happened over 100 years ago because they’re so very relevant today. Things like drinking water quality and sewage treatment are exactly the same today as in 1900.
Public health interventions and epidemic intensity during the 1918 influenza pandemic (Hatchett, Mecher & Lipsitch 20073)
Early implementation of certain interventions, including closure of schools, churches, and theaters, was associated with lower peak death rates, but no single intervention showed an association with improved aggregate outcomes for the 1918 phase of the pandemic. These findings support the hypothesis that rapid implementation of multiple NPIs can significantly reduce influenza transmission, but that viral spread will be renewed upon relaxation of such measures.
So use of these interventions was associated with fewer deaths back in the days before movies had sound and hospitals had antibiotics. This is not shocking news. It was, after all, a real pandemic - tens of millions of deaths in a much smaller worldwide population.
The authors are also telling us the lower peak death rates were “associated with” the interventions, meaning they can’t really prove cause and effect. We’re not going to worry about that part for now because it doesn’t alter the point of this article/rant.
Ignoring that cause and effect bit, notice that the authors can’t tell us which interventions they think helped - places with multiple interventions in place seemed to do better but we don’t know if that’s because of masks, reducing crowding, or any of the other measures in place. No single intervention was associated with a significant improvement.
And as noted above, viral spread then continues normally after the NPIs are stopped.
If highly effective NPIs are put in place early in the epidemic, and these result in a smaller epidemic, then a large proportion of the population will remain susceptible to the renewed spread of the virus once interventions are relaxed. In the absence of an effective method of otherwise inducing immunity in the uninfected population (i.e., a well matched vaccine), such an epidemic is likely to have two phases, with the first phase mitigated by NPIs and the second commencing after NPIs are relaxed.
We are starting to see some of the genesis of the idea that we should implement NPIs until a vaccine is available. The NPIs are only a stalling tactic, since once restrictions are lifted the virus is gonna do what a virus does. The authors are expecting development of antivirals or a vaccine for the new flu strain, otherwise your options are to stay locked in your room for the rest of your life, or go out and get immunity by getting infected.
Next up:
Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic (Markel et al. 2007)4
These findings demonstrate a strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.
Nothing really new here; this paper essentially agrees with the previous one. There is something else interesting, however - the dates of publication.
The slightly suspicious part
Both of these articles were published in 2007, and it seems odd that nothing else was published for the WHO to reference in the first 90 years after the 1918 pandemic.
And you know what else? The lead author from the first article (Hatchett) works for the NIH. In the second article, two of the authors (Lipman and Cetron) work for the CDC. The only other article I found on PubMed about this subject was authored by Markel, Stern and Cetron in 20085 (three of the six authors from that second article).
It seems a little strange that after 90 years of silence, there are three articles published in two years, and two government offices participated in them - and we can clearly see the genesis of some of the policies being implemented, based on the statements in these articles and the WHO report.
Now let’s talk about kids in gyms
This will be simpler, because it’s sillier.
An influenza outbreak among pilgrims sleeping at a school without purpose built overnight accommodation facilities (Staff & Torres 20116)
The kids (pilgrims) are sleeping overnight at a school, but the school isn’t like a Motel 6 and doesn’t have any overnight rooms (so no beds, mini-bars, tiny safes or crappy towels).
The event was a Catholic youth festival held in Sydney, Australia. There were 223,000 people attending, but we only care about these 700 because some of them got the flu.
This report describes a respiratory illness outbreak amongst a group of over 700 World Youth Day 2008 pilgrims staying at a basic accommodation venue for 1 week in July 2008.
One big group of kids slept in the gym, the rest slept in a bunch of classrooms.
At this venue, 1 group of pilgrims was accommodated as a large group in a gymnasium and another group was sub-divided into smaller groups and accommodated in classrooms.
More kids sleeping in the gym got sick than kids sleeping in the classrooms.
The attack rate for those with onset while at the venue was significantly higher amongst pilgrims accommodated in the gymnasium than those staying in the classrooms.
The Australian kids all stayed in classrooms, and all the Solomon Islanders stayed in the big, stinky gym.
Australian pilgrims were assigned to one of the 3 classroom groups based upon their parish of residence, and pilgrims from the Solomon Islands were accommodated in the gymnasium.
And what can we learn from the kids?
The difference in attack rates observed between the Solomon Islander and the Australian groups whilst at the school, could be attributed to the differences in accommodation used whilst at the school.
Oh wow - the difference in attack rates could be attributed to their accommodations. Strong stuff. Or the difference could be something else- we can’t say for certain.
There’s nothing hugely objectionable in this study and the authors were thorough and included as much data as possible.
But for the WHO report, this is really thin evidence.
Why the hell are we still doing any of this?
Whether one believes these NPIs work or not, the reasoning behind them was to slow down the spread (the attack rate) of the virus. Everyone eventually gets exposed with or without the NPIs, but they could (in theory) be beneficial for one of two reasons:
Preventing hospitals from being overwhelmed so everyone gets good quality care
Buying time for development of vaccines or antivirals
Our health system is not overburdened so reason number one is not applicable. We’re told that we have super duper effective vaccines available now, so reason number two is also not applicable. So to summarize the current use of NPIs:
There’s almost no evidence they actually work, per the people who conduct research in this field.
Even if they did work, both possible reasons for using them don’t currently apply (if they ever did).
So why are we still following these measures?
Obligatory complaining about the CDC, who are completely useless and should be disbanded
Keep in mind that the CDC, FDA, and NIH failed to conduct any randomized controlled trials on available antivirals (Hydroxychloroquine, Ivermectin) while everyone waited for exciting new vaccines. We may have had effective antivirals available the whole time, but didn’t know we did. It’s truly a shame that multi-billion dollar budgets aren’t sufficient to fund a randomized controlled trial or two.
Instead we implemented unproven, draconian measures. In our example (Avoiding Crowding) the WHO could only come up with three references they thought were worth mentioning. Two of those were about the 1918 flu pandemic, and both said they can’t tell us which interventions helped and which didn’t (so we have no idea if reducing crowding was key).
Both of those papers had participation from the CDC and NIH, those same organizations that wouldn’t test existing drugs (probably because no one could make a fortune on them, see my other article on this subject).
And we have kids in a gym.
Everyone’s life has been upended to implement measures that no one can prove actually work, and even if they did work the justifications for them ended long ago.
The correct time to be done with these mandates was before we started. At this point, there are no justifiable reasons to continue except maybe politics - which may have been the actual reason for these restrictions from the very beginning.
Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza; World Health Organization 2019. ISBN: 978-92-4-151683-9.
https://www.who.int/influenza/publications/public_health_measures/publication/en/
From Dictionary.com: Kabuki is a form of classical theater in Japan known for its elaborate costumes and dynamic acting. The phrases Kabuki theater, kabuki dance, or kabuki play are sometimes used in political discourse to describe an event characterized more by showmanship than by content. https://www.dictionary.com/e/pop-culture/kabuki-theater/
Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity
during the 1918 influenza pandemic. Proc Natl Acad Sci USA. 2007;104(18):7582–7
(https://www.ncbi.nlm.nih.gov/pubmed/17416679, accessed 26 June 2019).
Markel H, Lipman HB, Navarro JA, Sloan A, Michalsen JR, Stern AM, Cetron MS. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007;298(6):644–54. (https://jamanetwork.com/journals/jama/articlepdf/208354/
joc70085_644_654.pdf)
Markel H, Stern AM, Cetron MS. Theodore E. Woodward award: non-pharmaceutical interventions employed by major American cities during the 1918-19 influenza pandemic. Trans Am Clin Climatol Assoc. 2008;119:129-38; discussion 138-42. PMID: 18596866; PMCID: PMC2394704.
https://pubmed.ncbi.nlm.nih.gov/18596866/
Staff M, Torres MI. An influenza outbreak among pilgrims sleeping at a school without
purpose built overnight accommodation facilities. Commun Dis Intell Q Rep. 2011;35(1):10–5.