Matt, Andrew and Nicola
Every week, more is written on COVID-19 than any individual could possibly read. Collectively, the COVID19 Actuaries Response Group read more about the outbreak than most, so we’ve decided each Friday to provide you with a curated list of the key papers and articles that we’ve looked at recently.
Modelling – reports
Imperial College reports
The MRC Centre for Global Infectious Disease Analysis at Imperial College London continue to produce interesting reports on COVID-19 (their site can be found here)
Report 16 – Role of testing in COVID-19 control (23 April 2020)
This report notes that immunity passports based on antibody or infection tests could face significant technical, legal and ethical challenges. They conclude that, whilst molecular testing is vital in monitoring the pandemic, its direct contribution to preventing transmission is likely to be limited to healthcare workers, patients and other high-risk groups.
Report 17 – Clinical characteristics and predictors of outcomes of hospitalised patients with COVID-19 in a London NHS Trust: a retrospective cohort study (29 April 2020)
This study found that older age and male sex, plus comorbidities such as renal failure, were associated with increased odds of death. It also found that ethnic minority groups were over- represented in their cohort, and that people of black ethnicity may be at increased odds of mortality compared to whites. The authors suggest that further research is urgently needed to investigate these associations at a larger scale.
The role of genes in COVID-19 symptoms
The latest data from researchers at King’s College London, based on data logged by pairs of twins on the COVID-19 Symptom Tracker app, suggests that genes are 50% responsible for the presentation of key symptoms of COVID-19. This includes fever, fatigue and loss of taste and smell. 
This study presents the largest detailed description to date of hospitalised COVID-19 patients. The multivariate analysis undertaken allows us to understand how factors such as age, sex and comorbidities interact to determine overall risk of death for individuals.
Age was found to be a strong predictor of mortality. The influence of sex and comorbidities was less strong. The authors note that “although age-adjusted mortality rates are high in the elderly, most of these patients were admitted to hospital with symptoms of COVID-19 and would not have died otherwise”. We commented on this and another multivariate study from New York in a recent bulletin.
“The wider impacts of the coronavirus pandemic on the NHS” – Institute for Financial Studies report
The Institute for Financial Studies has been applying itself to evaluation of a number of economic and resource matters that the epidemic is generating for the future. In a recent article they investigate “The wider impacts of the coronavirus pandemic on the NHS” (Link). Of great concern is the clear evidence of backlog building up on a range of elective procedures, care volume drops and appointment cancellations. Collectively these will result in delayed diagnostics with severe implications. The article is well worth a read for assessing possible insurance related implications for morbidity, mortality and health over several years into the future.
Estimating the burden of United States workers exposed to infection or disease
The easing of lockdown will be a challenge; not least the timetable for return to work for many of those currently not able to work from home. Understanding which occupational groups are at most risk of infection can help with the public health effort in in planning for potential subsequent infectious disease outbreaks. This analysis suggests that 10% (14.4 M) of United States workers are employed in occupations where exposure to disease or infection occurs at least once per week.
Clinical and Medical News
Remdesivir in adults with severe COVID-19
Remdesivir is an antiviral known to be effective against Middle East respiratory syndrome coronavirus, SARS-CoV-1, and SARS-CoV-2 replication in animal models. Hence, it is a drug of interest in the fight against SARS-CoV2. Disappointingly, recently published results from a double-blind, placebo-controlled multi-centre trial report that Remdesivir use was not associated with a difference in time to clinical improvement
However, patients receiving Remdesivir had a faster time to clinical improvement than those receiving placebo among patients with symptom duration of 10 days or less, though this did not reach statistical significance. This finding warrants further
investigation.
Internet Searches for Unproven COVID-19 Therapies in the United States
Whilst the use of on-line meeting platforms and the ability for fast-track publication of research have (in some ways) been a positive that has emerged from the period of social distancing, the internet has also unfortunately provided us with the ability to access questionable information, and products.
This was highlighted in some interesting analysis which showed alarming increases in internet searches for purchasing chloroquine and hydrochloroquine following high profile endorsement.
Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid-19
The interaction between the SARS viruses and ACE2 has been proposed as a potential factor in their infectivity. Given the common use of ACE inhibitors and ARBs worldwide, guidance on the use of these drugs in patients with COVID-19 is urgently needed. On the balance of the evidence reviewed in this publication , researchers suggest that these drugs should be continued in those patients in otherwise stable condition who are at risk for, being evaluated for, or with COVID-19.
Studies are underway to test the safety and efficacy of these drugs including recombinant human ACE2 and the ARB losartan in COVID-19.
An analysis of SARS-CoV-2 viral load by patient age
Whether or not children are sources of COVID-19 infection is not fully understood. Professor Drosten from the University of Berlin and his team analysed the variance of viral loads in patients of different age categories in this study (Link).
They suggest that they have to caution against an unlimited re- opening of schools and kindergartens in the present situation – children may be as infectious as adults.
What policy makers need to know about COVID-19 protective immunity
This review cautions against hastiness when it comes to easing lockdown. In particular, the article notes that the linchpin for a strategy to move out of lockdown seemingly rests on increased testing and contact tracing, possible return-to-work permits based on immune status, repurposed or new therapeutics, and, finally, vaccination.
Concern that a [COVID-19] related inflammatory syndrome is emerging in children in the UK ,
An alert to GPs in the UK says that in the “last three weeks, there has been an apparent rise in the number of children of all ages presenting with a multi-system inflammatory state requiring intensive care across London and also in other regions of the UK”.
The absolute numbers are very small, and the syndrome appears to share some features with serious COVID-19. The rationale of this alert is to allow clinicians to recognise potential cases so that appropriate and timely interventions can be provided.
Data
ONS data by local area and socioeconomic deprivation
The ONS published analysis of COVID-19 deaths in England & Wales between 1 March and 17 April by various geographic factors, including region, local authority, middle layer super output areas and index of multiple deprivation (IMD) deciles .
Unsurprisingly, London is the region with the highest age-standardised mortality rate for deaths involving COVID-19 (85.7 per 100,000 over the period 1 March to 17 April).
This is nearly double the rate in the second highest region (43.2 for West Midlands) and five times the rate in the lowest region (16.4 in the South West).
Focussing on local authorities, the highest rates were found in London (144.3 in Newham, 141.5 in Brent, 127.4 in Hackney), with high rates also found in and around other major cities including Liverpool, Birmingham and Manchester.
Aggregating data according to Urban Rural Classification presents a similar picture, with the highest rate in areas classified as urban major conurbations (64.3 per 100,000 over the period 1 March to 17 April) and the lowest rate in rural hamlets and isolated dwellings in a sparse setting (9.0 per 100,000).
Of particular interest is the analysis of death rates by Index of Multiple Deprivation (IMD) decile (chart reproduced below). This shows that the three most deprived deciles have age-standardised mortality rates (for deaths involving COVID-19) that are more than twice as high as the rate in the least deprived decile.
In addition it can be seen that this COVID-19 IMD differential is greater than the corresponding differential based on all deaths. In other words, COVID-19 linked deaths are proportionately greater in the most deprived areas.
We have previously commented on the various sources of data on deaths, both from COVID- 19 and all-cause. Much of the data on COVID-19 deaths has related to those who died in hospital.
ONS have published data coming out of the Care Quality Commission on the number of deaths in care homes in England . Typically there are fewer than 400 deaths per day reported in care homes – this data shows that in the period up to 24 April 2020 the figure has passed 1,000 on several days, with up to 500 of these confirmed as involving COVID-19.
John Appleby of The Nuffield Trust has reviewed the data on deaths from causes other than COVID19 over March 2020, noting that deaths from other main causes (other than dementia and Alzheimer’s disease) were significantly lower than their five year average.
And finally…
Virtual meetings
Everyone who’s been working from home for the past weeks will have participated in endless virtual meetings, sometimes on platforms that you didn’t even know existed before the pandemic.
Here are some interesting things people are doing with the format:
For a $100 donation, a California animal sanctuary will allow you to invite a llama, a goat or a range of farm animals onto your video call
Noticing that people are giving themselves (often disastrous) home haircuts during lockdown, a pair of friends are offering £15 video consultations with a barber – the money is split between the barber and NHS charities
1 May 2020
Really interesting read. Thanks
Cheers David