^{The Friday Report – Issue 17}

By Matt Fletcher and Dan Ryan

Ryan and Matt

COVID-19 Actuaries Response Group – Learn. Share. Educate. Influence.

Every week, more is written on COVID-19 than any individual could possibly read. Collectively, the COVID‑19 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

Initial Estimates of Excess Deaths from COVID-19, 8 April 2020 (link)

This SAGE paper was published on 12 June 2020 but received much attention recently, following a report in the Telegraph (link) and other newspapers highlighting the headline conclusion that lockdown could result in 200,000 excess deaths.

The report represented the best estimate of excess deaths based on data available in April 2020. It notes specifically that most of the 200,000 deaths reported (185,000 over the medium and long term) are based on an assumption of 75% of elective care being cancelled over 6 months and not re-prioritised, and that with reprioritisation the actual impact would be much smaller.

The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries: A 9-Country Demographic Study (link)

This study notes the variation of observed Case Fatality Rate across countries (for example, 9.3% in Italy compared to 0.7% in Germany) and considers the contribution of the age distribution of confirmed cases to this range.

The conclusion is that selectively testing and identifying older cases is likely to increase estimates of the lethality of COVID-19 within populations – in Germany, testing was disproportionately among younger individuals, where in Italy, Netherlands and Spain it was among older individuals. Overall, 66% of the variation across the 9 countries considered in detail is explained by the age distribution of cases. After adjusting for these differences, the age-standardised median CFR is 1.9%.

Clinical and Medical News

Oxford Vaccine Group Phase I/II Trial Results

On 20 July, the much-awaited results (link) of the multi-centre Phase I/II trial of the ChAdOx1 nCoV-19 vaccine led by Professors Sarah Gilbert and Andrew Pollard at the Jenner were released. The study found no serious adverse events in in the test group (n=543), and showed specific T cell responses at day 14 and IgG responses at day 28.

By way of reminder, the body initially generates the much larger IgM antibodies before switching progressively to the production of IgG antibodies which are more nimble and specific. Patients were able to generate neutralising antibodies to a new infection. However, it is worth noting that the study protocol involved a booster vaccine at day 42. This has clear implications for rolling out the eventual vaccine, regarding both production and administration.

Long-lasting antibodies (?)

Back in March, Florian Krammer and his lab at Mount Sinai shone a light on the potential for convalescent serum therapy to help in the management of COVID-19, leading to programmes around the world. They have continued to investigate the extent and duration of antibody responses, and a pre-print study this week (link) on 19,860 individuals screened in New York City indicated the majority of those testing positive for COVID-19 with mild to moderate symptoms showed stable levels of IgG antibodies thereafter. These antibodies, most likely produced by long-lived plasma cells in the bone marrow, were able to neutralise new infections for a period of at least 3 months.

(But in this time of ‘emergency epidemiology’, not all results will point the same way – a small study by King’s College London (link) looked at the concentration of neutralizing antibodies over 94 days and found that the concentration could fall to become almost undetectable after around one month.)

Rashes – yet another symptom of COVID-19

Various clinical datasets have greatly expanded our understanding of those symptoms that should be associated with SARS-CoV-2 from the initial set of persistent dry cough and fever. A pre-print study (link) that looked at over 300,000 UK users of the COVID Symptom Study app indicated that those with positive swab tests were 1.67 times more likely to have a body rash. The study also reported on a separate online survey (n=11,546) of those with rashes, and this indicated that rashes were the only clinical sign in 21% of those with positive swab tests. Thus, recognising rashes is very important for identifying new cases of COVID-19.

Hydroxychloroquine – preliminary results from RECOVERY trial

Preliminary results (link) from the Randomised Evaluation of COVID-19 therapy (RECOVERY) on the use of hydroxychloroquine that has attracted so much attention and controversy are not encouraging. The study of 418 patients treated with hydroxycholoquine (against a control group of 788) indicated that patients were less likely to be discharged alive at 28 days (60.3% vs 62.8%), more likely to require ventilation (29.8% vs 26.5%) and were likely to spend longer in hospital. Although the differences are slight, they point in the wrong direction.

COVID-19 Behaviour Tracker

The ongoing collaboration between YouGov and public health experts at the Institute of Global Health Innovation at Imperial College London brings together weekly survey responses across 30 different countries looking at changes in behaviours and attitudes in the time of COVID-19. The underlying data can be explored at https://github.com/YouGov-Data/covid-19-tracker.

As of today (24 July), it is mandatory for customers in England to wear face coverings in shops, supermarkets, shopping centres, banks, building societies and post offices. It is therefore rather opportune to look at differences in self-reported use of face coverings in different countries around the world (using data from June 28-July 5).

Nuffield Trust – lessons for healthcare systems from COVID-19

Whilst the deficit in expected hospital admissions has reduced significantly in May and June compared in April, waiting lists are expected to increase significantly for the rest of the year as the healthcare system is forced to operate below normal capacity and population health suffers from missed or delayed treatment.

The Nuffield Trust has released an excellent briefing (link) that focuses principally on European healthcare systems and asks what lessons can be learned. It describes the common strategies that many healthcare systems, including the NHS, adopted such as prioritisation based on immediate need, partnerships with the private sector and the creation/freeing up of additional capacity.

The report highlights that the NHS is likely to face greater strain because, before the pandemic, the UK had higher occupancy rates than other countries but fewer doctors, nurses and capital assets. Many hospitals lack single-occupancy rooms and common areas are too restricted to allow segregated movement.

The report warns that much investment will be needed to update facilities, and that the extra capacity so far announced will be insufficient. The report praises innovation and flexibility in patient triage and care delivery, but challenges over-staffing with high vacancy rates, dependence on volunteers and demands on those that brought us through the first wave.

Data

ONS: Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 30 June 2020

This is an update of the previous ONS report which covered the period to 31 May 2020. Overall, the conclusions are similar to the previous report – specific statistics drawn out were:

• 9% of deaths occurring over the period involved COVID-19;
• London had by some way the highest age-standardised mortality rate of COVID-19 deaths and the South West had the lowest;
• The age-standardised mortality rate for COVID-19 deaths in the most deprived areas was more than double that in the least deprived areas (140 per 100,000 vs 63)

All English regions and Wales saw increases in COVID-19 mortality between March and April, followed by decreases in May and June. In London, the mortality rate involving COVID-19 fell by 96.7% from its peak.

And finally …

It’s been a few weeks since we’ve ‘been outdoors’ in our weekly roundup, so a couple of interesting outdoor-related stories to finish.

Whilst indoor gyms and swimming pools are re-opening in the UK tomorrow (25 July), they will be at reduced capacity with more regulations – will more of us make use of rivers over what’s left of the summer months? (wild swimming)

Lockdown is thought to have been good for hedgehogs, as lower traffic volumes have led to fewer encounters with cars. However, there is some concern that this means that scavenging prospects may be reduced for some birds of prey. (mixed outcomes)

24 July 2020