COVID-19 – The Tipping Point
April 8, 2020
Tom Jefferson, Carl Heneghan
A quick look at the distribution of SARS 2 cases around southern Europe shows that viral circulation is widespread.  Higher incidence may be explained (at least in part) by the old adage “seek and thou shall find”. Translated into technospeak, it’s ascertainment bias.
If you test, test, test you will find.  Epidemics are no strangers to ascertainment bias. In the spring of 1918 military censorship ensured that most information relating to a mysterious acute respiratory syndrome was suppressed. Except for places like Spain which had not joined the war and had no censorship. So selective release of information made it look like most cases came from the Iberian peninsula – hence the name “Spanish flu”.
Technospeak notwithstanding, there can be little doubt that Covid 19 may be far more widely distributed than some may believe. At the time the first symptomatic case was diagnosed In Vo Euganeo, Italy, about 3% had already been infected – most were asymptomatic. 
Nor can there be little doubt that the price of lockdown to society and economic paralysis is likely to be paid for generations to come. In the short term economic devastation seems certain, imposing a heavy penalty on us and probably successive generations.
In Bergamo, Italy, clinicians reflected on how to prepare for the next outbreak. Their view is that focussing on hospitals is the wrong way to manage COVID. 
The symptoms of COVID-19 are unusual, wide-ranging, and in some cases can be severe: over-referral can lead to significant numbers either turning up or sent into hospital. The disease then spreads rapidly in hospital settings.  Healthcare workers have both a higher risk of exposure, and of being the vectors of onwards transmission – as happened in the 2002-3 SARs outbreak.
Because there are no licensed treatments for COVID-19 non-pharmaceutical interventions, management of complications and early recognition of those deteriorating and most likely to benefit from hospitalisation, should be the mainstay of management.
Changing the emphasis from hospitals to the community could avert a disaster for the wider population. Care in the home setting restricts movements of the infected. All those with a fever and a cough should stay at home; they could be prescribed pulse oximeters, and oxygen could be delivered to severely affected cases; rescue antibiotics prescribed along with daily video-monitoring could be used to detect deterioration. In the older population, the mildly ill and the recovering, food supplies should be delivered at home.
Older Patients admitted to hospital are at greater risk of delirium, pressure sores, adverse effects of new medications, malnutrition and hospital-acquired infections.  An older person admitted to hospital runs the risk of never seeing the light of day again. This is probably the clearest message coming from Italy.
Lockdown is going to bankrupt all of us and our descendants and is unlikely at this point to slow or halt viral circulation as the genie is out of the bottle. What the current situation boils down to is this: is economic meltdown a price worth paying to halt or delay what is already amongst us?
Tom Jefferson is an Epidemiologist.
Disclosure statement is here
Carl Heneghan is Professor of Evidence-Based Medicine, Director of the Centre for Evidence-Based Medicine and Director of Studies for the Evidence-Based Health Care Programme. (Full bio and disclosure statement here)
Disclaimer: the article has not been peer-reviewed and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health. The views are not a substitute for professional medical advice.
1 https://www.ecdc.europa.eu/sites/default/files/documents/Communicable-disease-threats-report-28-mar-2020_0.pdf (accessed 29 Mar 2020).
2 https://catalogofbias.org/biases/ascertainment-bias/ (accessed 29 Mar 2020).
3 WHO Director-General’s opening remarks at the media briefing on COVID-19 – 16 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—16-march-2020 (accessed 29 Mar 2020).
4 Crisanti A, Cassone A. In one Italian town, we showed mass testing could eradicate the coronavirus | Andrea Crisanti and Antonio Cassone. the Guardian. 2020. http://www.theguardian.com/commentisfree/2020/mar/20/eradicated-coronavirus-mass-testing-covid-19-italy-vo (accessed 29 Mar 2020).
5 https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080 (accessed 30 Mar 2020).
6 Older Patients: Common Risks for Seniors in the Hospital. https://www.parentgiving.com/elder-care/older-patients-at-risk-in-the-hospital/ (accessed 30 Mar 2020).