The Evidence that social distancing and other measure work to save lives

Here is a good starting point for debate:

Scientific and ethical basis for social-distancing interventions against COVID-19

• Joseph A Lewnard
• Nathan C Lo

Published:March 23, 2020DOI:https://doi.org/10.1016/S1473-3099(20)30190-0

On Dec 31, 2019, the WHO China Country Office received notice of a cluster of pneumonia cases of unknown aetiology in the Chinese city of Wuhan, Hubei province.
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The incidence of coronavirus disease 2019 (COVID-19; caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) has since risen exponentially, now affecting all WHO regions. The number of cases reported to date is likely to represent an underestimation of the true burden as a result of shortcomings in surveillance and diagnostic capacity affecting case ascertainment in both high-resource and low-resource settings.
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By all scientifically meaningful criteria, the world is undergoing a COVID-19 pandemic.
In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to reduce mixing of susceptible and infectious people through early ascertainment of cases or reduction of contact. In The Lancet Infectious Diseases, Joel Koo and colleagues
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assessed the potential effect of such social distancing interventions on SARS-CoV-2 spread and COVID-19 burden in Singapore. The context is worthy of study, since Singapore was among the first settings to report imported cases, and has so far succeeded in preventing community spread. During the 2003 severe acute respiratory syndrome coronavirus (SARS-CoV) outbreak in Singapore, numerous non-pharmaceutical interventions were implemented successfully, including effective triage and infection control measures in health-care settings, isolation and quarantine of patients with SARS and their contacts, and mass screening of school-aged children for febrile illness.
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Each of these measures represented an escalation of typical public health action. However, the scale and disruptive impact of these interventions were small compared with the measures that have been implemented in China in response to COVID-19, including closure of schools, workplaces, roads, and transit systems; cancellation of public gatherings; mandatory quarantine of uninfected people without known exposure to SARS-CoV-2; and large-scale electronic surveillance.
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,
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Although these actions have been praised by WHO,
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the possibility of imposing similar measures in other countries raises important questions. Populations for whom social-distancing interventions have been implemented require and deserve assurance that the decision to enact these measures is informed by the best attainable evidence.
• View related content for this article
For a novel pathogen such as SARS-CoV-2, mathematical modelling of transmission under differing scenarios is the only viable and timely method to generate such evidence. Koo and colleagues
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adapted an existing influenza epidemic simulation model
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using granular data on the composition and behaviour of the population of Singapore to assess the potential consequences of specific social-distancing interventions on the transmission dynamics of SARS-CoV-2. The authors considered three infectivity scenarios (basic reproduction number [R0] of 1·5, 2·0, or 2·5) and assumed between 7·5% and 50·0% of infections were asymptomatic. The interventions were quarantine with or without school closure and workplace distancing (whereby 50% of workers telecommute). Although the complexity of the model makes it difficult to understand the impact of each parameter, the primary conclusions were robust to sensitivity analyses. The combined intervention, in which quarantine, school closure, and workplace distancing were implemented, was the most effective: compared with the baseline scenario of no interventions, the combined intervention reduced the estimated median number of infections by 99·3% (IQR 92·6–99·9) when R0 was 1·5, by 93·0% (81·5–99·7) when R0 was 2·0, and by 78·2% (59·0–94·4) when R0 was 2·5. The observation that the greatest reduction in COVID-19 cases was achieved under the combined intervention is not surprising. However, the assessment of the additional benefit of each intervention, when implemented in combination, offers valuable insight. Since each approach individually will result in considerable societal disruption, it is important to understand the extent of intervention needed to reduce transmission and disease burden.
New findings emerge daily about transmission routes and the clinical profile of SARS-CoV-2, including the substantially underestimated rate of infection among children.
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The implications of such findings with regard to the authors' conclusions about school closure remain unclear. Additionally, reproductive number estimates for Singapore are not yet available. The authors estimated that 7·5% of infections are clinically asymptomatic, although data on the proportion of infections that are asymptomatic are scarce; as shown by Koo and colleagues in sensitivity analyses with higher asymptomatic proportions, this value will influence the effectiveness of social-distancing interventions. Additionally, the analysis assumes high compliance of the general population, which is not guaranteed.
Although the scientific basis for these interventions might be robust, ethical considerations are multifaceted.
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Importantly, political leaders must enact quarantine and social-distancing policies that do not bias against any population group. The legacies of social and economic injustices perpetrated in the name of public health have lasting repercussions.
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Interventions might pose risks of reduced income and even job loss, disproportionately affecting the most disadvantaged populations: policies to lessen such risks are urgently needed. Special attention should be given to protections for vulnerable populations, such as homeless, incarcerated, older, or disabled individuals, and undocumented migrants. Similarly, exceptions might be necessary for certain groups, including people who are reliant on ongoing medical treatment.
The effectiveness and societal impact of quarantine and social distancing will depend on the credibility of public health authorities, political leaders, and institutions. It is important that policy makers maintain the public's trust through use of evidence-based interventions and fully transparent, fact-based communication.

Here is some of the work that expert opinion depends on, so far the in the covid-19 pandemic the mathematical models have proven to be accurate.


Targeted Social Distancing Designs for Pandemic Influenza
Abstract
Targeted social distancing to mitigate pandemic influenza can be designed through simulation of influenza's spread within local community social contact networks. We demonstrate this design for a stylized community representative of a small town in the United States. The critical importance of children and teenagers in transmission of influenza is first identified and targeted. For influenza as infectious as 1957–58 Asian flu (≈50% infected), closing schools and keeping children and teenagers at home reduced the attack rate by >90%. For more infectious strains, or transmission that is less focused on the young, adults and the work environment must also be targeted. Tailored to specific communities across the world, such design would yield local defenses against a highly virulent strain in the absence of vaccine and antiviral drugs.

Exploring the Science of Social Distancing and What it Means for Everyday Life
Feature Story | April 3, 2020

As the coronavirus outbreak has spread throughout the United States, social and physical distancing measures have taken many forms — such as business and school closures, stay-at-home orders, and everyone being urged to keep six feet apart.
Recently, the National Academy of Medicine and the American Public Health Association held a pair of webinars on social distancing — or minimizing close contact with others — to slow the spread of coronavirus. These webinars were the first in a planned series that will explore different aspects of the public health response to COVID-19, and had a total audience of more than 18,000 listeners. The next webinar will be held on April 9.

“We may call it social distancing, but it’s really about physical distancing,” said Nancy Messonnier of the Centers for Disease Control and Prevention (CDC), a panelist at the March 25 webinar. Messonnier reminded the online attendees that the term does not imply cutting off ties to loved ones.
During the 1918 flu pandemic (known as the Spanish flu), many U.S. cities used the same social distancing strategies that are currently in place. Generally, the earlier these cities implemented social distancing measures, the more effective they were; evidence shows that they were able to delay the peak of deaths and the death toll overall.

“With the flu, we knew the inflection point in which the virus infected a certain amount of people,” said Howard Markel, distinguished professor and director of the Center for the History of Medicine at the University of Michigan. However, because this is a novel coronavirus, he said, “We’re learning as we go. We’ll have more data to evaluate how well social distancing strategies are working — but it’ll take weeks.”
A top question from attendees was, “How long will social distancing last?” The answer is unclear, but the goal of social distancing is to “buy time” and build the health care system’s capacity to respond to and control the pandemic, said Markel.
Researchers are also examining whether coronavirus cases will decline as summer approaches, the panelists noted. Understanding how changes in temperature and humidity affect coronavirus could help inform which social distancing strategies are used, at what level of intensity, and for how long.

It’s also important to consider the social and economic costs of social distancing, said Mitch Stripling, national director of emergency preparedness and response at Planned Parenthood Federation of America.
“When you put social distancing restrictions in place without support … you push more of that disease to the most marginalized,” said Stripling. He added that this is not likely to be the last pandemic we’ll see, which raises the importance of sustainable social distancing measures.
“Social distancing impacts everyone,” concluded Marc Lipsitch, professor of epidemiology at the Harvard T.H. Chan School of Public Health. “If we don’t do everything we can — ramping up testing, getting more ventilators in hospitals — it will be an even bigger tragedy. We need to use this time wisely.”

How Will We Know Social Distancing Is Working?
More than 100 million Americans have been asked to stay home by state or county authorities as of early April, said Anne Schuchat, principal deputy director at the CDC, and panelist of the second webinar, held on April 2. But there may be some glimmers of hope, she added. Preliminary data from California and Washington — the first states in the nation to mandate residents to stay home and keep physically apart — has shown that social distancing is working.

Nonetheless, social distancing is one of many tools, not a single solution to the pandemic, emphasized Jennifer Nuzzo, senior scholar at the Johns Hopkins Center for Health Security.
The eventual end of social distancing measures “will be a question of easing up, not lifting measures overnight, so we don’t find ourselves back to where we started,” said Nuzzo. Pointing to the successes of South Korea, she noted that public health measures like isolation of existing cases, contact tracing and monitoring, and community testing will be an essential next phase of the response in the U.S.
In addition to better disease surveillance data, there is also a need to measure the level of strain on the health care system — including whether and where supply shortages are occurring, and the level of burnout among providers. “If we want to ease social distancing, we also need to have confidence that the number of new cases won’t overwhelm the health system in the U.S.,” Nuzzo added.
“We need Personal Protective Equipment (PPE) and ventilators — but we also need the people behind them.”

We’re Only as Strong as Society’s Most Vulnerable
Sandro Galea, dean of the Boston University School of Public Health, considers the COVID-19 pandemic a traumatic event experienced at the population level.
“We may see anxiety and symptoms of post-traumatic stress disorder (PTSD) on a wide geographic scale,” he cautioned. That may be tied to job loss and economic downturn, or the stressors that may come with caring for an aging parent or someone with a disability — which are already vulnerable populations. Mitigating social and economic stressors can help prevent mental health impacts, Galea noted.

People with physical or cognitive impairment, service industry workers who don’t have health insurance, and health workers are among the most vulnerable, said fellow panelist Jason Karlawish, professor of medicine at the University of Pennsylvania. Expanding access to health insurance, unemployment benefits, and even the Internet (in light of school closures) are just a few considerations, he said, but that list is far from complete.
“The more vulnerable a person is, the further up in the line they should be for testing, vaccine, and treatment,” said Karlawish.
Concluding the webinar, moderator Sharon Inouye, professor of medicine at Harvard University Medical School, emphasized that physical and social distancing measures will likely continue for weeks or even months, which has important implications for caring for people who require hands-on assistance, particularly in nursing homes or settings that people cannot leave. “That’s where we face this dilemma of how we can continue to provide care for people, prevent them from getting the disease, and maintain their well-being and quality of life,” she said.

Has The Curve Finally Flattened In Italy? | Morning Joe | MSNBC

NBC News' Matt Bradley reports from Italy on the coronavirus infection rate, death toll and efforts to reopen parts of the economy. Aired on 4/13/2020.

Sweden is doing a limited form of social distancing, schools and universities are closed and there are no mass gatherings among other measures. There is no mandatory shelter in place orders, but there is by no means a consensus in the country on this approach, many people are taking appropriate precautions on their own. Let's compare some nordic countries and see how the are doing.

*2 million saunas for 5 million population (Hot/cold therapy) almost everybody in Finland does Sauna and often combined it with ice baths.



Sauna is not too popular in Sweden or Norway.

As we can see Sweden currently has almost 4 times the mortality rate of Norway but only tested less than 20% than Norway has.
Sweden has almost double the mortality rate of Denmark and they have done over twice as much testing as Sweden.

Finland is an outlier and has a mere 11 deaths per million and has conducted a bit less than 30% more tests than Sweden per capita. Sweden has 8.2 times the mortality rate as Finland per 1 million population, and Norway has 2.27 times the mortality rate than Finland per million, Denmark has 4.5 times the mortality rate per million than Finland.

So, like America, Sweden is number one in mortality among the Nordic countries on a per capita basis.

*These numbers are not evidence of the efficacy of hot cold therapy to boost the innate immune system with controlled stress (other evidence exists for that), but the anomaly in the data sure is interesting...

All other Nordic countries practice social distancing and stay at home orders (recommendations like here in Canada) and most businesses are closed.

As virus deaths rise, Sweden sticks to 'low-scale' lockdown
Sweden is pursuing relatively liberal policies to fight the coronavirus pandemic, even though there has been a sharp spike in deaths

STOCKHOLM -- Crowds swarm Stockholm's waterfront, with some people sipping cocktails in the sun. In much of the world, this sort of gathering would be frowned upon or even banned.

Not in Sweden.


It doesn’t worry Anders Tegnell, the country’s chief epidemiologist and top strategist in the fight against the coronavirus pandemic.

The 63-year-old has become a household name in Sweden, appearing across the media and holding daily briefings outlining the progression of the outbreak with a precise, quiet demeanor.

As countries across Europe have restricted the movement of their citizens, Sweden stands out for what Tegnell calls a “low-scale” approach that “is much more sustainable” over a longer period.

President Donald Trump has suggested that a rising number of COVID-19 deaths indicate Sweden is paying a heavy price for embracing the idea of herd immunity — that is, letting many individuals get sick to build up immunity in the population. He said: “Sweden did that -- the herd. They called (it) the herd. Sweden is suffering very, very badly. It’s a way of doing it.”

But Swedish Health Minister Lena Hallengren recently told The Associated Press: “We have never had a strategy for herd immunity.”

So far, Sweden has banned gatherings larger than 50 people, closed high schools and universities, and urged those over 70 or otherwise at greater risk from the virus to self-isolate.

The softer approach means that schools for younger children, restaurants and most businesses are still open, creating the impression that Swedes are living their lives as usual.

Yet as Johan Klockar watches his son kick a ball around a field during a soccer practice in Stockholm, the 43-year-old financial analyst says it's not like that. He and his wife work from home and avoid unnecessary outings. They socialize in a very small circle, and limit their son’s contacts to people he sees at school or soccer practice.

“Society is functioning, but I think it’s quite limited,” Klockar said. “Other than this sort of situation — schools, soccer practice — we basically stay at home.”

And while most businesses in Sweden are still operating, the economic cost of the pandemic is already being felt. Last week, 25,350 Swedes registered as unemployed, according to the Stockholm Chamber of Commerce — a larger increase than during the 2008 financial crisis.

In contrast, just across a narrow strip of sea, neighboring Denmark is already talking about reopening society. They imposed a much stricter lockdown four weeks ago, closing borders, schools and businesses. This week, the prime minister said by acting early, Denmark averted the tragedy that struck hard-hit nations like Italy and Spain, which together have seen at least 37,000 virus-related deaths, and will be ready after Easter for a slow return to normal life that starts with reopening preschools and primary schools.

For weeks, the numbers of COVID-19 cases and fatalities were proportionally similar between Sweden and Denmark, but while the economic results of the strict isolation are being felt in Denmark, Sweden’s mortality rate has reached more than 88 dead per million, compared with around 47 dead per million in Denmark.

Sweden, with a population of 10 million, has registered 899 deaths, while Denmark, with 5.8 million people, has 273 deaths. Worldwide, the virus has infected a reported 1.8 million people and killed 114,000, according to a tally by Johns Hopkins University. Still, due to limited testing, different ways of counting the dead and deliberate under-counting by some governments, experts believe those numbers vastly understate the pandemic's true toll.

After a sharp spike in deaths in Sweden, Prime Minister Stefan Lofven proposed an emergency law allowing the quick closure of public venues and transportation if needed. Lofven also warned citizens to prepare for possibly up to thousands of deaths.

Nevertheless, Tegnell, the chief epidemiologist, insists that Sweden’s approach still seems to make sense, though he also acknowledges that the world is in uncharted territory with the virus.

He argues that while Sweden might have more infections in the short term, it will not face the risk of a huge infection spike that Denmark might face once its lockdown is lifted.

“I think both Norway and Denmark are now very concerned about how you stop this complete lockdown in a way so you don’t cause this wave to come immediately when you start loosening up,” he said.

He said authorities know that the physical distancing Swedes are engaging in works, because officials have recorded a sudden end to the flu season and to a winter vomiting illness.

Lars Ostergaard, chief consultant and professor at the Department of Infectious Diseases at Aarhus University Hospital in Denmark, agrees it is too soon to know which approach is best.

"Every day a person is not being infected because of the strict lockdown, we are a day closer to a cure," Ostergaard said, underlining the advantage of the Danish approach. But he acknowledges that the long-term consequences of a locked-down community could also be “substantial.”

“There is no right or wrong way," Ostergaard said. "No one has walked this path before, and only the aftermath will show who made the best decision."

Vanderbilt Health Policy COVID-19 model finds evidence of flattening curve, recommends distancing policies continue

Apr. 9, 2020, 4:52 PM

by Jake Lowary
Vanderbilt University Medical Center researchers have found evidence of the rate of COVID-19 infection slowing in Tennessee, which reduces the chance that the state will run out of hospital capacity for patients.
They stress, however, that social distancing is needed to keep the rate of spread low and that any future rollback of social distancing policies must be contingent on widely available testing and comprehensive tracing of infected patients and the people they were in contact with.
“We all want to go back to some sort of normal, but to be able to relax some of the social distancing guidelines, you have to have in place widespread testing and robust contact tracing,” said John Graves, PhD, associate professor of health policy and director of the new Center for Health Economic Modeling at Vanderbilt.
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Evidence that social distancing works

One problem with people arguing that "lock downs don't work", is the rather loose term "lock down", this is important because it describes a wide variety of approaches to social distancing and the enforcement of it. In some Asian countries that have had past experience, proper preparation and extensive testing, they have had more relaxed social distancing rules, but make no mistake they have rules, careful monitoring, extensive and intrusive (by western standards) contact tracing.

In most western countries, many businesses and almost all schools have closed and social distancing is loosely enforced. In Canada I can go to the grocery store, the pharmacy and even other retail business, even go for a walk, the government supplies a generous dole for many, we have a unemployment insurance and the government is stepping up with help for business. We have to take this approach while we prepare for massive testing and other measures that will allow us to emulate the South Korean model to the extent that we can. Fortunately testing just got a lot cheaper and quicker, and in Canada will be widely available in a couple of months. Its still gonna hurt, 20% of the economy ain't coming back anytime soon and that applies to most western countries. We are wealthy and have the luxury to choose to keep to our principles and values and have good healthcare systems that dramatically lower the mortality rates. This improvement in patient outcomes will continue as treatments and protocols are continuously improved.

In developing countries its a completely different matter, social conditions are often crowded and many people have to work everyday to eat that day. Often goons are stationed at every intersection and people are locked into crowded apartment buildings in atrociously hot weather and not allowed access to the outdoors, this is the "lock down" that many in developing countries experience. Needless to say there will be enormous social pressure to go back to "normal" and hunger is gonna drive millions if not billions out their doors and into the streets. We will soon see what lack of personal distancing measures look like on a massive scale, the 3 months of monsoon won't come early enough for many in tropical countries.

Here is the effect of personal distancing on the infection rate trend lines so far, some argue that this can be accounted for by a travel ban, but a travel ban is just a form of social distancing only on another scale, the underlying principle is the same. The vulnerable such as the elderly are the low hanging fruit and are like the canaries in the coal mine for most places and the first indication that there is an outbreak, it's a crude and callus form a testing really. The trend lines clearly indicate that social distancing is breaking the back of the exponential growth rate of infection, variations in the rates depend on the time of implementation of social distancing orders, the kind of measures taken and their adherence by the public.

There are a lot of variables here and the first one is, what is meant by the term lock down, the definition is too loose to even form a meaningful question, let alone as one to obtain meaningful answers. Another factor is the effect of herd immunity since many are asymptomatic and the answers to that one will be coming over the next several weeks as antibody tests are rolled out in Canada and the USA.

We all have our biases and they are strongest when our passions are aroused, intelligence is no defence either, that's why the scientific process is so careful in trying to remove biases, conscious or subconscious. In this case the numbers don't lie, they are what they are, it's in our interpretation of those facts, are where the bias are to be found, both for and against social distancing.This is the worst data there is, it correlation data with a huge amount of variables, but there is a clear trend in it thus far. More importantly, it is validating the predictive power of established mathematical models, there is power in prophecy.

COVID 19 State by State: Some Graphs Turn a Corner