Following the seasonal evidence for hospital admissions

An updated post first published in the Spectator on 20 Oct 2020

This is an updat of a post first published in the Spectator on 20 Oct 2020: It still holds true

https://www.spectator.co.uk/article/will-covid-cause-a-winter-crisis-in-the-nhs/

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Warnings of exponential growth of the F word “Flu”, COVID-19 cases, now RSV cases and on the horizon metapneumovirus are multiplying. By sheer chance, all have licensed remedies or prevention interventions in their name or are in development. 

The warnings are inevitably followed by a rise in hospital admissions and are the sole winter focus for Governments. For 20 years, we have heard nothing but “flu”. All are one-track, one-pathogen scenarios which entirely ignore reality. Except, of course, for the F word “flu”. “Flu” is, however, a three-card shell game that allows politicians and their underlings to issue scientifically vague warnings and always keep people under the hammer. Using the word “flu” for politicians and their underlings means this: heads I win, tails you lose.

Cases of respiratory disease fluctuate throughout the year, and so do related hospital admissions and, unfortunately, deaths. This gives rise to the seasonal effect, where more people die in the winter than in the summer. 

However, the causes of admission to the hospital for acute respiratory infections are as varied as the pathogens causing them. Few have specific drugs to negate their impact, so we rely on general care and support measures and antibiotics if there is a superimposed bacterial infection. In post-severe cases of Covid-19, dexamethasone can be used to good effect in those in intensive care.

The question, though, is whether we should rely on dire warnings that we are heading in the “wrong direction” or whether we need to rely on modelling and other predictions to fathom what lies ahead. Or is there an alternative way to look at the data in a context that can help the government interpret what might happen next?  

Everyone in the northern hemisphere knows that with the onset of autumn, acute respiratory infections and unplanned hospitalisations increase. 

In 2017, in an answer to a Parliamentary Question, Philip Dunne MP, the then Minister of State (Department of Health), provided the number of unplanned accident and emergency attendances resulting in an admission and a primary (main) diagnosis of respiratory condition between 2010-11 and 2016-17.  The downloadable file, helpfully tabulates the data for admissions in England by month, age category and by year. 

The data show that the worst month was December in six of seven years. Approximately 1000 admissions per day occur in the NHS in England for respiratory conditions. There is a rise that starts in September and peaks in December-January and then tails off as we go into Spring, reaching the bottom in Summer. In a “good” year, we see admissions go below the 15,000 mark. 

The seasonal effect should be a barometer for planning and future actions. The figures are based on Government data. We can use them as a benchmark for the severity of the situation month by month. 

September saw around 21,000 unforeseen attendances and admissions, leading to around 700 unplanned daily admissions. However, by the end of September 2020, around 300 patients were admitted to England per day—less than half of what we would typically expect. The difference is marked, especially with the complete absence of alarm in September  2015, which “topped the September charts” with over 21,000 admissions.

Here is the golden opportunity for governments to prepare prospective testing of all admitted patients, not just for Covid but for the other common pathogens, so we can finally find out exactly what is happening. Searching only for one pathogen misses the others. 

From the beginning of the Covid-19 story, we thought that understanding the evidence for how the virus was transmitted would hold the key to mitigating the effects of the viral pandemic. We also had a hunch that this would help us differentiate between the ravages of SARS-CoV-2 and those induced by our response to it.

The seasonal effect in the Northern Hemisphere significantly impacts what happens year to year.  The most significant impact occurs at the beginning and end of our lives: most increases in admissions are observed in those under 1 year old and those over 85 years old.  Over 16,000 under 1 year get admitted for respiratory conditions yearly - a nearly six-fold increase from August to December.

The seasonal effect also significantly impacts deaths. From 2017 to 2018, England and Wales had 50,100 excess winter deaths. Over 85-year-olds account for over 5,000 admissions in December, and the observed variations in fatalities each year are primarily driven by this age group.

And as this winter’s panic over the “quademic” rescinds, we see the inevitable rise in respiratory followed by a fall that mirrors their arrival. As we predicted two weeks ago, based on the latest data, the headlines have disappeared until next year, when regular winter service will resume.

The Intense Influenza Frenzy means only one thing: Positivity is Decreasing

This post was written by two old geezers who would like to pay homage to the ghost of Dr William Farr: what goes up must come down.