I live in west of Wales, a wonderful part of the world to live and during the current season, my three consultant colleagues and I decided the best way to help our colleagues is to try and maintain a consistent presence in each of our four hospitals. As a result, I have spent most of my days during the UK “lockdown” season in Bronglais General Hospital in Aberystwyth.
This has allowed me to reflect on the pandemic through the interactions with colleagues in this part of mid Wales. In my first presentation to the Bronglais “house” on 16th March, I suggested I had no reason to believe this novel coronavirus would behave any differently to any other infectious disease in its penetration across the three counties of Carmarthenshire, Ceredigion and Pembrokeshire, which are served by the Hywel Dda University Health Board.
I arrived in this location in 1990 to take up my first NHS consultant post in Carmarthen. Methicillin Resistant Staphylococcus aureus (MRSA) was spreading across the UK but at a slower pace than viral diseases. Numbers rose initially in the east of Wales, moved along the M4 corridor from Cardiff to Swansea before arriving in Carmarthen, later spreading to Haverfordwest in Pembrokeshire before heading north to Ceredigion. The Senedd Research team at the National Assembly for Wales have produced a graphic that illustrates this.
This pattern is generally repeated on an annual basis with norovirus, the cause of winter vomiting disease to the extent that I suggested this is what we should expect with this new coronavirus.
The UK is now talking about the peak having been reached, albeit with social distancing measures having flattened the peak and making a plateau. This is excellent news and so far has allowed the NHS to cope with the caseload. However, talk of the plateau in our part of Wales has left us somewhat perplexed, as our numbers of admissions have not risen as far as we had anticipated compared with our colleagues in the east of Wales. Yet even our numbers appear to be plateauing.
My epidemiology colleagues in Cardiff publish daily detailed updates of the coronavirus cases, which I have been studying since they began to produce them. I now hone in on the Local Authorities table tab and a recent copy is reproduced below:
If you examine the last column, “Positive Proportion,” you will see the positivity in the east is highest, Aneurin Bevan University Health Board counties at their height showing a figure of 45% in Blaenau Gwent and Newport, although now declining in this latest table. The positivity declines as you move westward, through Cardiff, Cwm Taf, Swansea and then my area, Hywel Dda. In Hywel Dda, the highest rate in Carmarthenshire, followed by Pembrokeshire and then the lowest rate in Wales is in Ceredigion. This therefore is demonstrating the pattern I was anticipating in early March, based on previous experiences of the arrival of new infections into Wales. North Wales infections are independent of the south and west Wales experience, infections arriving through a similar travel pattern along motorways and trunk roads from the Merseyside and Manchester conurbations.
Powys is very rural, with no major trunk roads but multiple smaller access routes from both England and Wales. It was however the rurality of Powys and Hywel Dda counties that set me thinking whether this spread of infectious disease observed in Wales is accounted for by a variation in population density. The population of Ceredigion is the smallest of our three counties yet the geographical area is similar to the other two counties.
I have therefore downloaded the COVID-19 data, together with mid-year population estimates and the geographical areas of all 22 local authority areas in Wales. The aim being to examine rural distancing as a natural defence against infectious disease spread.
How might rural distancing influence the pandemic?
This is where we get into the prediction game and once again, I would warn my readers that these are my thoughts and do not necessarily represent the views of either my employer or the health board where I practice microbiology. There will be many different opinions about how the future will play out.
Many are talking about the risk of second waves. I am less fearful of such. In a previous post, I talked about minor and asymptomatic infections being a large unmeasured part of this current pandemic. Data coming out of Italy is confirming that this is likely to be a considerable proportion of the population. With a symptomatic positivity rate of 45% as the highest urban rate in Wales, there is no reason to suspect serum surveys when they are conducted will not reinforce the Italian data and that minor and asymptomatic infections will mean a considerable proportion of the urban populations will have met the virus, and based on all previous respiratory infections, will be immune at least for an initial period of time yet to be determined.
In the rural communities, and at its height, Ceredigion reached 11% positivity, our populations will continue to be at risk. However, as lockdown rules are relaxed and our visitors come back to enjoy all the beauty on offer, and if we ask symptomatic visitors to either stay at home or self-isolate, then the risk of a person active asymptomatic infection arriving is statistically less likely. Therefore, because of the natural rural distancing, I suggest we will continue to see sporadic cases and family clusters for quite a time in west Wales.
Our biggest risk will probably be with hospital and nursing/residential home outbreaks and we will need to be on our toes to spot quickly and isolate cases. This is going to be much easier from the middle of May onwards when local testing of SARS-CoV-2 is available.
Finally, as we reflected in an ITU discussion on Friday, our population in Ceredigion may be of particular value to the Oxford and London vaccine groups as they seek a population with lower exposure rates on who to test their vaccine efficacy.
That’s interesting Mike. Thanks
Interesting thinking Mike and I wouldn’t disagree with what you say. Many of us in Ceredigion, north Powys and south Gwynedd are probably living in social distancing under normal circumstances anway!.
It’s yet another fascinating bit of learning to come out of this pandemic. Rural distancing as a reason for others to come and work with us in this special part of Wales.
Interesting reading. However as someone who is shielding because of being at higher risk, it potentially means my personal lockdown will be longer than most?
I’m in the same situation as you, and have the same concern.
Perhaps this article might inspire a few General Practitioners (GPs) to consider moving to the Beautiful Rural Tranquility of Machynlleth – in North West Powys – (thus regionally allocated to Bronglais Hospital & Hywel Dda) – where there is an ongoing shortage of GPs – with 1 or 2 GP Vacancies unfilled – for quite some time – in the Machynlleth Health Centre Practice.
A lot of our Health Board adverts try to highlight why we love this area so much. Let’s hope so.
Thank you for a clear presentation of information. It’s nice to have actual unvarnished facts.
A very interesting article. However, many of us in Ceredigion had the symptoms of Covid-19 over a period of time extending from mId December to mid March, and were recovering by ‘lockdown’. My symptoms started on January 25th, lasted for over four weeks and, as a result of the infection I have now been left asthmatic. It will be interesting to see, if antibody testing becomes widely available, whether we did in fact have Covid-19 or something else.
Thanks, Stephanie.
You are not the first to say this. I think this would be unlikely, although, if you were found to be antibody positive, I guess you would naturally attribute it to when you had a severe infection during the winter season. However, when we were first testing, we did both COVID19 and all the standard viruses and we were getting lots of alternative positives with the COVID19 being negative. My first blog post in this series tried to expose this issue: https://phw.org.uk/2020/04/10/a-question-of-scale/
This explains my take, with a wide range of symptoms associated with all the respiratory viruses from the very mild to the very severe. Normally, the very severe are few and far between and do not have a major impact on the national consciousness. Locally, these other viruses can cause the same family distress, sometimes with deaths being recorded. It’s when we have deaths on the scale that we have seen this year that the respiratory viruses get the attention that they do.
The plan is still to do some antibody surveys but currently as you may have read, there remains doubt over the sensitivity of the tests offered so far. I have no idea over how an antibody test would be offered, but if you were positive, the more likely reason in my mind would be asymptomatic infection during the recent period. For now, I would still advise you consider yourself non-immune and still at risk of infection. I anticipate as we get local testing, testing will eventually be available to anyone with symptoms.
Thank you very much for your reply and advice. I am following Government guidance; we all need to do so in order to keep ourselves and others safe.
I fell ill on Dec 6th and continued to be ill all over Christmas. My dry cough and quite extreme shortage of breath finally eased at the end of January. My daughter who lives near London, succumbed to it a week later, despite not being in direct contact with me. We infected our entire family over Christmas. They were all very poorly with it. Have not stopped wondering as I’ve not had a chest problem previously for over 3 years!
The other thing I was reminded of recently is we have had quite a lot of mycoplasma recently, which is a bacterial infection but detected using the same molecular techniques. Although antibiotics have a place for this infection, because it behaves like a respiratory virus infection and is self limiting, unless you had a test at the time, you might not have needed to go to your GP.
Thank you for this interesting perspective on rural communities and the spread of infection.
I lived in and around Machynlleth for many years but since June last year I moved to Uganda.
What has caught my attention is the low rates of infection in many countries across Africa.
Africa is also mostly rural with often large spaces between villages and trading centres.
I think air travel has been the main method of transmission worldwide, and looking at flying patterns, on an app called FlightRadar 24, you can see how the patterns of concentration of flying mirror the areas with the highest outbreak of Covid 19.
Uganda has handled the outbreak well, closing down the airport, public transport, shutting schools, and banning private vehicle use except for those working for the essential services.
The borders are closed except for goods traffic.
Almost all active cases have come from air travellers and goods lorry drivers entering from Kenya and Tanzania. All drivers are tested upon entry.
https://covid19.gou.go.ug/ for the lates statistics.
The Ministry of Health in Uganda bases its management of COVID 19 upon its experience of managing other infectious diseases like ebola, which had a much higher mortality.
Very interesting Mike thank you very much. A bit off point (and sorry you must know this already so at a risk of repeating badly) but the now first confirmed death of COVID in USA was Feb 6 with no history of travel so community transmission which means it could have been there since December. There is also a belief that many deaths occurred previously in California but were recorded as flu deaths (as they didn’t know about COVID). They are going to try and check back on many of these to see if true and antibody studies suggest many more have been infected than thought previously.
A Guardian article a few weeks back showed that the first Covid deaths here in the UK were now known to be late Feb, earlier than previously thought. It would be interesting to have thoughts from an expert about how long its thought its been here for, going with stories of people who had a bad illness from December onwards, including a nurse and her son i spoke to who had a ‘bad and unusual pneumonia’ in late January.
Personally, I’m 33 and I live in rural Wales (although a tourist hotspot) and last week of Feb following a week or so with a very harsh sore throat I suddenly had breathing issues, noisy breathing (crackling etc) followed by days of shortness of breath, aches, headaches, chest pain, sweats, loss of voice, loss of taste (didn’t think anything of it at the time), stomach issues and extreme fatigue to the point I would fall asleep sat down without trying to.
I went to see a nurse (was asked if i had been to China or Italy as this was early on) and was told my asthma was back (having been told it had gone 4 months prior after giving readings higher than an average person and never needing inhalers) and was given antibiotics and steroids. I had to ask for an additional batch after a week as it didn’t really improve the breathing. Didn’t feel myself until late March and that’s when I contacted the nurse, explained what I had and she told me about her illness and her sons and told me there’s a chance that it could have been COVID and that I should take Vitamin D supps. At the time the timeline didn’t make sense but as more info comes out the timeline isn’t impossible anymore particularly as I had been to Liverpool 2 weeks before becoming ill (with a friend from Ceredigion who was ill at the time which is interesting after reading Stephanie’s point above). Also as Stephanie noted above whatever I had in Feb seems to have ‘woken up’ the asthma a little after never having it really for years and years.
As I say very unlikely thats that what it was but a reliable antibody test is crucial I guess to get the overall infection picture
Also sorry another question, what are your thoughts on the many studies about the correlations between low vitamin D levels and bad outcomes in respiratory infections? Particularly as the most hit groups of people by COVID 19 are generally those with low Vitamin D levels
Apologies this is probably far too long for a reply but would love to hear your thoughts!
Thanks Sion, for taking the time to work through this. These discussions are valuable. My own staff highlighted a report in the Sunday Times (available here: https://www.thetimes.co.uk/article/tracker-app-suggests-coronavirus-arrived-at-new-year-rcsvkdrgn ) I personally do not subscribe so have not been able to review other than what is freely available. The headline, “Tracker app suggests coronavirus arrived arrived at new year,” belies the same potential flaw that I was exploring in my reply to Stephanie, that all the respiratory viruses have a common set of symptoms that the body produces in response to such infection. So if someone has a severe respiratory/flu like illness, they will remember it and may associate it with the start of the pandemic. But over the winter season in our part of Wales, we had many different respiratory viruses circulating and we had a number of influenza A and human metapneumovirus infections, some of who were severe enough to be admitted to our ITUs.
As the new coronavirus arrived, we were testing for the wide range of viruses and continued to see more of the other viruses initially before the SARS-CoV-2 virus began to increase. So flu-like and more severe infections earlier in the year were more likely to be other viruses but then switched to be more likely to be SARS-CoV-2. Potentially, your illness, being closer to March, may well have been with the new virus, although it largely will also depend on where in rural Wales you are based. As explained in the main text, risk seems to vary by county, with Ceredigion at the lowest risk but definitely circulating by March, so some is likely to have been around in February.
However, as with Stephanie, important not to be lulled into thinking you have met the virus, unless you have the opportunity to have an antibody test, if one becomes available and how widely it is used.
I have not personally looked at the studies around vitamin D and respiratory infections but I recognise there has been discussions with both this and other respiratory infections.
Good evening Mike, thank you very much for taking the time to respond, and I agree these discussions are very valuable. I also enjoyed your previous piece ‘A Question of Scale’, very interesting and somewhat reassuring! It will be interesting to see what comes out of the study in California re: looking back at deaths put down as flu seeing as a community transmitted death in early February.
In terms of mine, I agree 100% its most probable that this wasn’t it and somewhat ‘wishful thinking’, and was a form of flu (which makes the prospect of catching COVID19 if a regular virus did that to me pretty scary!). I’m making sure to behave as if it wasn’t CV in order to protect myself and those around me. I live in Pen Llyn so waves of people coming in an out, work in a local authority, go to the gym often and was in Liverpool 2 weeks prior to being ill so plenty of places to catch something I guess. I’ve had chest infections before, I just remember thinking at the time before even considering CV that this is very weird, never ever had breathing that sounded like a paper bag crumpling before and that level of fatigue and chest pain when breathing, and also the length it took to get over it, better one day then something else wrong next day etc.
One thing that did make me think it wasn’t CV was that surely more people around me would have been ill although my wife did have sore throats and coughs around same time and my toddler also had a cough for a long time and conjunctivitis. Also from what I’ve read on levels of asymptomatic and the percentage of mild illnesses there’s no guarantee they would have been ill? A widespread reliable antibody test will be so valuable when (if!) it comes out.
In terms of Vitamin D I’ve just put a link to a good video by Dr John Campbell alongside a few links to interesting articles. It was a bit troubling to see the other day the NHS UK twitter account tweet out that ‘Contrary to reports in the media, Vitamin D does not protect against COVID19’ – whilst it may be technically true and not proven against this particular virus, it has been proven to lessen frequency and severity of respiratory illnesses as per the BMJ article below. Considering the very low risk of any issues from taking supplements and the potential to lessen severity in many groups (such as elderly, BAME, overweight) I just thought it was a very strange thing for the NHS to tweet out. The last link is a study from South Asia looking at vit d levels in patients in hospital side by side with the severity of their illness.
https://www.youtube.com/watch?v=GCSXNGc7pfs
https://www.bmj.com/content/356/bmj.i6583
https://www.ncbi.nlm.nih.gov/pubmed/32252338
https://tilda.tcd.ie/publications/reports/pdf/Report_Covid19VitaminD.pdf
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484
Thanks again Mike,
Sion
Thanks, Mike, I find your blog is very interesting and insightful. What I have never been able to understand, is why HDUHB has implied that our peak in Dyfed will be in May, when our area locked down at the same time as the rest of the UK and the positive proportion of COVID in our population was lower. Our practice work-wise for the GPs is very quiet and we are not seeing the flood of patients that we were told to expect. Would it not have been expected that our plateau would occur roughly at the same time as the rest of the UK? Perhaps I am missing something obvious. Thanks again. John
Thanks John. Good to hear from you. In that same presentation I refer to on 16th March, my personal prediction, based on looking at the WHO/China report, was we would get to a peak tomorrow, so how wrong was I! . . . . .
I’m working on my thinking for a new blog around my favourite subject Complexity. I am reminded that in any system, the outcome is very dependent on the starting conditions and the starting conditions in China are different to those in Italy, which are different to those in the UK. At a local level, as we see, the starting conditions are different in Carmarthen, Pembrokeshire and Ceredigion.
I suspect it would also be very difficult implement different approaches to lock down in different regions of the country and probably underlies why the debate about release is so difficult.
The lack of routine patients, let alone COVID patients is an increasing worry in both primary and secondary care and I hope is one of the other drivers influencing the release from lockdown.
Good Morning, I live in Dyfi Valley Health Care area where we (over 65’s) were offered a pneumonia vaccination as well as others ‘flu, shingles etc. I think there was a high take up. Would the pneumonia jab have been helpful against Covid 19? Norma
Hi Norma,
Thanks for your enquiry.
The pneumonia vaccine you get is specifically against bacterial infection with Streptococcus pneumoniae so in respect of the COVID19 directly, it does not have a benefit. However, classically with Influenza virus, the virus damages the cilia in the respiratory tract which are the “hairs” that waft natural secretions up the respiratory tract and keep it clear. This damage then allows the bacteria to gain access to the depths of the lung and set up bacterial pneumonia. During the winter seasons, we see increases in bacterial pneumonia with the pneumococcus and the vaccine will offer protection against this. I do not yet have a feel for whether we have had an increase of pneumococcal pneumonia secondary to the COVID19 infections but this is certainly the case with other respiratory viruses as well as the Influenza virus.
The pneumococcal vaccine is certainly of value in our older population, which includes me! However, at 67, I thought I better go and check why I only get offered the flu vaccine. I checked the “green book” and I can see I must have missed an alert somewhere, so I better get in to the GP and also advise my wife the same!
Mike
I could be misunderstanding your reasoning here-but a 45% positivity rate just tells us that we are testing for far too few people? It has very little about the proportion of the population infected. Let’s say that we are underestimating cases by a factor of six given a potential large degree of asymptomatic infection-that would still leave the vast majority of populations across Wales with no immunity and susceptible.
Your blog seems to imply that testing evidence points to a large number infected, but the positivity rate would only imply that if it had been a random sample? Have I misunderstood something?
Very many thanks for taking the time to think through this issue, Ben.
To date, the only substantive evidence we have in Wales and the UK largely comes from the testing of symptomatic individuals. We know from our own test referrals in Hywel Dda that our tests include a few with no symptoms and with yesterday’s announcement by the Welsh Government to test all nursing and residential home residents when a case is detected, we will begin to collect the evidence not only of asymptomatic infection but of no infection.
In the Local Authority table from Public Health Wales, the column before positivity rate is tests per 100,000 population. While there is considerable variation, what struck me is that Blaenau Gwent and Carmarthenshire generally seems similar. Indeed in the most recent data for 1st May, Carmarthenshire is testing more cases yet the proportion infected remains lower and is declining a few percentage points at much the same rate as Blaenau Gwent.
What I have not exposed in these blog posts is a more detailed discussion of the proportion of people who appear below the waterline in my iceberg analogy who do not get infected. When I do my presentations, to date I have been talking about these two groups of individuals, on the basis that with every other viral respiratory infection, the population below the waterline fall into these two groups. What we do not yet know but are accumulating data on, is the proportion in each category. A recent BMJ article reports that 80% of COVID 19 cases are asymptomatic. What we do not yet know is how many people, when exposed to the virus, do not get the infection with COVID 19, yet there will be a proportion. That being said, I always warn my listeners and readers that this should not make them blasé about this current infection. This is an unknown for every individual until they meet the virus and everyone who does not know that they have had the virus, should continue to consider themselves susceptible.
I found this article from 2018 a useful read about the 1918 influenza pandemic. It illustrates how host factors influence the risk of acquiring infection with a respiratory virus. There is now evidence of this with COVID 19 with black and ethnic minority groups being apparently at increased risk of acquiring the virus. Host factors seem to explain the difference in infectivity between SARS-1 and SARS-2. Coronaviruses are not the same as influenza viruses and do not seem to have the same capacity for genetic shift and drift such that unless there is a genetic change in the virus, as seems to be the case with the 1918 pandemic, I would still hold to my views expressed in the original post.
Again, all that being said, please continue to follow current government advice. I and my family are doing so as this can only be speculation on my part.