Talk Evidence
Talk Evidence covid-19 update - Confused symptoms, fatality rate uncertainty, Iceland’s testing
27 Mar 2020
For the next few months Talk Evidence is going to focus on the new corona virus pandemic. There is an enormous amount of uncertainty about the disease, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. We're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week 3.50 - There is a lot of confusion around symptoms, we hear what Carl's review of the case studies has found, and why he thinks fever and persistent dry cough may not be a sign of all cases. 10.30 - where are we with research into antiviral treatment 17.30 - John Ioannidis has expressed concerns about the quality data used in modelling and therefore our pandemic response. We hear what his concerns are, and what needs to be done to answer them. 29.10 - Iceland is the only country attempting to do population level screening, we hear from Kári Stefánsson, CEO of deCODE genetics which is working with the Icelandic government to allow everyone to access testing for the virus.
Chapter 1: What is the main topic discussed in this episode?
Welcome back to Talk Evidence. Well, we're in lockdown. We're recording this at home, totally remotely.
Chapter 2: What symptoms are commonly associated with COVID-19?
We're in three different cities. So if this sounds a little different, that's why. Before we get into the evidence, I just wanted to say that obviously in this crisis, we're going to be focusing very much more on COVID-19 across all of the podcasts that we do, not just Talk Evidence. So for the next few months, we'll be mostly talking about that.
As the evidence is quickly changing, we're also going to be doing some extra talk evidences, trying to keep you up to date with that changing picture. So this is the point, if you've not subscribed to do that, we're on Apple Podcasts, Spotify, wherever else you get your podcasts from, and we'll try and keep you abreast of everything that we know.
So now that's over, it's time to introduce ourselves.
Chapter 3: What is the current research on antiviral treatments for COVID-19?
I'm Duncan Jarvis, Multimedia Editor for the BMJ. And as always, I'm joined by Helen and Carl. Helen, can I get you to introduce yourself?
I'm Helen MacDonald, UK Research Editor for the BMJ. And I'm coming to you from Bath today, where it's very sunny.
And Carl, how about you?
Hi, it's Carl Hennigan here.
Chapter 4: What concerns does John Ioannidis raise about COVID-19 data quality?
I'm not quite sure what my role is anymore. I'm in my hut in the garden in Oxford. It's a COVID hut. You might hear some birds in the background if you listen very carefully. And I am also editor-in-chief of BMJ Evidence-Based Medicine.
Great. And I'm, as everyone's saying this, recording from Brighton and I'm looking outside and there are some seagulls circling. So if you can hear that in the background, that's why. So, Carl, you've been doing an awful lot around COVID-19 at the moment. It's been a busy time for you. What have you been up to?
Well, one of the things is when it started to emerge, and particularly the guidance changed not only in the UK, around the world, we started to realise that there were a significant number of questions
Chapter 5: How is Iceland conducting population-level COVID-19 testing?
that were coming at us all at once for contextualised evidence about things like face masks, to drugs, to what about steroids, what about treatment of pneumonia in community hospitals.
And what we did is put together our team at the centre, but a huge number of people who've joined us to start producing rapid evidence reviews, trying to answer some of the questions that can help clinicians on the ground, particularly in this first few weeks, facilitate decision-making. Because what's really important here is that actually everybody doesn't panic.
And there are issues here which are having to made up on the hoof, like how do you examine somebody when you've only got a few minutes because they're overwhelmed? How do you minimally examine people without actually touching the patient? So there are loads of things you need to do differently. And we're trying to help produce some of the evidence to help them decisions.
Great.
Chapter 6: What is the significance of asymptomatic COVID-19 cases?
Well, we're going to get into some of that in a second, but, you know, as always, we do a start and a stop in Talk Evidence, and we've got a couple of them now. So, for a start, we are going to be talking about symptoms. Now, I've had something. I've had some sort of cough, maybe a very slight temperature, but this is the time of year that we're all getting respiratory infections anyway, so...
Who knows if it's COVID. Helen, have you got any clarity for me there?
Well, this is exactly what I've been thinking about this week and what I've been hearing lots of my clinical colleagues talking about. And I think it is time to start thinking more broadly about the symptoms of COVID-19.
So a lot of the public information has been very centred on fever and cough or dry cough and breathing problems because those have been the things that have been triggering self-isolation here in the UK.
Chapter 7: How does the case fatality rate for COVID-19 vary across populations?
But in our previous podcast, we mentioned that there were
various case series starting to come out describing symptoms um that people have had and some of those have got quite big now to about a thousand people or so so i think it is time to start looking at the spectrum of um symptoms that people have because i think out in the public people might be kind of falsely reassured by only having a runny nose or or um just feeling a bit under the weather.
And I know Carl and his team have been working a bit on this. And I think we should hear more from him on the kind of symptoms that we're starting to see.
Yeah, look, I mean, it's very interesting. I think there's sort of been a hone down on just two symptoms, hasn't there? Fever and cough. And if you've got fever and cough, you've got potentially COVID and you should be tested. And if you haven't got them, you don't require testing because you might have something else. That is being shown by the evidence emerging to be incorrect.
The first thing is to say, if you look at the Diamond cruise ship and there was a piece in the BMJ which looked at the village in Italy who tested all the people in the village, that actually half the people in this outbreak will be asymptomatic. They just won't know they've had it. So they may feel a bit unwell.
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Chapter 8: What challenges do researchers face in estimating COVID-19's lethality?
They might feel a little bit hot, but they just would not present normally saying I've got symptoms. So that's number one. Number two is then is to say there are much more than a cough and a fever. There's a whole myriad of symptoms that appear in a systematic review, which has 19 studies in now, the majority in China, but some outside of China.
And these are systematic review of what, Carl, of the case series?
So there is, yeah, systematic review of 15 cross-sectional studies and four case series. That include the study you've just included, which is one of the largest studies. There are lots of preprints. And then there's stuff that's gone through journals that actually has some element of peer review and some element we feel of consistency and accuracy.
We're finding lots of problems with the preprints. We're just not quite sure how they arrived at the figures, whether they're accurate. They don't have tables with numerators and denominators in. So they've been rushed out there. So we feel like when we look at them, and we've even got one where it's been published twice with the same data and they don't look the same.
So we're focusing on the peer reviewed publications. And I think there are some important aspects. The first thing we're railing against is providing a point estimate. So what you'll see is, for instance, 90% of people have a cough. Well, actually, across the 19 studies, cough in adults varies between 48 and 74%. So there's actually quite a wide range, depending on where you are in the context.
Fever is much tighter, 89 to 96% of adults. But get this, in children, fever is 28 to 60% of children. So much less, much higher variation. So what we're seeing is even if you just go and fever and cough, a significant proportion of people will have COVID without them symptoms. And then other symptoms are a whole myriad of things from fatigue, myalgia, headache, diarrhea, loss of appetite.
Some people will have sore throat, 3% to 20%. And then there's some other things, tachycardia, anosmia, conjunctivitis, like your eyes are burning. So there's a huge variation in the symptoms. And I think this is what's making this such a...
Not just not an interesting, interesting is the word, but a difficult disease to deal with because it's spreading rapidly because half the people are asymptomatic. Some people have symptoms that are not consistent with what you think COVID is and they may not be tested or are let out back into going back out into the workplace and infecting other people.
So what we're saying is in this current situation, anybody with symptoms that looks like an acute respiratory infection should be tested for COVID because they've got a chance they actually do have it.
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