Outside the marginals

A commentary on the politics that followed the UK 2010, 2015 & 2017 elections (and THAT referendum)

Covid19 – Attempting a Personal Risk Assessment

My doctor has confirmed that I count as “vulnerable” (due to lung problems) and therefore I should socially-distance for “at least 12 weeks”. This is the only real mitigation step offered by this government (so far; drafting this on 21 March 2020). Can applying Health and Safety principles – particularly with regard to Risk Assessment help me take steps that are both proportionate and effective?

The Health and Safety Executive (HSE)says:

As an employer, you’re required by law to protect your employees, and others, from harm. Under the Management of Health and Safety at Work Regulations 1999, the minimum you must do is:
  • identify what could cause injury or illness in your business (hazards)
  • decide how likely it is that someone could be harmed and how seriously (the risk)
  • take action to eliminate the hazard, or if this isn’t possible, control the risk
HSE: Managing risks and risk assessment at work: Overview [accessed 21 Mar 2020]

How might this approach, Harms > Hazards > Risks > Mitigations, apply at a personal level?

Harms

The “obvious” principal personal Harm is catching Covid-19 (the disease caused by the virus SARS-CoV-2 [Ref: World Health Organisation WHO]) and suffering the consequential problems.

Other Harms that have to be considered are:

  • the possibility of getting the disease and passing it on to others
  • dangers arising from a breakdown in order due to the government losing the confidence and support of the public.

Catching it and passing it on are closely related (disease harms). Dangers arising from a breakdown in order can be considered later.

Hazards

Hazards are things – items, processes, people – who can cause harms.

Disease Hazards

In respect of disease harms the hazards seem to arise from ingesting the virus, either directly through inhaling airborne droplets or indirectly from contact with surfaces already contaminated with the virus.

Airborne Droplets Hazard

To get contact with it from airborne droplets you need to be in an area occupied (or possibly very recently occupied) by someone with the virus who is spreading it by coughs and sneezes (or possibly by merely exhaling). [Ref: WHO Q&A on Coronaviruses: How does COVID-19 spread? [accessed 21 Mar 2020]]

“Area” is not easy to define. The WHO mention within 1m, and many governments are recommending a 2m distance. In considering the risk to Health Care Workers (HCW), the WHO asks:

Does the HCW have history of traveling together in close proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance?

WHO risk assessment for Health Care Workers. Q1E for determining “community exposure” [accessed 21 Mar 2020]

Clearly it is not a case of “1m 1cm, good; 0m 99cm, bad”, the exposure hazard is likely to be something like an inverse square law relationship.

Inverse Square Law relationship: Double the separation, quarters the hazard.

The logic applies to a directional sneeze; it will cause a cone of contamination. The sneeze is at the point of the cone and you are at the base and the size of that base quadruples (quartering the intensity of the hazard) for every doubling of the distance from the source.

“The further away you are the safer you are”

Clearly with an inverse square law relationship the hazard reduces as you get further away, never totally disappearing but reducing quickly.

Impact of Inverse square law

We have to rely on the likes of WHO to judge both the exact shape of this curve and their subjective judgement as to when you are far enough away that the exposure can be disregarded. One presumes that their judgement is based on experience of other airborne diseases and includes consideration of length of exposure.

From what the WHO say we can conclude that travelling on a bus sat next to an infectious person is a definite hazard in respect of airborne transmission; passing someone in the shopping aisle probably is not (as long as they are not coughing and sneezing). A brief conversation with a check-out operator lies somewhere between these two examples.

Those partying on Saturday afternoon on the seafront in Lincolnshire [Ref: Lincolnshire”Live”] or Largs [Ref: HeraldScotland], to name just two examples, do not perceive prolonged close contact as a hazard. To them it might mean mild flu; to their mothers and grandmothers (who no doubt are being visited this Mothering Sunday) it could mean pneumonia and a death either in a stressed out hospital or alone in self-isolation.

Surface Contact Hazard

In respect of contact with a contaminated surface the level of transmission hazard is less clear.

There is much to learn about the novel coronavirus that causes coronavirus disease 2019 (COVID-19). Based on what is currently known about the virus, spread from person-to-person happens most frequently among close contacts (within about 6 feet). This type of transmission occurs via respiratory droplets. Transmission of novel coronavirus to persons from surfaces contaminated with the virus has not been documented. Transmission of coronavirus in general occurs much more commonly through respiratory droplets than through fomites¹. Current evidence suggests that novel coronavirus may remain viable for hours to days on surfaces made from a variety of materials.

(US) Centers for Disease Control and Prevention (CDC): Environmental Cleaning and Disinfection Recommendations, [accessed 21 Mar 2020 – my emphasis]
¹ Formite: any agent, as clothing or bedding, that is capable of absorbing and transmitting the infecting organism of a disease. [Dictionary.com]

It appears that the opinion about this hazard is still evolving. For instance my search engine today appears to quote the (US) Occupational Safety and Health Administration (OSHA) as saying:

Safety and Health Topics | COVID-19 – Control and …
https://www.osha.gov/SLTC/covid-19/controlprevention.html
Close contact generally does not include brief interactions, such as walking past a person. Environmental Decontamination . At this time, there is no evidence that the COVID-19 is spread through environmental exposures, such as coming into contact with contaminated surfaces.

DuckDuckGo Search Results for “covid contact with surfaces” [21 Mar 2020]

Yet go to that source and the phrase “there is no evidence that the COVID-19 is spread through environmental exposures, such as coming into contact with contaminated surfaces” is not to be found; presumably advice is changing.

(See also this letter in the New England Journal of Medicine, Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1, March 17, 2020, DOI: 10.1056/NEJMc2004973 particularly figure 1 [Accessed 22 Mar 2020])

The WHO say:

People can catch COVID-19 from others who have the virus. The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth.

WHO Q&A on Coronaviruses: How does COVID-19 spread? [accessed 21 Mar 2020] – my emphasis]

The object that droplets land on can include the hands of the infected person who then goes about their normal business operating handles, shaking hands, passing items to others. The variety of surfaces is wide:

  • a door handle,
  • an escalator handrail,
  • a pack of food examined in the supermarket,
  • touch screens on ATM’s,
  • a package put through a letter box,

How long the virus survives on a surface seems to depend on the type of surface and the temperature/humidity although there appears to be a shortage of specific definitive (medical or governmental) advice.

Risks

Hazards give rise to a risk that people suffer harm. The risks have to be assessed where possible.

Once you have identified the hazards, decide how likely it is that someone could be harmed and how serious it could be. This is assessing the level of risk.

HSE: Managing risks and risk assessment at work: Steps needed to manage risk [accessed 21 Mar 2020 – my emphasis]

Doing a Risk Assessment

As with many risks these cannot easily be assessed quantitatively. There is a danger that a search for precision gets in the way of taking any action to mitigate those risks.

In an employment situation you may stratify risks by means of a matrix considering Impact or Seriousness against Likelihood:

If a risk is assessed as High and Certain, you don’t do it. But where else you decide that an action is unacceptable is down to your attitude to risk. As a personal tool in the current situation, the High and Medium lines are unacceptable to me (equating to serious illness or death) particularly if the likelihood is “possible” or greater (or “unknown” – I’m not a natural gambler).

Your attitude is also moderated by the cost or inconvenience of avoiding the risk.

Problems in applying in a Societal Setting

Unfortunately the inconvenience of self-isolating or even moderate social-distancing is perceived as high by those who see the personal impact of getting COVID-19 as low. They may be financially stretched or self-employed or on a zero hours contract, so the cost of self-isolating is very real when set against the possibility of having a mild dose of flu like symptoms. And that ignores the inconvenience of not being able to party in Skegness or Largs!

But the impact is not just the impact on them (the harm of getting the disease). It is the impact of infecting others, say checkout assistants, waiting staff or relatives, who then pass it on to yet more people who might be medically vulnerable (the harm of infecting others).

In situations where you are trying to balance one group’s assessment of the inconvenience to them against the risk to others, you need either strong social pressure or government action. We seem at the moment to have neither. This increases the likelihood of a harm.

Having this Prime Minister just appealing for “responsibility” (The Sunday Message) seems to have no effect. Do we have no respect for him, or has everyone given up on the media so just don’t know – Or both?

On Friday: “I hope to visit my mother on Sunday”
In the Sunday Times: “Don’t visit your mother”

Prime Minister changing views on required precautions (sample) – quoted on Channel 4 News 22 Mar 2020

So I suspect that most medically vulnerable people are trying to socially distance and this is being driven by the actions of others and the uncertainty being made worse by “our” government.

Personal Access to Information

In the UK, we suffer from a lack of data when it comes to assessing the risk. The Government is not following the WHO’s exhortation to “test, test, test” [Ref: WHO, Director-General’s opening remarks at the media briefing on COVID-19 – 16 March 2020, [Accessed 22 Mar 2020]] (British Exceptionalism – “We have sovereignty!”) and data is being released late and at a level of granularity that can scare without being useful.

The UK daily infection count (as at 9:00AM) is not being released until about 7:00PM (Scotland has its figures out by 2:00PM). Both Governments give details at “Upper Tier Local Authorities” Level.

This means that a single figure is given for, for instance, the whole of Scotland’s Border Council or for the County of Northumberland. Both these areas have very discrete sub areas.

PHE: Total UK COVID-19 Cases Update, 22 March 2020
What to make of that little spot representing the whole of Northumberland?

Just knowing a total daily count for the whole of the Northumberland County area of: 0, 0, 2, 4, 6, 7, 10, does not help. It may be that all 10 infections are in Berwick on Tweed, Northumberland and therefore part of the Borders outbreak and not resulting from commuter infection from Newcastle. Add the lack of testing and we have no clue as to how many are infected (and hopefully at home); we are trying to make judgements blind. I fear the government is as well – as a preferred mode of operation.

Recorded regional infections (selective testing)
Data from:
PHE: Total UK COVID-19 Cases Update [Accessed daily]
Scottish Government: Coronavirus in Scotland [Accessed daily]

Consequent Personal Decision Making

You are forced back on trying to make “rule of thumb” decisions:

  • Where a risk cannot be quantified, but can be mitigated at little cost, there is no point in delaying whilst looking for a more accurate quantification – you mitigate.
  • If we can conceptualise a hazard as potentially leading to an unacceptable harm but cannot quantify the current level of risk, we have to mitigate whatever.

The need for such decisions are the consequence of the government’s failure over the past few weeks – and lead to people taking possible unnecessary mitigating actions – such as laying in stocks for a 12 week long social-distancing siege.

The HSE recommend (in the employment situation) that you decide:

  • Who might be harmed and how
  • What you’re already doing to control the risks
  • What further action you need to take to control the risks
  • Who needs to carry out the action
  • When the action is needed by
HSE: Managing risks and risk assessment at work: Steps needed to manage risk [accessed 21 Mar 2020]

Who might be harmed and how

As stated at the top the people who may be (immediately) harmed are yourself directly (through catching the disease) and others through being infected by you.

How people are harmed directly depends on their medical situation. Those who are over 70 and those who have “pre-existing medical conditions (such as high blood pressure, heart disease, lung disease, cancer or diabetes)” [Ref: WHO Q&A on Coronaviruses: Who is at risk of developing severe illness? [accessed 21 Mar 2020]] are thought to be most at danger of being harmed. This is through the disease either directly effecting them very seriously or through it rendering them more susceptible to complicating conditions such as pneumonia.

As someone who has lung disease (despite being a never-smoker) the risk of harm is higher not necessarily because I am (all other things being equal) more likely to catch COVID-19, but because if I get it the consequences are likely to be worse. So whilst the “Jack the Lads” seen on the Friday’s News drinking in Wolverhampton (A COVID hotspot) may only get mild flu (a harm they may consider they can ignore) they represent a risk of infecting others who may become more seriously ill, may become economically inactive or unable to support their family and may consume significant NHS resources.

These consequential harms to society of passing on the infection are too easily ignored.

One thing that is known is that COVID-19 seems more infectious than “normal flu”. With “normal flu” an infected person will on average infect about 1.3 people (i.e. the virus manages to infect a bit more than one person for every person who has it (and hopefully recovers), so the virus can just self-sustain), whilst for COVID-19 the “R0 rate” as it is called is between 2 and 3. [Ref: LiveScience, How does the new coronavirus compare with the flu? [accessed 21 Mar 2020]]. That means the capacity for one infected person to infect others (the second of the harms originally listed) is about twice that of flu. The risk to our health infrastructure is significantly greater.

The point has been made that deaths due to COVID-19 (53 on 20 March 2020 in the UK out of an COVID attributed total of 233) is small compared to average total daily deaths in the UK of about 1,688, so the risk (of death) might be considered relatively small. But the consequential impact of COVID on the NHS should not be ignored and the impact on others who might need intensive care or those who are having “elective surgery” put off can also not be ignored. The risk of additional suffering is considerable.

The rate of COVID infection is doubling approximately every three days; unchecked this means that the proportion of daily deaths due COVID can also be expected to double every three days. 53 on 20 March; say 106 on 23 March, 212 in 26 March, 424 on 29 March, 848 on 1 April, 1696 on 4 April. So in about a fortnight COVID deaths could be greater than all other deaths combined. How long until this government gets a grip? Will it?

Considering my personal risks in a “no mitigation” situation, I conclude that they are unacceptable. I suspect that most over 70s and people with pre-existing medical conditions would feel the same.

What you’re already doing to control the risks

The “no mitigation” situation in which we all found ourselves at the beginning of our awareness of COVID-19, was to do virtually nothing.

At a personal level, however, the run up to a possible No Deal Brexit meant that some of us had laid in some long-life stocks of household essentials in case the channel ports should seize up for a few (2 or 3?) weeks. But beyond that we expected that the Government and the NHS would be adequately prepared for national emergencies.

It was expected that the Government had done some planning for a Pandemic. Whitehall had plans for SARS and H1N1, and had had to take tough action in respect of medical staff returning from treating the (overseas) Ebola crisis. They had taken drastic action during problems like Foot and Mouth – even though there were some complaints that because it was “too little, too late”, Foot and Mouth had got out of control.

What further action you need to take to control the risks, who needs to carry out the action and when is the action needed by

Initially, early infections resulted in people being taken into specialist isolation wards and people returning to the country who might be infectious were quarantined and it looked as if the government was on top of the problem.

However, a few weeks later, they are (still) talking about further measures, people with the disease are just being told to “self-isolate” and there is “emergency” legislation scheduled for next Monday. The disease has “got a grip” and NHS staff are seriously concerned about:

  • Lack of Protective Equipment
  • Lack of Testing of Staff, (leading to unnecessary self-isolation)
  • Lack of Ventilators
  • Lack of ICU beds (and associated facilities)
  • Next: Staff Burnout?

We cannot buy toilet roll, tinned meals, dried pasta or paracetamol.

The personal impact is that many citizens are being told to socially-distance themselves for 12 weeks* (with a possibility of it being longer). This sounds like a reasonable way to avoid infection, except that it is not practical to totally isolate yourself from the world for almost three months (without the facilities of a small farm).

Socially-distance is different to self-isolate*. The later should be total quarantine; with social-distancing (my current situation), it means minimising social contact. As my GP says, “if you have to go to the shops go, but minimise the number of times”.

I fear, given the lackadaisical example set by the government*, that many who are self-isolating, but don’t feel “too bad”, will break their quarantine just to get to the shops. The requirement to self-isolate comes immediately any symptoms show; it’s not “after you have laid in supplies for a two week siege” or had a final drink with your mates.

Who needs to carry out the actions? Well it has to be individuals as Government and parts of society at large do not seem able or prepared to do much about it.

When do we need to carry out the actions? Delay does not improve the situation – contrary to the government’s Boosterish belief.

(* As I draft this, Channel 4 News – 22 March 2020 – is reporting that 1,500,000 million of the most medically vulnerable will “shortly” be told not to social-distance but to self-isolate. Policy is still drifting.)

Conclusion

The employment approach to Risk Assessment can only take us so far. In employment we are required to behave and acceptable codes of behaviour can be set down and enforced. There is leadership. In most employment situations the Health and Safety environment would seem to be better understood than the current national emergency environment.

So personally how do I control this unquantifiable risk?

The dangers are to me unacceptable so I have to do something and the only thing I can do is social-distance myself – which I have been doing for about a week. I now expect to be told this should be self-isolation.

I live alone so should be able to keep the virus out of my house except for two things.

  • I receive post through my letter box.
  • I will have to go shopping at some stage (breaking self-isolation)

Postal Deliveries

Postal deliveries expose me to the unknown hazard of transmission via contaminated surfaces. Contamination can happen at source (although most mail I receive is I suspect automatically printed and enveloped), or during distribution – most notably by my post man or woman who every day touches nearly every front gate and letter box whilst doing their rounds. The Royal Mail is relatively sanguine:

We will continue providing the best delivery service for you and protect  the health of our people, and our customers. We have provided guidance to our people to help prevent the spread of any infection. We are doing so in line with preventative guidance from Public Health Authority.  We have also made a series of adjustments to our parcel handling procedures. We are keeping our ways of working under continuous review. 

Public Health England (PHE) has advised that people receiving parcels are not at risk of contracting the coronavirus. From experience with other coronaviruses, we know that these types of viruses don’t survive long on objects, such as letters or parcels. This complements the highly publicised guidance from PHE for people to wash their hands more often than usual using soap and hot water. 

Royal Mail: Coronavirus update (Last updated 20 March 2020), [Accessed 22 Mar 2020]

This would not seem to be totally consistent with advice quoted earlier about the virus surviving for possibly a few days on surfaces.

So it would seem that caution needs to be applied to handling mail. Read it and then bin it or quarantine it for a few days and then decontaminate your hands by washing them.

Shopping

Shopping would seem to be the major issue. Both in terms of getting it and considering whether the shopping has been contaminated. In terms of avoiding contamination buying food that is wrapped or even tinned/packed before the emergency will reduce risk. Does freezing food kill the virus? I can’t find definitive (i.e. Medical or Academic or Responsible Government) advice. In practice, life becomes near impossible if I have to consider that all food packaging is contaminated – you cannot wash down packages of frozen food. This is a risk I may need to take.

You can / should eat your way through most of the contents of a fridge in about a week and the contents of a more closely packed freezer in possibly three or four weeks. Because of the “panic buying” the opportunity to buy in a few weeks worth of dry and tinned goods was missed – but I still have some of my No-Deal Brexit stores.

In about five weeks time I will be short of food and living on a reduced diet (but I have to remember that if I am inactive I require fewer calories). The risk assessment I have to make is:
Do I:

  • Shop next week to refill my fridge and possibly increase my stores of frozen and dried food, or
  • Break out the UHT and canned vegetables and wait a few weeks?

If I shop next week and become ill, I may become part of the peak demand on the NHS. But in a few weeks the environment may be more infectious because I can’t see this government regaining/gaining any grip on this situation – I can see an Italy-style situation developing.

Next week the shops may still be short of many of the things I would wish to buy. Will the situation have deteriorated further in a few weeks or will there be some more drastic form of shop enforced rationing (which means I may have to do weekly shops rather than one shop say every four weeks – undermining social-distancing)?

Many of these concerns and uncertainties are driven by lack of confidence in “the authorities” and the continuing game of catch up.

Alternative view

I’m retired, I have a medical condition; I am therefore a drain on the national economy. Whilst getting COVID-19 may give the #NHS a short-term problem, in the long-term it may be best for the UK Economy.

So should I take precautions and live a monkish life of self-isolation or say “if I’ve got to go, I’ve got to go” and get out and enjoy myself? I suppose it depends how you want to meet your end.

I’m going out now; I may be some time?

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