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Herd immunity with age segregation: Is this our miracle pill to save both lives and livelihoods?

By May 12, 2020Current

TL;DR – Is COVID 19 actually two diseases? And does Dr Finian Tan have the answer to unlock the Catch-22?

So I came across a very loooooong but uber-interesting post on COVID-19 on Facebook a couple of weeks back. It’s a litlte technical, but the details were so fascinating and the proposed solution captivating. So yea, I read all of it, and in the spirit and my personal belief that we all should read as diversely and from as many different viewpoints as possible, I so wanted more people to read it.

So I reached out to the author of the Facebook post and sought his permission to republish the entire 5,590-word post. Guess what? I finally got a reply back today, and it’s a YES! Thanks much, Dr Tan!

First things first, it’s written by a Dr Finian Tan

I checked out his LinkedIn account, and Dr Finian Tan appears to have stellar engineering background.

Career wise, other than what looked to be academic research work and petroleum trading work in the earlier years, he has been mostly involved in banking, investments and related work, including a stint as Deputy Secretary in MTI with the Singapore Government. He’s now mostly known as a very successful venture capitalist. Dr Tan’s first and also best known in the industry for being one of the earliest majoir investors in Baidu, which is now one of the largest internet companies in China. But back in the day, no one really knew what it was doing, what it was gonna do, and how it would end up. It was also Dr Tan’s first venture capital investment. It would also turn out to be one of his most inspired.

He’s currently the chairman of Vickers Ventures, a global life science and deep tech venture capital firm. A firm that he also founded.

Pssst, you should also check out his beautiful home!

What the Facebook post is about

His post touches on how most countries do not carry out mass enough testing for COVID-19 and since the number of infected cases is a function of the number of tests carried out, he opines that the mortality rate is overstated.

The bulk of the post centres around mortality by age, and the huge disparity in terms of mortality amongst the young patients and the old ones. Since the mortality rate is significantly higher in the older age group, Dr Tan is of the view “COVID 19 is actually two diseases. One for the young which is mild and has a very low mortality lower than the flu. And one for the elders, which has a much higher mortality.”

Today, most countries adopt the strategy of social distancing and shelter-in-place, which typically takes the form of a lockdown or some form of movement restriction. But with his approach of tackling COVID-19 like two diseases, he has an interesting proposition, which “is the direct opposite of the policies being used.”

“Instead of preventing the spread, we should open the economy totally – without social distancing at all, whilst protecting the old completely, until a vaccine is found or herd immunity is reached.

This would require a big change in our isolation rules though. Families would have to be separated by age and anybody who is needed to care for the elders would have to be protected with them. But it would be better than isolating everybody from everybody as we are doing now. Or opening up with social distancing policies and with borders closed.

Since 66 pct of the population is below 50, herd immunity could be reached within a short timeframe of 2-3 months and thenafter, the old and the young can be reintegrated again. Much quicker than waiting for a vaccine and a huge difference to the duration of the depressed economy. The world could open immediately. We would in effect be using the virus itself to “vaccinate” the young thereby reaching herd immunity with a minimal mortality a magnitude lower than the flu.

This is the most logical approach. For example if the tigers in a zoo suffer fatally from a disease and all the other animals catch it but very mildly, however could spread it to the tigers. Do you isolate the tigers until all the other animals have reached herd immunity and the virus disappears before reintegration or isolate all the animals individually from each other and close the zoo until a vaccine is found?”

Dr Tan’s proposed solution segregates the seniors and supports the total opening of the economy for the young. He terms this as “herd immunity with effective age related segregation”.

While this can be an emotionally difficult decision since it means people may not be able to meet their elderly parents and loved ones for a stretch of time until a vaccine is developed, it is also not a cheap solution. However, if it works, the costs will probably still be much, much lower than to close the economy indefinitely.

In his Facebook post, Dr Tan also weighs in on how to make this “herd immunity with effective age related segregation” proposal work.

“For those that are currently living in nursing homes, the solution is pretty simple. They will continue to live there. But all support staff will also have to do the same. It must be a virus free precinct with no entry or exit of people. Food supplies can be prepared before hand so there is stock to last through the segregation period. If urgent supplies are needed, they need to be delivered by large plastic containers and left outside for the staff to collect with disposable gloves, and the containers disinfected.

For those who live at home, there could be two types of scenarios catered for.

1. Those that want to stay in their own homes will have to find accommodations for the young that want to live in the free world.

2. Those that prefer to move out into a larger space where they are not confined to their small homes may choose to stay in a virus free hotel or resort that has been negotiated with a discount for local residents.

A basic income or subsidy could be provided to all above 65s to allow them to defray part of the costs of having their younger family members move out, assistance to live at home by themselves or to pay for the room in a virus free hotel or resort.

People who decide to break the rules and go out of their homes will do so at their own risk. But people in virus free hotels or resorts will have to be either quarantined in a quarantine area in the hotel or if tests are full proof enough, prove that they are virus free before being allowed into the virus free hotel or resort again.

Perhaps a lesser amount could be provided to those aged between 50-64.”

I have been talking about the dilemma that the governments of the world are currently facing when dealing with the coronavirus. Do we prioritise saving lives above protecting livelihoods? Is there any way that we can save both lives and livelihoods without any tradeoff?

Balancing lives and livelihoods has never been this tricky

Right now, for countries that have implemented lockdown, we’re seeing people suffering from loss of jobs and income. This cannot go on forever since what is the point of being able to stay alive without being able to actually live lives? And for countries that dare not shut the economy, they are probably losing more lives than they care to test.

If you need specifics, well, here are some numbers that might shock.

  • The US has reported  20 million jobs lost in April
  • India has reported 210 million jobs lost in April
  • South Korea saw a record high of application of unemployment benefits in April
  • Thailand estimates job losses of 10 million due to COVID-19
  • Malaysia has reported over half a million jobs lost in its seven weeks of Movement Control Order (MCO)
  • Singapore has seen a total of 8,663 business entities closed in April, more than double the number in March and it’s the highest in recent years. Economists have warned that more businesses will go under after the Government cuts the 75% wage subsidy under the Jobs Support Scheme (JSS) covering the CB period. And it will be worse once the temporary freeze on loan repayments is lifted.

My point is we’re about to see a recession so bad that analysts are saying it will be worse than The Great Depression in the 1930s. And the longer we need to shut the economy down, the worse the situation will be. Perhaps we do need to think out of the box a little and the solution needs not necessarily be 100% lockdown or 100% opening up.

While you may or may not agree with the points in Dr Tan’s post, I am sure you will find some useful information as well as some food for thought. So go read!

Here’s the Facebook post in full,

Dear Reader

I used to be a Deputy Secretary in the Ministry of Trade and Industry of the Singapore Government and am currently the chairman of Vickers Ventures, a global life science and deep tech venture capital firm. We have several companies that are finding therapeutics and vaccines for COVID-19 and so am thinking about solutions to this pandemic, and the devastating effect it has on the world, on a daily basis.

1. MORTALITY BY AGE

Let me state a few facts about what we know of the virus so far. The average mortality is about 1.5 pct, which is 15 times higher than the seasonal flu which has a mortality of about 0.1 pct. This very high mortality is why the world is trying to contain its spread as much as possible. However this is merely an average number. In fact the mortality differs greatly depending on age. Data from Korea has shown that the mortality ranges as follows:

80s 11.6pct
70s 6.3
60s 1.5
50s 0.4
40s 0.1
30s 0.1
20s 0
10s 0
0s 0

2. DISPARITY BETWEEN THE OLD AND THE YOUNG

As can be seen, for people below 50, and using the age demography of Korea, the average mortality is in fact less than 0.05 pct, lower than the average mortality for the flu, which the world has well accepted as part of life. No country has ever instituted a lockdown of any kind to stop the spread of the common flu.

The reason countries are doing their best to contain the spread of the corona virus, even for the young, is not because of the mortality of the infection to the young but because young people who get infected may infect their older relatives and friends whose mortality is unacceptably much higher. In fact the above data from Korea shows that the mortality for those aged 50 and above to be 4 pct (with sufficient hospital care) or a factor of 80 times that of the below 50s.

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If hospitals are overwhelmed, these numbers could be even higher. Of the 20 pct or so of people who need hospital care, several experts have said more than half would not survive without oxygen or ventilators. This would bring the average mortality up from 1.5 pct to 10 pct (a factor of 6 increased) which is not too different from the statistics in areas which had more patients than ICU spaces.

3. A PLAUSIBLE REASON FOR AGE RELATED MORTALITY

The fact that the severity of the disease grows with age has perplexed the scientific community. Many have suggested that this is because of underlying conditions. This is not a good enough reason for the observation. If this were the only reason than we should see a high mortality for the very young too, like the flu. Premature babies for example, struggle tremendously with a simple cold like the RSV virus, and often need oxygen or even ventilators and can stay in the NICU for many weeks. We are not observing the same effect on the very young from the corona virus. In fact, the opposite. Most young babies show almost no symptoms at all.

To understand this, we need to first understand that the trigger that tips an infection into the disease of Acute Respiratory Distress Syndrome needing oxygen or ventilators is viral load and viral diversity exceeding the disease threshold.

There is evidence to suggest that the main cause of the large viral load and diversity is due to antibody dependent (or mediated) enhancement or ADE.

Antibody mediated or dependent enhancement occurs when there are antibodies in the body that have memory of a previous related (serotypical) corona virus infection, and that try to bind to the virus (antigen) but are not able to neutralise it. When that happens they actually work against the body by entering the cell and multiplying the virus and releasing them into the body. So if you assume that the antibodies are like midfielders in a soccer team, when they try to prevent attackers from passing through but fail, they switch sides an attack their own goal.

This has been shown in another RNA virus called Dengue (a mosquito borne disease) and also SARS1 (which occurred in Asia in 2003), another corona virus. It also explains why a huge amount of recovered COVID-19 patients show low or no antibodies suggesting that antibodies were not responsible for the patient’s recovery. There is also data to suggest that antibodies correlate with worst disease. In fact the WHO has been recently quoted as saying that antibodies may not be sufficient to explain recovery and antibody diagnostics may not confirm immunity.

Let me explain ADE using Dengue as an example. There are 4 types of Dengue. Dengue 1-4. If a person gets bitten by a mosquito carrying Dengue 1 say. The person will develop very mild symptoms. If he or she subsequently gets bitten by a mosquito carrying Dengue 1 again, he or she is immune. If however the person gets bitten by a mosquito carrying Dengue 2-4, then he or she will likely develop Dengue Hemorrhagic Fever. We call the first bite the original antigenic sin. If another sin is committed, the punishment is very severe. So the second bite by a diff serotype tips the infection into the associated disease.

In the case of COVID-19, the older a person is, the more coronavirus infections he or she has been exposed to (25% of the common cold are from corona viruses) and the higher the likelihood that one of them could have been a related virus. Which then triggers the infection into the disease of Acute Respiratory Distress Syndrome (ARDS), needing oxygen and ventilators to support them.

This would explain why even the very young with underdeveloped lungs don’t seem to get severe disease because they never had any related viral infections in the past (no original antigenic sin).

The underlying conditions then dictates the recovery process.

Based on ADE, the disease progression will be as follows

Infection -> history of related infection which dictates whether the infection is triggered to the disease -> underlying conditions dictate type or speed of recovery.

Some people may ask if that’s the case why then are there a few cases when the young develop severe disease? There are a couple of explanations for this. The original antigenic sin could have been passed from mother to child at child birth. Or the child or young person could have been exposed to a very high viral load and diversity which quickly exceeded the disease threshold.

4. VACCINES AND ADE

If there is indeed ADE in COVID-19, then how will antibody based Vaccines help? Since they might actually give the original antigenic sin and induce ADE when an infection happens? Well many antibody vaccine companies are tying to design their vaccine so that they will not induce ADE. Whether they can achieve this is left to be seen.

Thankfully antibodies are not the only weapon used by our adaptive immune system. When viruses (antigens) escape the antibodies and infect the cells, Killer Tcells come into action to destroy the infected cells. The WHO has also recently been quoted to say that T-cells might need to be involved for recovery from COVID-19. Thankfully there is at least one company, Emergex, which I am involved in, which focusses on vaccines that induce only Killer T-cells, conferring immunity without potential antibody-mediated side effects.

5. MORTALITY HUGELY OVERESTIMATED

Mortality data however could be hugely overestimated because of the lack of mass testing. This is because the total number infected is most likely underestimated. Therefore for the same number of deaths and a larger number of infected cases, the mortality comes down.

Data from Los Angeles for early April (published 21 April 2020) has shown that more than 4 pct of LA County could be infected with a death toll of about 900 people as of 26 Apr 2020). This works out to a mortality of about 0.2 pct as opposed to 1.5pct (a factor of 7.5 less). If this is accurate then the mortality for young people would be similarly 7.5 time less or 0.0067pct which would be more than a magnitude lower than that of the flu. If we assume a population of 330m and 66pct of it below 50, this results in a mortality of 15,000 people in total upon reaching herd immunity, less than the number of deaths already in America with just a few pct of the population infected.

Some people say that the deaths due to COVID-19 might be under reported by as much as 50 pct. If we assume so, this would bring the mortality for the young to 0.01pct, still a magnitude less than the flu. And it doesn’t change the mortality of 80 times more for the old.

Some people also say that the deaths due to COVID-19 might be over reported. Because hospitals are so overwhelmed, some simply label deaths of other causes as COVID-19 deaths.

6. THERAPEUTICS WILL BRING DOWN MORTALITY

Gilead has just released interim data on their clinical trial results for Remdesivir, an anti viral medication for post infected people suffering from covid 19, originally developed for Ebola. The placebo controlled trial involved more than a thousand patients and shows that patients recovered in 30 pct less time and resulted in about 30 pct less deaths, though the latter didn’t show statistical significance yet.

If we assume that Remdesivir will be approved shortly since it is a repurposed pre-approved drug, then u might assume a 30 pct lowering of mortality bringing mortality back down to 0.0067 pct for the young.

7. COVID-19 MORTALITY VS OTHER MORTALITIES

A mortality of 0.0067 pct for the below 50s is still not zero. But let’s compare it with the mortality of various other causes

Covid 19 (50 and above if hospitals overwhelmed) 1.2pct (1200 per 100k)
Covid 19 (50 and above) 0.2pct (200 per 100k)
Flu 0.1pct (100 per 100k)
Road traffic 0.018 (18 per 100k)
Covid 19 (below 50) 0.0067 (7 per 100k)

8. AN ALTERNATIVE SOLUTION TO SOCIAL DISTANCING AND SHELTER-IN-PLACE

So in actual fact COVID-19 is actually two diseases. One for the young which is mild and has a very low mortality lower than the flu. And one for the elders, which has a much higher mortality. Higher than the flu.

This brings about a possible solution that is the direct opposite of the policies being used. Instead of preventing the spread, we should open the economy totally – without social distancing at all, whilst protecting the old completely, until a vaccine is found or herd immunity is reached.

This would require a big change in our isolation rules though. Families would have to be separated by age and anybody who is needed to care for the elders would have to be protected with them. But it would be better than isolating everybody from everybody as we are doing now. Or opening up with social distancing policies and with borders closed.

Since 66 pct of the population is below 50, herd immunity could be reached within a short timeframe of 2-3 months and then after, the old and the young can be reintegrated again. Much quicker than waiting for a vaccine and a huge difference to the duration of the depressed economy. The world could open immediately. We would in effect be using the virus itself to “vaccinate” the young thereby reaching herd immunity with a minimal mortality a magnitude lower than the flu.

This is the most logical approach. For example if the tigers in a zoo suffers fatally from a disease and all the other animals catch it but very mildly, however could spread it to the tigers. Do you isolate the tigers until all the other animals have reached herd immunity and the virus disappears before reintegration or isolate all the animals individually from each other and close the zoo until a vaccine is found?

9. IT’S NOT A CHEAP PROPOSAL

For the proposal to work the segregation must be very serious though. More than a typical shelter in place policy as we have now. Because for two months as herd immunity is reached the virus will be everywhere. Seniors must not go out to unprotected places at all. The government may have to assist with their food etc. Maybe even lodging. Perhaps villages can be earmarked and separated.

Segregating one third of a population is a monumental task. It is however better than separating everybody from everybody.

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And it’s overall much quicker saving lives and livelihoods. And surely cheaper than paying everybody their salaries to stay at home. And better than opening up partially with social distancing still in place which will increase the mortality and yet not get back to the normal economy we are used to. Even if it takes longer than anticipated to reach herd immunity.

10. UNIQUENESS OF THE PANDEMIC THAT LENDS ITSELF TO THIS STRATEGY

This strategy is only possible because of a few very important characteristics of this pandemic:

  1. The very large disparity in mortality (80 times) between two groups which allows the group with much lower mortality to be allowed to live their normal lives.
  2. The low mortality group has a mortality that is in fact more than a magnitude lower than many other diseases that the world is used to, like the flu
  3. The low mortality group forms a large enough group that herd immunity can be reached which then allows reintegration of the two groups way before a vaccine can be found.

11. NEW METRICS TO MEASURE SUCCESS

The current metric of total number infected is measured everyday. The higher the number, the worse it is. Seemingly. In fact, this metric needs to be split between the total number of young and old infected separately. The higher the number of the former does not provide the correct information we need to protect the vulnerable since the mortality is lower than the flu and we don’t provide flu numbers on a daily basis.

More importantly when reflected as a total, it masks the more important number of infected seniors. The higher the number of the latter will mean that our segregation policies are not working and we need to step up on it. So a total number is actually meaningless because it doesn’t inform us of the most important figure we need to measure – that of the vulnerable group.

Singapore for example, has had a recent spike in the total number of infected people. Mostly from the dormitories housing foreign workers. As a result, the numbers are increasing daily. But the foreign workers are almost all young. And they don’t have older siblings or parents living in the dorms. We therefore show large numbers of infected cases and a very low mortality of 0.1 pct. And although we have thousand of young foreign workers infected, not a single one of them has needed oxygen or ventilators so far. Some people are saying that our medical services must be extremely good to have such a low mortality.

Malaysian on “How did Singapore let covid-19 get out of control after they were doing so well?”

If we use the metrics of measuring the number of young and old infected separately, we will get a much clearer picture. The number of young people infected is increasing. This means a quicker time to herd immunity with almost zero mortality risk which isn’t as bad as say the flu. And the number of seniors infected is increasing slightly, not from the foreign worker spread but from community spread at large which means segregation between the young and old needs to be improved.

The excellence of our medical services should be measured by the numbers recovered vs the numbers that need hospital care. And not vs the total infected since there is such a huge age effect.

12. THERE ARE ONLY 4 POSSIBLE RESPONSES

  1. Shelter in place and livelihood disappears. I would term this option Keeping the population naive through total containment.
  2. Semi open with social distancing. Which doesn’t allow the economy to go back to normal and eventually very high mortality again. Flattening the curve doesn’t reduce the number of deaths. It just delays the same outcome because the virus will not stop until herd immunity is reached. I would term this option as keeping the population naive through social distancing.
  3. Total opening and 6 times more than the average mortality could die because the hospitals will be overwhelmed. Until herd immunity is reached. I would term this option as herd immunity without effective age related segregation.
  4. Segregate the seniors and total opening of the economy for the young as in this proposal. I would term this as herd immunity with effective age related segregation.

Some are saying that the herd immunity strategy has already been considered by the UK and abandoned. The UK did consider it but they were seeing deaths of old people which means an ineffective segregation policy. Which would be option 3. They eventually gave it up because the mortality would be way too high. Now more and more people are saying that the mortality is overestimated and so this option should be applied again. They go on to say the mortality is in fact like the flu since much more people are infected than realised. Though I do state that mortality is indeed overestimated but it clearly cannot be so overly stated that it is just like the flu. It can’t be. Because the flu doesn’t overwhelm hospitals which COVID-19 clearly did in Italy and would have done so in NY if the shelter in place policy wasn’t implemented. And if hospitals are overwhelmed, then these mortality numbers jump by a factor of 6. So option 3 is clearly not tenable as it will result in too high a mortality.

Others are saying that option 4 is already being applied in Sweden and some other countries. This is not true. Sweden’s strategy is option 2 but on the more open side whilst trying to maintain social distance policies. Though they may reach herd immunity earlier, their mortality is still high and their economy will never be back to normal until and unless they can truly open.

This proposal is different. It involves full segregation of our seniors. And full openness of the economy for the rest. I mean totally open. Including open borders. So that herd immunity is developed for all viral strains. Any half measures will be punished with a huge mortality result. Until natural herd immunity is reached or a vaccine is found (which will also lead to herd immunity by vaccination) whichever comes first.

13. REINFECTION DOESN’T MEAN HEARD IMMUNITY OR THAT VACCINES CANNOT WORK

First, we need to be clear that there are indeed bona fide cases of reinfection by different strains and not just a deactivation of an existing disease. There could be two reasons for non bona fide reinfections:

  1. The level of viral content could be below the detectable levels of the test kit. HIV kits used to only be able to test at levels of 1000/cc of blood. But after much technological improvements it can now test below 50/1000. COVID-19 test kits have only just begun so it will take a while for it to reduce its detectable levels.

  2. The virus could be in viral reservoirs in the body but no longer in the blood or mucus membranes at detectable levels.

In fact the data from Korea that suggested the possible reinfections were not able to contact trace the spreader that reinfected the persons which causes doubt that the reinfection were bona fide. The international vaccine institute based in Seoul has said that the patients were most likely experiencing reactivations than reinfections and that the corona virus infection is likely to be protective, meaning that it is likely to bring about immunity.

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But even if there is indeed bona fide reinfection of an individual by a different strain, it doesn’t mean herd immunity or vaccines cannot work. We have to distinguish between individual immunity and herd immunity. RNA viruses cause disease as a swarm of closely-related but distinct variants (quasi-species). Herd immunity arises when the population as a whole has immunity to all variants of the swarm, even though the level of individual immunity to each variants may differ. So you can have herd immunity even when an individual is not immune.

14. WHAT IF HERD IMMUNITY DOESN’T WORK?

Can we wait until we know for sure that those infected cant get reinfected?

It is not normally possible to test that a person can or cannot be reinfected, because no person will volunteer to be reinfected. Just like Vaccine clinical trials. We can’t inject a vaccinated person with a specific virus to see if it works.

What we do in vaccine trials is, we inoculate a small population of say a thousand people and then let them go back to their environment, which is normally selected to be prone to the infection and we wait and see. After a specific time, we collect the results and then compare the inoculated people with the unvaccinated general population to see if there is any prophylactic (protective) effect. We then do a statistical analysis to calculate p value (the likelihood of the results being due to pure chance). If the p value is less than 5 pct (less than 5 pct due to pure chance), the vaccine is typically approved and the whole world is inoculated.

Based on the 3 million infected so far, not a single one has been proven to be reinfected. There have been some possible reinfections (but most likely reactivations), but these have not be confirmed as reinfections. Even if they were, the numbers have been so few that the p value would be very very low. Meaning those who have been infected are very very much less likely to get the infection a second time than a naive person. This means that if the real virus were a vaccine going for approval, it would have been approved with 3000 times less patient data. 3 million patients would make it the largest clinical trial in the world.

Having said above that it is not normally possible to infect people in clinical trials with a particular virus. Young people are in effect volunteering to be subject to viral challenge trials. Both naive and infected patients, so we may see some controlled results coming out soon. Nonetheless the point made above is still valid. We have more data already from the real world of the effectiveness of the real virus as the vaccine in young people than any clinical trial for vaccines ever in history.

Some people say that other vaccine clinical trials have longer periods of trials than COVID 19 has had so far. This is true. But for a vaccine to be found within 12-18 months that everybody is hoping, short cuts will have to be made, which will result in a phase 3 trials lasting not more than a few months. Which would be equivalent to the real life trials we have seen in the real world so far.

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15. TESTING FOR THE WHOLE POPULATION IS NOT NEED SO URGENTLY

The above proposal does not involve mass testing to be implemented. All it needs is proof of age. The senior group will continue with the shelter in place segregation or stay in a virus free area and so testing will not be necessary until they are unwell or if there is a spread in a virus free area.

Mass testing will be required to ascertain whether herd immunity is reached. Which will be months from now. This will allow the industry the time to develop better and quicker tests and scale up the production so that we can check for herd immunity when the time comes. Antibody tests may not be enough to check for immunity since evidence has shown that some recovered patients have very low or no antibodies. We may need to develop tests for memory Tcells as well. Antigen testing is also in the works. This may be very helpful in detecting the virus quickly if they can be accurate enough. This proposal allows the time for technology to catch up.

16. WHAT IF A VACCINE IS NOT FOUND?

In 1984, the world predicted that a vaccine for HIV would be found in two years. 36 years and 32 million deaths later, the world is still waiting for an HIV vaccine. In 1997 President Clinton challenged the US to come up with a vaccine within a decade. 14 years ago, Scientists said we were still about 10 years away. Today they are saying we are still 10 years away.

Granted that HIV is more difficult than the corona virus. It mutates faster and attacks the immune system which vaccines target to help fight the infection. But dengue is an RNA virus not too different from the corona virus, and it has still eluded Scientists for decades. In 2017, a large scale effort in the Philippines was found to worsen the symptoms of the disease (ADE) and hundreds of children died as a result.

The combined efforts towards finding a vaccine for the corona virus however is of the largest scale ever in the history of vaccine discovery. About a hundred companies are racing towards the finish line. I am optimistic that one will be found, within the 12-18 mths timeframe. Not because the companies have suddenly decided to search for a vaccine for the coronavirus, but because many of us have been developing technology to deal with a mutating RNA virus for many decades and have reached a point of proving our tech in clinical trials for other RNA viruses when COVID-19 hit the world. So all that remains for us to do is to shift our focus from one RNA virus to another and that doesn’t take as long. When you add to it the desire by regulatory bodies to short cut the process, 12-18 months seems like a doable timeframe.

But what if indeed a vaccine is not found or takes much longer than the 12-18 mths that is expected of it?

Well this proposal is still the cheapest and most sustainable solution. Protecting the elders, and letting the virus be the vaccination for the young, until herd immunity is reached, before reintegration. This strategy is independent of the timing of when a vaccine needs to be found.

17. A POSSIBLE IMPLEMENTATION PROPOSAL

As mentioned, segregating a third of the population is going to be a monumental task. We could split the segregation into two. A voluntary one for those aged between 50-64, and a different set of guidelines for 65 and above.

During a shelter in place law, people are forced to stay at home not just because we are trying to protect them, but also to prevent people from spreading the virus. So its a dual purpose law. If this proposal is adopted, then the sole reason for segregating the elders is for protection. Since the world will be totally open and there will be no masks or social distancing at all outside in the big bad world.

So it shouldn’t be a law (the stick) that protects the elders, but subsidies (the carrot) that allow them to implement the recommendation.

For those that are currently living in nursing homes, the solution is pretty simple. They will continue to live there. But all support staff will also have to do the same. It must be a virus free precinct with no entry or exit of people. Food supplies can be prepared before hand so there is stock to last through the segregation period. If urgent supplies are needed, they need to be delivered by large plastic containers and left outside for the staff to collect with disposable gloves, and the containers disinfected.

For those who live at home, there could be two types of scenarios catered for.

  1. Those that want to stay in their own homes will have to find accommodations for the young that want to live in the free world.

  2. Those that prefer to move out into a larger space where they are not confined to their small homes may choose to stay in a virus free hotel or resort that has been negotiated with a discount for local residents.

A basic income or subsidy could be provided to all above 65s to allow them to defray part of the costs of having their younger family members move out, assistance to live at home by themselves or to pay for the room in a virus free hotel or resort.

People who decide to break the rules and go out of their homes will do so at their own risk. But people in virus free hotels or resorts will have to be either quarantined in a quarantine area in the hotel or if tests are full proof enough, prove that they are virus free before being allowed into the virus free hotel or resort again.

Perhaps a lesser amount could be provided to those aged between 50-64.

If governments are in doubt about whether their hospitals will be overwhelmed by opening the economy totally for the young. They could use a two stepped approach. Protect the elderly first of course. Then open up gradually. Begin with social distancing and washing of hands for those who live with older folks. Then gradually open up more and more, whist checking on the health of the young, the hospital capacity etc. This will take longer to herd immunity but may be seen as a more prudent approach by governments.

18. R0 PRONOUNCED R NOUGHT

R0 is a scientific number that denotes how infectious or contagious a disease is. It is also called reproduction number. Latest data indicates that r0 is about 5.7 (and not 2-3 as previously thought), meaning that 1 person infects 5.7 people. This is lower than mumps (r0 of 10) and measles (r0 of 18) but higher than the flu since we are not all naive to it.

What’s important to note is that r0 reduces as more and more people are infected enroute to herd immunity and will reach zero when herd immunity is reached. This strengthens the case for targeting to reach herd immunity with the least mortality rather than prolonging shelter in place and keeping the population naive and susceptible.

R0 also controls how much of the population is needed to reach herd immunity. Based on the new figure of 5.7, herd immunity will be reached at 83pct In order to achieve this, people below 65 (and not 50) should be the cutoff for segregation.

19. MORBIDITY STUDY NEEDED

The proposal above has been based on mortality studies. Even though the mortality for the young may be low, in a total open economy situation, a lot of people is expected to become infected enroute to herd immunity, and a small proportion will need hospital care.

However since the numbers are large, even a small proportion could mean large absolute numbers which might overwhelm areas that don’t have sufficient hospital facilities.

There is enough morbidity and time to morbidity data available from New York to calculate the amount of increase in hospital capacity needed to ensure that everybody that needs a ventilator has one, before opening up the economy. The experience in New York has shown that capacity can be doubled or even tripled in a matter of weeks and preliminary morbidity studies show that most developed countries won’t need to increase capacity by so much, so this shouldn’t be a limiting factor to the proposal if planned right.

20. CONCLUSION

I realise that this is a direct opposite to the measures being undertaken by almost every country in the world, which is keeping the population naive through social distancing. Unfortunately this would would only result in a low mortality if done to the extent that the economy will be devastated. Herd immunity with effective segregation as in the above proposal would result in the best outcome in terms of both mortality and overall economic good.

Some people are saying that they prefer the current shelter in place policies just in case the assumptions are wrong. That they prefer to wait for more data before opening up the economy. But the shelter in place policy is also a decision. As is relaxing it. By what data are we deciding to implement such a containment policy?

Mortality.

But we are containing everybody because of mortality for the elders, not the young. For the young there is no data to support containing them as their mortality numbers are less than the flu. So people who ask for more data before relaxing the containment rules for the young, should also be asking for more data before the young are contained.

Before implementing such a policy though we need to ascertain the mortality assumptions that I have derived from Korea and Los Angeles to ascertain a more accurate mortality number for the young. Data is now available from Santa Clara, New York etc. Whether the cutoff age is 50 or higher (say 65) or a hybrid with different subsidies for the two groups can be decided based on mortality vs economic cost. The key to success is in the execution and the best time to plan this is during a shelter in place period.

 

Finian Tan (PhD Cambridge University)
Founder and Chairman
Vickers Venture Partners
A global life science and deep tech venture capital firm
[email protected]

Originally written on 22nd March 2020. Last updated on 3rd May 2020.

 

 

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Maggie O

Author Maggie O

Digital extrovert. Social introvert (warning: 93% introverted!) In the day, I work at the labour movement to put cai-png on the table and ice-cream in the fridge. In the night, I read a lot and write a little. Also, all views expressed in my contribution pieces here are based on my personal opinions, and they do not reflect the ideas, ideologies, or points of view of my employer (past, current and future).

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