Responding to Covid-19 – the way forward

Responding to Covid-19 – the way forward

by Dr Angela Anderson
article from Wednesday 20, May, 2020

COVID-19 caught virtually all governments and health systems across the world unawares. Leaders seeking to cover their missteps are at pains to emphasize that the pandemic’s progression has been a steep learning curve for all involved. Nevertheless, when this learning translates into new policy, it is always conditioned by political exigencies that streamline the ‘science’ and the ‘evidence’.

However, the government is now asking – ‘How prepared were we for the Covid-19 pandemic and how can we prepare for any future outbreak?’

In the following I have identified steps that, going forward, both UK and Scottish governments should be taking. I base them on what leading scientists have said, experience of the pandemic in the UK and elsewhere, and my own history as a senior policy manager in public health. Unlike our leaders, however, I have no political axe to grind.

First, government at all levels needs to move faster. It only takes a week for the number of confirmed cases to double.  Professor Anthony Costello, University College London, thought we should have asked the following questions by the end of January*:

  • Do we have sufficient testing capacity?
  • Do we have sufficient contact tracing capacity?
  • Do we have sufficient PPE? 
  • Do we have enough ICU beds, ventilators and staff to run them?

 

Second, pandemic experts need to be brought on board and listened to. Epidemiologist Professor Rowland Kao advised that thousands of Coronavirus deaths in Britain could have been avoided if officials had imposed the lockdown a fortnight earlier. Researchers at the University of Edinburgh said that at least 2,000 lives would have been saved in Scotland if the measures were brought in on March 9 instead of March 23. According to Professor Kao, the Scottish Government's scientific advisers would have known that a major outbreak was imminent in February. 

On March 12 Professor Whitty announced the end of the contained phase. Although many areas of the country were still largely unaffected, the British government abandoned any attempt to use testing and contact tracing to contain the virus, focusing instead on hospital testing. This approach flew in the face of the WHO’s mantra “Test, test, test”, and its advice that “you can’t stop a pandemic if you don’t know who is infected”. Newcastle University Public Health Professor Allyson Pollock also wrote to the Scottish government on March 21 advising them not to abandon testing and tracing, which are core tools for containing the disease. Despite sending a follow-up email, she never received a response.

Third, testing capability and capacity must be increased and effectively managed, using all available laboratories.

The UK’s modelling was based on the flu virus, meaning that they did not initially factor in testing because it is not part of the standard flu epidemic response. Accordingly, there was a failure to ramp-up testing following the successful development of a test for Coronavirus by Colindale’s Public Health laboratory at the stage when the UK had no deaths from the virus. This has had tragic consequences. It left the government no choice but to abandon containment and introduce other measures such as social distancing.  In South Korea, which continued with testing, tracing and isolating contacts of infected individuals, the death toll is at the time of writing 259 – whilst the UK death toll stands at 33,998.  In the absence of a mass testing and contact tracing program, we have no idea how many people have been infected. 

Although the UK government is now increasing testing, thousands of test results are disappearing into a black hole that NHS boards can’t access. Authorities across the UK say they can no longer access data for swabs conducted outside NHS hospitals, which would help them control outbreaks locally. Officials used to provide the results but NHS boards have now been told ‘no data is being reported until further notice’. An internal NHS update email, seen by the specialist news website Health Service Journal, said full information from the national testing programme (NTP) cannot be reported 'until further notice’. The problem arose on May 4. Reporting will now only include tests that have been conducted in NHS labs, which only account for around half of the total swabs carried out.  It means that more than 7,000 people who have tested positive for the coronavirus in the past three days are now untraceable. It comes after furious GPs slammed the ‘failing’ government for leaving them in the dark about how many people in the community are infected. Testing enables detection and surveillance. It also needs to be effectively managed'.

However, it is only the first step. The routes of transmission must be cut off by tracing contacts and requesting self-isolation or quarantine. Fines should be imposed on those breaking quarantine conditions. 

Fourth, as in South Korea, it would be helpful to have thermal imaging scanners put in place at all airports, seaports, the Channel Tunnel, train stations and subways. They should also be placed at the entrances and exits to large shopping malls, supermarkets and other stores in order to detect individuals with a raised temperature, who can then be checked and tested for the virus.

Fifth, when adopting a phone app to aid contact tracing, the public should be allowed to choose between the NHS Bluetooth app currently being tested on the Isle of Wight and the Apple/Google app adopted throughout Europe. This will facilitate travel between the UK and Europe when travel restrictions are lifted. A study suggests that the UK NHS contact tracing app may not work properly if your phone is in your pocket. Signals were reduced by about one-third when someone with a phone in their front pocket faced away from a second person carrying a phone, possibly because the body absorbs some of the Bluetooth signals. This suggests, in the words of Doug Leith from Trinity College’s School of Computer Science and Statistics, that ‘reliable proximity detection using Bluetooth received signal strength is probably not going to be that easy’. There is also a problem in supermarkets and on trains, where phones struggled to distinguish the distances between various people. Covid-19 app development leader Geraint Lewis admitted on Monday that the app does not work on the latest Huawei devices or some older mobile phones. The new tool will only work with devices running either Apple iOS 11 or Android 8 upwards.

Sixth, PPE production should be ramped-up, making use of all companies with the ability to produce reusable gowns and that have passed the stringent safety checks. We should also ensure all staff in healthcare, social care and care homes have the appropriate PPE.  Edinburgh University’s Global Public Health Professor Devi Sridhar noted that some of the original PPE recommended to doctors was in line with that required for flu*. Face masks should be available for purchase in shops.

Seventh, there is a need to ensure that any further easing of lockdown measures is fully supported by an effective Test, Trace and Isolate program. 

The government has announced plans to measure the threat from Covid-19 in England with a new five-level, colour-coded alert system.  This will help the government decide how tough social distancing measures should be. 

Level 5 (red) – a material risk of healthcare services being overwhelmed – extremely strict social distancing

Level 4 – a high or rising level of transmission – enforced social distancing

Level 3 – the virus is in general circulation – social distancing relaxed

Level 2 – the number of cases and transmission are low – minimal social distancing

Level 1(green) – Covid-19 is no longer present in the UK – no social distancing

The level will be determined by Covid-19’s reproduction (R) number (a scientific measure of how fast the virus is spreading) and the number of confirmed coronavirus cases at any one time

According to Professor Whitty, the current position is best described as level four – the virus is still being transmitted widely and many social distancing measures will not be relaxed. 

The government says it will liaise with the devolved administrations in Edinburgh, Cardiff and Belfast as they develop their own versions. 

Eighth, government at all levels needs to be much more transparent and provide information on the epidemic as we move forward in order that they can obtain the support of the public for any measures they are putting in place. Measures to control the pandemic depend on public consent to be effective. Public consent depends on trusting the authorities which cannot be maintained without transparency. This was a lesson South Korea learnt after the MERS outbreak in 2015. 

Yet some NHS managers have tried to stop doctors speaking publicly about shortages of personal protective equipment,the BBC has been told. Whistleblowers UK said more than 100 healthcare workers had contacted them since the beginning of March, raising concerns about Covid 19 and PPE. Dr Jenny Vaughan, law and policy lead at campaigning organisation Doctor’s Association UK said their concerns hadn’t been listened to: “These are people genuinely raising concerns who went to the people who should have listened to them and felt either they couldn’t raise a concern or they weren’t listened to. If you have a transparent open culture of reporting and people feel free that they can speak up about safety concerns, it saves lives”. 

Ninth, as we search for an effective vaccine and effective treatments, we should be ensuring now the infrastructure is in place in our health service to distribute them. At the moment Scotland is nowhere near prepared enough to handle mass vaccination against Covid-19. Professor Phil Greening of Heriot-Watt University said the country is currently nowhere near prepared enough to handle the logistical nightmare of vaccinating millions of people in a very short space of time.  Preparations to administer millions of vaccines must start now, or Scotland risks compounding the economic damage already caused by the pandemic. 

Professor Greening from the University’s Centre for Sustainable Road Freight said: ‘People need to start realising that when an effective vaccine is developed every [country] is going to want to vaccinate at the same time, as it releases the economic shackles. Every country is going to be trying to access the same resources at the same time. It will be like the problem with PPE, magnified by a thousand.’

Within this context, Greening said, preparation is the only way to make sure that every resident will have equal access to the vaccine. He also warned that, with London most likely to be a priority, those in rural communities such as Orkney and the Hebrides will probably be the last to receive a vaccine.

Tenth, if in future there is notification by WHO of any similar viral pandemic with as rapid transmission and such serious consequences for the whole population as Covid 19, our borders should be quickly closed to all except essential goods and services. Any returning nationals should be tested for the virus and asked to self-isolate or go into quarantine for 14 days. All other measures as noted above should be put into place until the pandemic is over and the virus is no longer circulating in the community. 

Screening at airports fell by the wayside when the UK Government abandoned its first attempts at tracking and tracing patients early on in the crisis. 'The UK is one of the very few countries in the world to actually have no checks at borders for anyone coming in,' Scottish government health adviser Professor Devi Sridhar warned last week. 'It is an outlier.' Last month Health Secretary Matt Hancock revealed that 15,000 air passengers were arriving in the UK every day. This equates to around 800,000 since our lockdown began in March. This week there were, on average, 170 flights per day arriving at Heathrow, including ten in one hour from New York – one of the areas worst-affected by Coronavirus. Other flights came directly from Rome, Madrid, Tehran, Shanghai and Guangzhou.

According to US think-tank the Pew Research Center, at least 90 per cent of the global population are in countries with restrictions on non-citizens arriving, while 39 per cent live behind borders entirely closed to foreigners. Yet while 130 countries have travel restrictions in place, Britain currently has an open border policy.

*The Country That Beat The Virus – What Can Britain Learn? Channel 4, 13 May 2020

Dr Anderson, who is now retired, worked as a Consultant in Public Health Medicine and then moved on to become a Senior Medical Officer in the Scottish Government where she led the Service Redesign change program for a number of years.

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