Don't Stand so close to Me! COVID-19 The UK Situation by Paul Oatt
In response to the COVID-19 crisis in the UK, the Government has ushered in new restrictive legislation under The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020, providing local authorities with powers to enforce business closures and coordinate responses with the Police on enforcement of social distancing measures. The powers allow Local Authority Environmental Health and Trading Standards teams to enforce closures of businesses that are selling food or drink for consumption on premises and take necessary steps, which can include the imposition of Prohibition Notices on premises, fines under fixed penalty notices or prosecution of persons whose actions are placing others at risk during this crisis.
At the same time the Government continues to encourage us all to stay at home as much as possible, amidst wider criticism of their overall approach, particularly the herd immunity strategy, and the overwhelming demand placed upon health services along with the large loss of life that is likely to ensue. But just how bad is COVID-19 in the UK? And given that we are not yet testing in the community, how do we measure it?
Prior to the UK’s lockdown, one possible modelled trajectory simulation by Davies et al, (not yet peer reviewed,) was run across 186 counties using age specific probabilities of symptom onset, transmission rates, hospitalisation (ICU and non-ICU) and death rates. The study found that a strategy without pharmaceutical intervention, reliant upon school closures, social distancing, protection of high risk and vulnerable groups and home isolation would have to be implemented and remain in place for many months at least, and if not followed could result in ‘16-30 million symptomatic COVID-19 cases and 250,000-470,000 deaths.’ With no measures in place this would lead to ICU bed capacity being overloaded, bringing NHS resources to breaking point.
The increased burden of disease on health services arising from COVID-19 cases prioritised for ICU treatment during this crisis, also means that there will be displacement of other patients with other types of chronic disease who ordinarily would use those same beds and facilities and be reliant upon the services of the same medical staff. This displacement is the opportunity cost of prioritising resources to address burdens of mortality and morbidity associated with COVID-19.
In recognition of the burden that the disease is going to place upon the NHS the first emergency hospital was built at London’s ExCel centre last month, with a 4,000 bed capacity. More are planned to be built across the country. At the same time the Government is also coordinating a series of temporary mortuaries nationwide, in response to the rising death toll.
Any measure or modelling of disease takes account of the reproduction number (R0) this is a measure of exponential growth, representing the number of new infections caused by a person who is already infected, Kurchaski et al estimated that in Wuhan prior to travel restrictions each infected person transmitted the disease to an extra 1 to 4 people. The infographic commonly used to illustrate this point shows an R0 of 2.5, and reducing this figure to below 1 through scaling back our contact with other persons by 75% should slow the infection rate sufficiently for the disease to die out.
At the beginning of April, preliminary estimates by Jarvis et al, found that current Government measures might be driving the R0 to below 1, estimating it to be approximately 0.62 95% CI (0.37, 0.89.) The study used an online survey of 1,300 persons disclosing the number of persons they had been in contact with the previous day, and compared this to a 2005-2006 study asking the same and found on average a 70% reduction in daily contacts which if sustained over coming months should reduce the burden on the NHS, forcing the epidemic into decline. However, reports this weekend suggest that a significant number of persons ignored the ban on social gatherings on Saturday 4th April prompting further public warnings against congregating and a warning that should it continue the Government may ban outdoor exercise altogether.
The reported figures of new infections and deaths that we see daily in the media are taken from the Governments own website, but slight differences in reporting mean that deaths from outside hospitals are under reported because they are compiled from deaths recorded up to 5pm the previous day, but there are variations of up to a few days between the actual time of death and that death being reported.
A recent Guardian article argued that by undercounting the number of deaths in this way, the data on the curve that we are all desperately waiting to see flatten, will be skewed. To illustrate the point the article uses the death rate reported on 30th March, (originally 159 deaths up to 5pm 29th March.) This figure was subsequently revised up to 463 deaths for that day alone, and could be revised again as ‘more deaths come to light.’ In the article, Prof Sheila Bird, formerly of the Medical Research Council’s biostatistics unit at Cambridge University makes the point that underreporting will mean that we underestimate the steepness of the curve and may think we are doing better than we are, whilst the real deaths continue on an upward trajectory. When the sombrero is finally squashed, we could be slow to recognise this too. Might this also mean that we will be slow to recognise and react to a second wave when that comes?
COVID-19 is caused by an acute respiratory infection called SARS-Cov-2. It is referred to as a novel pathogen because we still don’t know enough about it. Despite this there is mounting pressure to assess not only current viral infection but also to test immunity in order to limit economic damage and see people return to work without further risk. This is particularly important for health care workers as staff shortages through illness place a further strain on services. The test will also be essential for measuring the effectiveness of vaccines during clinical trials. Lessons learned from the SARS-Cov outbreak of 2002 show that persons who developed immunity back then still have neutralising antibodies now. But whether the same can be said for SARS-Cov-2 which has a 75% identity with SARS-Cov is not clear, and the upscaling of resources to develop an immunity test is stretching the resources of anti-body test developers.
The UK have ordered 17.5m “game changer” antibody home testing kits but doubts exist over the sensitivity and effectiveness of these kits which can produce a reliable result with 90% accuracy only when tested on hospital patients with severe symptoms and merely a 50-60% accuracy in detection amongst those with mild symptoms, but the latter are the intended target group.
There is of course a test to diagnose the disease, the polymerase chain reaction (PCR) nose throat test which detects viral particles, but the technology required to develop an antibody test is distinct because it requires a better understanding of the proteins forming the viral coat or shell of the virus and how it can trigger recognition in the immune system to produce antibodies that flag or neutralise the virus, Both of these tests are facing global challenges to meet supply.
It feels as if we are holding pieces of the puzzle here in the UK and trying to complete the jigsaw without the missing pieces. We have a lockdown of sorts and are preparing for the worst, but is this really going to be enough? In China lessons were learned from the Sars-Cov outbreak of 2002. A key strategy in the Wuhan outbreak was the imposition of a cordon sanitaire to limit and contain the spread of the disease. However, Wuhan has major transport links to other areas and it was recognised that the disease had already seeded elsewhere. Multi agency collaborations addressed the outbreak within Wuhan as well as the exported cases using isolation, treatment and social distancing to interrupt the chain of transmission, closure of wet markets and stricter safety measures on poultry markets, restriction of movement and introduction of temperature checks and quarantine measures.
Whilst genome sequencing of the virus was carried out protocols for diagnosis, treatment, epidemiological investigation, surveillance and PRC testing were established and continually revised. New hospitals were built and certain places repurposed to ensure everyone could have access to treatment. All primary cases were treated and their close contacts followed up as an R0 and were isolated and put under medical observation.
Over time the focus shifted to reducing clusters of cases as the curve began to plateau, and there was differentiation across areas in the approach to reducing spread of disease depending on the identification of these clusters, and gradually restrictions were able to be relaxed.
The Local Government Association have consolidated the data on Covid-19 to report using the data provided by the government, in a range of graphs that provide a clearer picture of the spread of disease.
Graph 1 shows that between March and April cases of COVID-19 were most prevalent in London and the West Midlands and the North West is catching up. But interestingly areas with the highest rates of cases were generally found to have the lowest proportions of people aged over 65, which suggests that measures are working to protect the vulnerable age group but the report comes with the caveat that this could change.
Graph 1. Cumulative COVID-19 cases per 100,000 people for all English regions and England last seven available days. (Local Government Association.)
On the 4th April the daily confirmed cases stood at 2,910 which was a decrease of 666 case from the previous day, however on the 5th April the daily recorded cases have shot up to 5,107 the largest increase we have seen. It does not appear that the plateau is yet within sight and the fluctuation demonstrates how unpredictable the disease is, and it is evident we still know very little, China admit there remain knowledge gaps on transmissibility, incubation, disease progression, risk of spread and even the effectiveness of prevention and control.
Knowing more about all of this would make a huge difference, and just as they continue to evaluate their strategy in China I suspect we will be doing that here in the UK for some time to come. Should we have enforced a lockdown earlier? Are the measures we have in place sufficient? Will people respect the Governments request to stay at home? And might we have to do it for much longer than we think?
And what of those new powers for closure? Early reports suggest that where non-compliance has been found most businesses have closed voluntarily and it has only been necessary to serve a handful of Prohibition Notices, but that like everything in this situation might change, let’s hope not.
Paul Oatt is the Author of Selective Licensing: The Basis for a Collaborative Approach to Addressing Health Inequalities, available now from Routledge, Taylor & Francis.
#COVID 19 #publichealth #coronavirus #publicprotection
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