Tuesday, August 25, 2020

Is the UK ready for a Covid winter?

To prepare my article for The Guardian on whether the UK is prepared for a Covid winter, I spoke to many experts who gave a great deal of helpful information and advice. Only a small part of that could be fitted into the article, and I thought it would be helpful to put some more of it out there. So here is the longer version of that article.

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No one knows what Covid-19 holds in the coming months, but no one well-informed takes seriously Boris Johnson’s claim that it could all be back to normal by Christmas. With local outbreaks already prompting lockdowns in Leicester, Manchester and Preston, and cases rising at an alarming rate in Spain and Germany, it’s entirely possible that there will be grim days ahead. The faster spreading of the coronavirus and greater difficulty of maintaining social distancing as the weather gets colder, coupled to a return of schools and a desperate need to get the economy moving again, will increase the challenge of keeping a lid on the threat. So are we ready?

The good news is that some of what was lacking in March, and which led to such a disastrous outcome in the UK, is now in place. By no means all of that shortfall can be blamed on the present government; political leaders had for years ignored the warnings of specialists in infectious disease that a pandemic was a near certainty, the frightening lack of preparedness exposed by the 2016 Cygnus flu simulation was ignored while the nation was in the grip of Brexit-mania, the UK had no industrial infrastructure for generating testing capacity at short notice, and the NHS had been worn ragged by years of austerity. Besides, this was an entirely new virus, and little was known about how it spreads and harms the human body.

Significant headway has been made on some of those problems over the summer. The bad news is that it still might not be enough, and the outcome depends on many factors that are still all but impossible to predict. “We’ve got to up our game for the autumn”, says Ewan Birney, deputy director of the European Molecular Biology Laboratory, who heads its Bioinformatics Institute in Cambridgeshire. “We’ll be inside more. Universities and schools will be running. There will be a whole bunch of contacts that we don’t have now.”

“We can anticipate a lot more infections over the next few months”, says virologist Jonathan Ball of the University of Nottingham. The prime minister has advised hoping for the best and preparing for the worst, pledging that by the end of October there will be at least half a million tests for the virus conducted every day, and that the NHS will receive £3 bn of extra funding. But as Chris Hopson, chief executive of NHS Providers says, much more is likely to be needed in the next month or two to keep Covid-19 under control.

The nightmare scenario, he says, is a combination of a second surge of Covid-19 with a particularly difficult outbreak of winter flu, alongside the normal pressures that winter puts on health services, while they are trying to restart services put on hold during the crisis period – and all this being faced by an exhausted staff.

“The NHS would struggle if all of that came together at once”, Hopson says. “We struggle with winter pressures at the best of times, with insufficient bed capacity and community care capacity to deal with the levels of demand that we get”. Covid-19 creates a capacity loss because of the need to keep people infected by virus on separate wards from those who aren’t.

It’s not all gloom. The situation with personal protective equipment is now a lot better than in March, as is the availability of ventilators for severe cases (which turned out not to be so central anyway). What matters most, however, both for health services and for controlling the virus in the community, is the capacity for testing.

The lack of testing in the population was what largely hamstrung the response top the first wave – scientists and public health authorities were flying blind, not knowing how widespread the virus was or where it was concentrated. It was lack of testing that created the appalling spread of infection in care homes.

The situation now is very different. The UK is conducting tests as widely and as fast as most European countries: around 200,000 each day. Most of these are analysed in the Lighthouse Labs that were quickly set up for the task; repurposed academic labs throughout the country are also helping. “We’re in a much better position than we were at the start of the pandemic”, says molecular geneticist Andrew Beggs, who leads testing efforts at the University of Birmingham. “The government has massively increased the capacity for testing in a short space of time, and I’m more confident than I was two months ago that we’re got a really good chance of successfully testing people.”

What we need, says Ball, is “sentinel surveillance”: actively going out and working out where infections are occurring, particularly in high-risk populations such as hospitals and care homes, but also schools and universities. The Office for National Statistics is collaborating with other bodies in a pilot survey that will test a representative sample of households in the general population – up to 150,000 people a fortnight by October – to gauge the extent of infection.

Most testing uses swabs to collect samples that detect the presence of the virus, but it’s also possible to get an antibody test that reveals if you have had the virus without knowing it. Test results are almost always returned within 48 hours – much longer than that and they become of little value – and often within a day.

That’s important for several reasons. It alerts public health services and epidemiologists to dangerous hotspots of infections, so that they can be contained locally. It lets hospital staff know which patients can be safely kept on general wards, and whether they themselves are safe to be at work. Regular testing will be essential for frontline workers such as those operating public transport; at schools and offices it should not only tell people with suspicious symptoms whether they need to self-isolate but reveal whether the colleagues they came into contact with should do so.

Tests can also show how many people have now had the virus and are likely to have some level of immunity. Ball says that while its currently thought that perhaps 10% of the population have had Covid-19, some antibody results imply that the infection rater may have been much higher – as much as 50%. He suspects that actual number is somewhere in between. The more people have already been infected, the slower the virus might spread – and also, the lower the actual mortality rate is likely to be.

What’s more, new types of test being developed by British companies such as Oxford Nanopore and DNANudge could reduce the waiting time to a few hours, or less, from a procedure as simple as spitting into a cup. They can also be much more portable. “That gives you a lot more options for where you put the testing”, says Birney (who is a consultant for Oxford Nanopore). It could become routine to make a test part of airport flight check-in; commercial centres could have a testing facility where office workers get checked out at the start of the day. These options are still a long way off – and they depend on whether the promising initial results from the new methods stand up, as well as the companies’ unproven ability to scale up production. But “even if one technology doesn’t work our for rapid onsite screening, we have others in the pipeline”, says Beggs.

Another option is testing for the virus in sewage to keep track of infection levels in different parts of the country. From one test, you’re testing many thousands of people, says Birney. The Department for Environment, Food and Rural Affairs (Defra) has such a scheme underway, but it’s still too early to know how effective it will be.

Despite all this good progress, however, Hopson warns that there’s a lot to be done to create the testing regime that the NHS really needs. “Testing is one of the key issues we need to get right to prepare for winter, and there’s a long way to go to get to a fit-for-purpose operation,” he says. Both the number of tests and their speed will need to increase, and Hopson thinks that ideally we will need about a million tests a day by the end of December. “That’s a very tall order”, he says.

Tests will be crucial in health and care settings, where you need to know fast where a new patient should be put. For care homes, this information is vital to free residents from the need to be confined to the rooms. Epidemiologist Ruth Gilbert of University College London’s Institute of Child Health says that the loss of mobility and social interaction in care settings can accelerate mental and physical deterioration.

Equally crucially, the system needs to be joined up: a test result needs to go at once into people’s health records accessed by local GPs. And Hopson says there needs to be greater local control – at the moment the testing infrastructure is too nationally based.

“If you want to manage this risk, there’s a highly complex logistical operation with a complicated delivery chain”, Hopson says. “We need the funding to expand the capacity. We need the tests at volume. We need to set up the capacity close enough to where it’s needed. We need to get the computer systems joined up. It’s such a complex end-to-end process, from scientists developing tests to GP surgeries needing to see the care records, and local authorities, and it needs to operate at speed.”

It’s vital too that positive tests be followed up by effective contact tracing, so that others who might have been infected can self-isolate. “This is not working as well as it should”, says Hopson. “We’re losing too many people down that chain [of contacts].” The number of people being contacted and made to self-isolate is far lower in the UK than in other countries – and it’s not clear how much they are self-isolating anyway. “There has been no data published on it, and we know it’s not happening”, says Susan Michie, professor of health psychology at University College London.

This is as much a socioeconomic issue as a medical one. “People who are financially unable to self-isolate for 14 days need to be incentivized to do so”, says Hopson – their lost earnings need to be covered by the government. He points out that some places with high levels of outbreak tend to have higher percentages of ethnic monitory communities where English is not the first language, who are not always keen to interact with the state. This clearly needs sensitive handling – contact tracing must not seem “just a white middle-class operation”, he says.

Given the amount of preparation still to be done, many were alarmed by the news that Public Health England, the organization that overseas public healthcare within the Department of Health, is to be replaced by a new organization called the National Institute for Health Protection. This will bring the tasks of PHE under the same authority as NHS Test and Trace and the new pandemic data hub the Joint Biosecurity Centre.

“The last thing we need is reorganisation on top of this”, said Birney in response to the news, which came as a surprise to many like him who are involved in preparedness. “Even if this was the ultimately best chess move for a future pandemic preparedness, there is no way doing it mid-pandemic is sensible.” More than 200 public-health professionals signed a letter to The Telegraph in which they declared themselves “deeply disturbed by the news of another top-down restructure of the English public health system, particularly mid-pandemic, and without any forewarning for staff.”

But Hopson is more sanguine, saying that the move won’t involve large-scale restructuring of jobs. “I can see why everybody is jumping up and down”, he says, “but the leaders say to us that this is not a restructure.” Everyone will carry on doing their existing jobs – “it’s just that there’s a new interim team at the top level to link the parts together and create better coordination between them.” Having two different organizations doesn’t make a lot of sense. Putting them under one leadership team seems to us to make good sense.” Gilbert hopes that the new agency will make its data more widely available than PHE did, to help advance the science.

One of the biggest and most controversial issues for the autumn is the return of schools. While there is a broad consensus that getting pupils back must be a priority, this will inevitably raise the risk of spreading the virus. Although still too little is known about how readily this happens via children, there is some evidence now that secondary-school pupils can catch and pass on the virus much as adults do, and that primary-school children can do so even if they suffer only mild symptoms – probably about 15-20% of children infected have no symptoms, says Sanjay Patel of the Royal College of Paediatrics and Child Health.

There are encouraging signs that schools might not be a big source of infection, though. Sweden left schools open, and didn’t see lots of outbreaks or transmission, says Patel. Teachers didn’t have higher rates of infection either – lower than taxi drivers and supermarket workers.

“Schools have been working incredibly hard to try to get measures in place for opening in September”, says Patel. They will aim to keep pupils within small contact groups or “bubbles”, but this is much easier at primary than secondary level, where pupils change groups for different subjects and are less inclined to observe distancing rules. “If there’s an outbreak in a school, then sensible decisions need to be made about whether a bubble, a year, or a school needs to be closed”, says Patel.

He predicts that schooling “will be hugely disrupted for individual children and families, for bubbles and for year groups – there will be closures and outbreaks, and lots of children will be in and out of school.” Children of course get lots of coughs and colds over winter, and “those children will have to be excluded at once until they get a test result back. That means their parents will also have to isolate for that period.” But he hopes that regular seasonal viruses might themselves spread less because of the new measures.

“We have some really good plans in place for this winter”, he says. “We’ve learnt a lot from the first surge, and there’s absolutely no feeling of panic.”

But he adds that there’s no zero-risk option either. “The best way of protecting against outbreaks in school is to minimize the amount of infection in the community”, he says. This means compensating for school openings with restrictions elsewhere. At the moment, he says, it seems young people meeting in bars, pose a far higher risk of spreading than schools. So “do we prioritize our ability to go and have a drink in the pub, or the future education of our children?”

“The government has done a lot wrong, but generally we’re making progress”, says Beggs. “The natural British constitution is to be a bit gloomy about our ability to do things, but if we could share all the achievements we’ve done in a more optimistic way, I think people would be more reassured.”

Ah, there’s the rub. Beggs is right to warn about the danger of trying to present everything in the worst possible light in order to discredit a government that performed so dismally in the initial outbreak (about which I’ve written elsewhere). This would be unhelpful, as well as unfair to the many authorities, scientists, health professionals and others who have worked so hard to improve the prospects. Yet the fact remains that the good work done on preparedness stands in stark contrast to the very public and very damaging missteps the government has taken and continues to take. The messaging is still confusing, even misleading: ministers (and some chief medical advisers) seem intent, for example, on stressing the low risk that Covid-19 poses to young children returning to school (so stop worrying, parents!), whereas the true danger there is about transmission through the population generally. Announcements of local lockdowns have been woefully mismanaged. The alarm about the reorganization of PHE was deepened by the appointment of Dido Harding – who has no public health experience, a terrible track record with managing the Track and Trace system, and is married to a Conservative peer – as its head. While contracts do have to be awarded swiftly, without the delay of a drawn-out tendering process, in circumstances like these, too many seem to be going to companies with close contacts to government and its advisers. Blunders like the exams fiasco (and the refusal of government to accept blame or consequences) undermine even further public trust in our leaders.

This issue of trust will be crucial. Imposing local lockdowns to contain hotspots, identifying contacts of people who test positive, and persuading them to self-isolate, would be a challenge at the best of times, and hinges on whether people understand what they are being asked to do and why, and whether they trust those making the rules. Studies have shown that public trust in the government has already been badly eroded, both by the mishandling and poor messaging of the first wave and by what many see as the betrayal of Dominic Cummings’ lockdown breaches. Scientific and public health systems can do all they can to prepare, but in the end so much will depend on leadership and execution. I have been encouraged by what I have heard about the former; about the latter, I fear I remain gloomy.

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During your research, did you come across much about the kinds of long-term health issues that Ed Yong has been discussing in his Atlantic articles, most recently here, https://www.theatlantic.com/health/archive/2020/08/long-haulers-covid-19-recognition-support-groups-symptoms/615382/ ?
The relative lack of hard data on this aspect of Covid-19 has been disconcerting.

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