Richard North, 28/03/2020  
 


Predictably, a media obsessed with personalities, has made its focus of the day the infection of the prime minister with coronavirus, along with the health secretary and the chief medical officer, all of whom have been tested and found positive for the virus.

Whether this trio are included in the 14,579 reported positive in yesterday's figures is not known, although they most certainly are not included in the list of the 759 dead. But their infection has served to drive off the front pages what are most certainly figures of concern, the cases up from 11,658 the previous day representing a 25 percent increase.

The deaths are of even more concern, up from 578, 181 more than the previous reporting period, representing a 31 percent increase, the overall total having doubled in less than four days, despite being limited to a record of those hospitalised in the UK who have died.

Away from the tedious fluff of the personalities game, though, there are serious questions being asked about the management of this epidemic in the wake of the publication of the minutes of the meetings of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), which has been advising the government on the Covid-19 epidemic.

Of special interest are the minutes of the Wuhan Novel Coronavirus Fourth Meeting on 30 January 2020, just as the first cases of what was to become known as Covid-19 were being reported in the UK.

It was then that the deputy chief medical officer, Jonathan Van-Tam explained that "the aim of case detection at this stage of the epidemic was to do everything possible strategically and operationally to prevent the establishment of community transmission in the UK – detection and isolation being the critical things".

This was exactly the right thing to say, and hardly controversial, coming straight out of the basic primer on the management of outbreaks of infectious disease. I referred to this as a strategy on this blog on 7 March and again a week later on 14 March, when I spelt out in detail the procedure which must be followed if there is to be any chance of ending this epidemic. Starting with the cases, I wrote:
These must be isolated from the population until they have ceased to shed the infective virus. But, bearing in mind that these people may have infected others before being removed from the infection chain, one must carry out a rapid process of contact tracing, with testing to establish whether they have been infected, and isolation of those who are infective.
Even then, however, we knew that the government had already abandoned the process of what is called in short "test and trace", in favour of an essentially laissez faire strategy of allowing the illness to rip though the community to achieve "herd immunity".

As to why the testing was abandoned, we now have the Financial Times on the case (free to read), purporting to tell us: "How the UK got coronavirus testing wrong", noting that the government had at first seemed to want a concerted contact tracing effort, but had then eased up.

This picks up on the comments of Anthony Costello, a UK paediatrician and former director of the WHO, whom I quoted on 16 March after he had been quoted in the Guardian, declaring that: "You test the population like crazy, find out where the cases are, immediately quarantine them and do contact tracing and get them out of the community". This, he said, was the "key bedrock" of getting the epidemic under control.

The FT has a shorter, more pithy version of this, having Costello say, "Testing is the basis of public health detective work to shut down an epidemic", adding that tests were vital for tracking down people with symptoms, identifying their contacts and quarantining them all until they were no longer infectious.

At first, says the FT, it seemed that the UK was going to follow this approach. But the steps it took next have become a source of concern for an anxious public and National Health Service workers on the front lines of the outbreak.

Although the UK became one of the first countries to develop an accurate test for the presence of the virus in patients, initially it used just one laboratory - Public Health England's Colindale facility in north London, which was processing about 500 tests a day this week.

As coronavirus began to spread around the world, the UK gradually enlisted more labs across the country, announcing on 11 March that it had carried out 25,000 tests in total and was aiming for 10,000 a day — a target it has yet to reach. Only gradually were more labs eventually involved.

Some experts, we are told, believe bureaucratic fiefdoms might explain why the Colindale lab was only gradually joined by others. The paper cites a senior academic, who says, "If I'm running a lab where every sample of a really interesting new disease has to come to me for testing, then I am in control of the data". He adds, "In that situation, it's a bit difficult to think 'We need a network of places and it doesn’t matter where the tests are done as long as all the data come together'".

That this could partly be the case would not surprise me. Before it became part of Public Health England, the Colindale facility was the headquarters of the Public Health Laboratory Service (PHLS), and home to the secretive Communicable Disease Surveillance Centre (CDSC), the organisations who put Edwina Currie up to launching the Salmonella and eggs scare in 1988.

When researching the structure of the public health system in England for my PhD, after discovering that a CDSC scientist had falsified data in a paper to the Lancet, wrongly attributing a food poisoning outbreak to eggs, the response of the organisations was to instruct their staff not to speak to me or answer any of my inquiries.

Not very much has changed, it seems to me, as the facility is still taking a dog-in-a-manger approach to the collection of data, unlike Germany which has a far more open and decentralised system, and one that is producing very different results.

The German system is also said to be far more effective in dealing with the epidemic, with a higher testing rate enabling the authorities to identify cases of coronavirus quicker and isolate people who have been infected, helping prevent the disease from being spread to vulnerable groups.

But there is something missing from the current narratives. There is a lot more to a "test and trace" programme than laboratories and the availability of tests. You need the "boots on the ground" to administer the tests, to interview cases and then to search out and interview potential contacts.

It is here that the UK system, as I explained in a recent blogpost, is dangerously weak, having centralised the system under the banner of Public Health England, concentrating the resource in a mere nine public health protection teams (HPTs) to cover the whole country.

To this day, therefore, there seems an inability to understand how poorly prepared we were for dealing with a major epidemic, despite claims to the contrary in late February.

As we now progress through an increasingly intrusive (but nonetheless incomplete) "lockdown", and the NHS is planning now on its third emergency treatment centre, this one in Manchester, the gruesome news is reaching us that a temporary mortuary is being built at Birmingham airport, with space for 12,000 bodies (pictured).

It is all very well, therefore, applauding the NHS, but one should realise that the front-line management of an epidemic is done in the field and in the laboratories. Only when that system fails does the hospital service have to get heavily engaged, while the population goes into lockdown.

Thus, when the clapping dies down, we need to be aware that we are actually dealing with what looks distinctly like a system failure – the price being paid in the steady accumulation of corpses, the curtailment of our liberties and the wrecking of the economy.






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