Richard North, 25/04/2020  
 


In this country, Public Health England (PHE) is the front-line body charged with managing the first response to an outbreak of infectious disease. It is rather ironic, therefore, that on 11 September 2019 the organisation launched its new infectious disease strategy for 2020-2025.

Only a few months later, it was to be embroiled in the most dangerous pandemic the UK has experienced since, perhaps, the "Spanish Flu" pandemic of 1918. And yet, despite the obvious and acknowledged threat of a new pandemic, preparing for one was by no means on the top of its list of priorities.

In its corporate strategy for 2020-2025, above all else, its first priority was taking steps towards creating "a smoke-free society" by 2030. Next in line was "healthier diets", and "healthier weight", helping people "make the healthy choice the easy choice to improve diets" and reducing "rates of childhood obesity".

One had to get past "creating cleaner air", "better mental health" and working "to improve the health of babies, children and their families" before, sixth in line was an "effective responses to major incidents", which included enhancing "our ability to respond to major incidents", which included pandemic influenza.

But even in the field of infection control, pandemic flu was not on top of the list. In the infectious disease strategy press release, first priority was antibiotic resistance and declining vaccination rates. Only then do we get to "pandemic flu" as a threat to health, with lip-service paid to "emerging diseases".

But, in the strategy itself (pictured), the only real concern is pandemic flu. "Pandemic Influenza", says PHE, "is the highest scoring risk on the National Risk Register of Civil Emergencies" (pictured).

It says something of this claim though, that it was not true. Not only that, the PHE strategy contradicts its own graphic. In an earlier section, it states that the 2017 National Risk Register for Civil Emergencies lists pandemic influenza and new and emerging infectious diseases threats as "two of the greatest threats which would have a serious effect on the security of the UK".

In actuality, though, the Register lists "Human diseases" as a threat, giving equal prominence to "Emerging infectious diseases" and "pandemic flu", with the two groups listed in that order – although the latter is given far more space. But therein lies a tale of its own because, as I noted yesterday, missing from the 2017 Register is any mention of SARS by name.

One will recall that SARS, as a pandemic disease, first emerged in 2002, the original outbreak starting, or so it is believed, in Guangdong Province, China, in November 2002. Over the following months, the illness spread rapidly to more than two dozen countries across Asia, North America, South America, and Europe.

By the time it was contained in July 2003, over 8,000 people had been affected, of whom over 750 had died. Interestingly, the majority of cases occurred among close family members associated with an initial case, and hospital workers who had cared for infected patients.

Although, by pandemic standards, this was a modest affair, it was enough to spook the WHO into listing SARS as a disease which "may constitute a public health emergency of international concern" in its 2005 revision of its International Health Regulations.

At that time, PHE had not been created and the front-line body responsible for managing the government's response to any SARS pandemic was the Health Protection Agency (HPA). In its 2007 annual report, however, it acknowledged the WHO's changes to its regulations, made "in the light of the global SARS experience".

However, in 2008, the Cabinet Office in its 2008 edition of its National Risk Register thought that the likelihood of a new disease like SARS spreading to the UK was "low". But at least the document did address the SARS threat specifically, devoting two long paragraphs to the issue, reflecting the WHO's concern.

But, it said, if an outbreak did occur, and preventative measures were not put in place swiftly, it thought that the impact would be relatively low, on the scale of the SARS outbreak in Toronto, Canada, which had 251 cases in two waves over a period of several months. And, with that – and possibly because of that – no specific plan for the control of SARS was produced.

Yet, as we are already aware, in October 2005, the Blair administration delivered a 177-page document setting out the UK Influenza Pandemic Contingency Plan. Confusingly, in the previous March, it had already published a supplement for planners in England – this one a more modest 24 pages. The publications spanned the tenures of two Secretaries of State for Health, initially John Reid who was in office until 6 May 2005, and his successor Patricia Hewitt.

Nevertheless, presumably in deference to the WHO, the next two editions of the National Risk Register (2010 and 2013) kept the reference to SARS, essentially unchanged. But by 2015 the two long paragraphs had shrunk to one sentence.

In between, we had seen the Lancet in September 2014 argue that emerging infectious diseases were "an important public health threat and infections with pandemic potential are a major global risk". SARS was prominently mentioned. Nevertheless, it was in the 2017 edition of the National Risk Register that the reference to SARS disappeared completely. Officially, SARS – as a named disease - had been removed from the list of potential threats to the UK.

It was here that we saw the generic category of "emerging infectious diseases" (EIDs), and even here the threat was downgraded. The consequences were put at "several thousand people experiencing symptoms, potentially leading to up to 100 fatalities".

Conversely, pandemic flu was deemed the much greater threat. Up to half of the UK population could experience symptoms, potentially leading to between 20,000 and 750,000 fatalities and high levels of absence from work. It was very clear which was seen as the most important.

By then, of course, the pandemic influenza preparedness plan had undergone several iterations, culminating in the 2014 plan, together with the strategic framework.

But that, and the 2017 National Risk Register, was by no means the government's last or only words on pandemic influenza. In 2015, it had produced a National Security Strategy and Strategic Defence and Security Review, which stated that "disease, particularly pandemic influenza, emerging infectious diseases and growing antimicrobial resistance, threatens lives and causes disruption to public services and the economy". SARS was not mentioned by name.

In July 2018, the government then published a Biological Security Strategy, drawing together "for the first time" the work that takes place across government to protect the UK and its interests from significant biological risks. And here, writ large, as a threat, was pandemic influenza. Again SARS was not mentioned.

Finally, courtesy of the Guardian, we see references to the 2019 National Security Risk Assessment (NSRA) – an "official sensitive" document which is not available to the general public. This, the Guardian says, "revealed" that "UK ministers were warned last year of risks of coronavirus pandemic".

But that is only partially true, with the emphasis entirely on pandemic influenza. The document does refer to the possibility of a respiratory coronavirus outbreak, such as the outbreak of Severe Acute Respiratory Syndrome in 2003, but suggests that Middle East Respiratory Syndrome, seen in South Korea in 2015, "poses the higher risk".

In terms of response, though, it says that the risk has "low confidence". There is "significant uncertainty", it adds, about the frequency with which an emerging infection may develop the ability to transmit from person to person. 

As to the impact, it concludes that there is "some uncertainty" as to whether a different emerging pathogen "would lead to an outbreak similar to those seen previously". This is hardly a clarion call to action: it is rated "amber" as opposed to the overall assessment on an "influenza-type pandemic" which is rated as "very high".

Unequivocally, for well over a decade, official risk assessments have focused on pandemic flu and the major threat, while the risk of SARS has been consistently downplayed, dismissed as a low risk.

Even in December 2019, in its summary of notable incidents of public health significance, the government was more focused on Ebola, and gave merely a passing reference to an outbreak of viral pneumonia of unknown aetiology identified in Wuhan, the capital of Hubei province in Central China. The pathogen, it noted, "was subsequently identified as a novel coronavirus". This was the very first mention of the outbreak.

Not until the January/February edition (published in March 2020) was Covid-19 the lead item, when the report noted that, on 30 January, the International Health Regulations (2005) Emergency Committee agreed that the outbreak met the criteria for a Public Health Emergency of International Concern.

As of 10 March 2020, nearly 81,000 confirmed cases and more than 3,100 deaths had been reported in mainland China, the vast majority in Hubei Province. In recent weeks, the report said, the outbreak had taken a more global focus with nearly 33,000 cases and 900 deaths reported in 109 countries or areas, including the UK.

So obsessed with pandemic influenza had the government been (with PHE majoring on its "smoke-free society") that they hadn't seen it coming. And, for want of a specific plan, when it did arrive, they used the influenza plan anyway. It was the only one they had. 

The rest, as they say, is history.






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