COVID-19: assessing the UK's response to a pandemic

  • Edna Astbury-Ward, Medscape.com

  • UK Medical News
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NHS critical care capacity is growing ahead of the predicted 'surge' in COVID-19 cases, including opening NHS Nightingale field hospitals. But questions remain over the UK's approach to testing and test targets.

England's first target of 25,000 tests a day hadn't been met before it was replaced with a 100,000 daily test target by the end of April.

Yesterday, at the daily Downing Street briefing, Government Chief Medical Adviser Professor Chris Whitty admitted the UK still has lessons to learn from Germany: "We all know that Germany got ahead in terms of its ability to do testing for the virus and there's a lot to learn from that, and we've been trying to learn the lessons from that."

Government Chief Scientific Adviser, Sir Patrick Vallance, said: "The German curve looks as though it's lower at the moment, and that is important, and I don't have a clear answer to exactly what is the reason for that."

Expert Panel

Professor Paul Cosford, emeritus medical director of Public Health England (PHE) is at the heart of the UK's response to the pandemic. On Tuesday 7th April he took part in the Royal Society of Medicine (RSM) webinar series on COVID-19, chaired by Professor Sir Simon Wessely, professor of psychological medicine at King's College London, president of the Royal College of Psychiatrists, and a consultant psychiatrist at King's College Hospital and at the Maudsley Hospital.

With the Government and the NHS working around the clock to fight COVID-19, Prof Cosford and Sir Simon explored the current and future state of testing, from the rapid research involved in creating tests for novel viruses, such as COVID-19, to the complexities of scaling up the country's testing capacity, and about possible exit strategies. 

Prof Cosford is a well-known voice during the current crisis. Last year he stepped down as the medical director of PHE after being diagnosed with an incurable cancer 2 years earlier. He said he "could no longer do justice to the intensity of work needed during major national incidents such as coronavirus". He said on his blog that "even for a pandemic expert like me, life in isolation has been a struggle".

Testing Targets

Prof Cosford said: "The extension of testing to NHS staff who may be self-isolating and don't need to is also really important so they can get back to work. That situation is boosted now with the 10 drive-through testing centres, with plans to increase to 15 by the end of the month." He went on to say that the UK now has new super laboratories in Milton Keynes, Alderley Park, and Glasgow. Alderley Park 'super lab' is one of three in the UK that will be testing swabs for COVID-19. All three have been set up quickly to respond to the Government's drive to test people across the country by the end of April.

Regarding the antibody testing, so far Prof Cosford was a little less optimistic. The goal he said was to be able to get testing kits that were accurate and simple to use (like pregnancy tests) into the home, but he said, "that so far they've been very disappointing and don't pass muster in that respect".

A sentiment that has also been endorsed by Professor Sir John Bell, regius professor of medicine, Oxford University, and government adviser on life sciences. The Government has ordered 3.5 million testing kits but the ones he has examined so far “have not performed well” and “none of them would meet the criteria for a good test”.

Profs Bell and Cosford's statements have been supported by Professor John Newton, director of health improvement at Public Health England, who said the tests were not accurate enough on people who had only had mild illnesses and were not good enough for public use.

Building Capacity 

Prof Cosford told RSM webinar listeners that other countries, such as Germany, have had a longer established base in the diagnostics industry which is why they have been able to test more people at an earlier stage than the UK.

Private laboratories have played a crucial role in Germany's testing regime. It is believed that laboratories in German universities, hospitals and government agencies have taken the lead in testing for COVID-19. In Germany between 2nd and 8th March, 43 laboratories conducted 36,067 tests. Last week, 97 laboratories conducted 313,957 tests.

Contact Tracing

Robust contact tracing was identified as one of the key initiatives that is going to be implemented in the UK exit strategy. Prof Cosford said that: “Currently there's a lot of work going on to scale up the process of contact tracing and currently there's an app being developed which uses Bluetooth signals to identify contacts."

The science behind this novel way of identifying those who have potentially been in contact with COVID-19 was published in Science journal March 31st. The project is co-led by Dr David Bonsall, senior researcher at Oxford University's Nuffield Department of Medicine and clinician at Oxford's John Radcliffe Hospital.

Prof Cosford said that the single most important thing in an exit strategy was to "damp down the numbers of infections, build NHS capacity, to treat, to ventilate and to provide all the care that is needed." After that, he suggested that very, very limited lifting of the social distancing restrictions together with robust testing and contact tracing could be a possibility.

Optimism and the R – Naught (R0)

Prof Cosford, who is an epidemiologist by profession, discussed the importance of understanding the relevance of R – Naught (R0), which he described as "the critically important number in all this".

R – Naught (R0) is an epidemiologic metric used to describe the contagiousness or transmissibility of infectious agents. He told the audience that it was vital to keep the R – Naught (R0) in the population below 1, which indicates the number of transmissions from person to person.

He went on to add that "if the social distancing measures that are in place at the moment are working as we hope they are working, then the R – Naught (R0) should be below 1, and we'll see in the coming weeks whether that turns out to be the case."

Currently, with the increases in cases and deaths, it seems that is not the case yet. However, Prof Cosford was cautiously optimistic. He said that “there are early signs that we can be hopeful and see a plateauing of numbers over the next couple of weeks. If we could possibly keep the R – Naught (R0) to 0.6 or less then the numbers of transmissions will go down rapidly, but if it keeps hovering at 1 then it will take many weeks to gradually reduce numbers."

Exit Strategy

Professor Sir Simon Wessely asked Prof Cosford what he thought about the suggestion of reopening schools before September and whether it would be wise to do that?

Prof Cosford responded that although the possibility of children getting severe complications from COVID-19 are much less than the rest of the population, particularly vulnerable people, it was a really difficult balance because "we don't truly understand how, or in what ways, schools contribute to the spread of the virus". He said it was a question that needed addressing sooner rather than later to give children a "semblance of normality".

He cautioned that what is "absolutely clear, when we do come out of the strict restrictions at the point we do, we must retain much of the social distancing advice. So I haven't thought about 'the school gate issue' but we are going to push very hard on people about responsible behaviour."

Prof Cosford also said the closure of schools had a "very significant impact on children, on their social wellbeing, their health, and also, of course, vulnerable children in particular who are safer being at school than at home".

The Importance of Government Relationships

Prof Cosford ended the webinar on an upbeat note. He said that despite his involvement with both the Ebola crisis and the Novichok attacks, COVID-19 was bigger than both combined.

He praised the Government. He said: "I'm always amazed at how government does manage to come together, the strength of the civil service… making it happen. The strength of relationships between Public Health England, NHS England, health and social care, the Cabinet Office and No 10, it does actually work as a really strong machine.

"Of course there are tensions. Of course, there are different views, when some people think that's an obvious thing you should be doing, and other scientific advice may not support all of those things that we need to think about.

"But if you want my overall view I think we have a remarkable system. Of course, there's a lot more that we need to do to get to the other side of this, and the last thing we can ever do, particularly at the moment, is to be complacent that we're getting everything right.

"Constant focus. Monitoring day-to-day. Are we doing the right thing? Are we sure we're doing the right thing? What's the latest piece of evidence to help us make sure that we'll have the communications and the right messages to people?

"What are the public behaviours we need to change? What are the issues about distributing testing, personal protective equipment, and so on? And getting all of those right. But as a system as a whole… we're lucky in many ways."

Adapted from Medscape UK.