Thursday 7 May 2020

Pandemic Times - How did we get here?

As I write this in early May 2020 the United Kingdom has sadly become the European country with the highest death toll from the COVID-19 outbreak. This made me look back to see how we ended up in this position. 

The viral infection first came to light in the Wuhan province of China when WHO reported deaths from an unusual type of pneumonia on 31st December 2019. A new coronavirus was identified as the cause, later named COVID-19, and on the 24th of January 2020 a paper in The Lancet described human to human transmission of the virus. It advised of the potential for a pandemic to occur, recommended personal protective equipment for healthcare workers due to airborne transmission, and the need to develop testing. On 30th January the WHO had declared a Public Health Emergency of International Concern

South Korea and Taiwan soon reported cases and took measures to screen the public for infection, to trace and isolate contacts of those with the disease, and these countries quickly got control of their outbreaks. In Iran and Turkey the disease became more widespread.

The virus was first documented in Europe when two Chinese tourists tested positive in Rome on 31st January. A second cluster was found in Lombardy 3 weeks later, and in this region the infection rate escalated dramatically, overwhelming local health services. The first cases in the United Kingdom were in Newcastle on 31st January, and in Spain on the same date a German tourist in the Canary Islands tested positive, 4 days after the first case had been found in Germany. At this stage the disease was clearly present in many countries across Europe, but national governments chose different policies to contain the disease. 2500 Spanish football fans from Valencia attended a Champions League game on February 19th in Bergamo, the centre of the Italian outbreak. By the end of February the British media watched in horror as the Italian situation was getting out of control. Soon we would go past Italy's trajectory while the Prime Minister of our country incomprehensibly states "many people are looking now at our current success". 

As countries around the globe stepped in line with the WHO advice on testing and quarantine, Britain remained out of step with everyone else. On March 4th Boris Johnson suggested, under the searing questioning of an ITV morning television programme, that Britain should "take it on the chin". Meanwhile government press officers leaked suggestions to their unquestioning media friends, such as Robert Peston who on 12th March ran with their story about the benefits of "herd immunity". This type of  kite-flying briefing, which told you what the preferred government policy was without anyone actually having to state it on record, was greeted with horror from the scientific community. The principle with herd immunity is that if you make enough people immune from a disease, the disease can no longer spread through the community. This is best dome by mass vaccination. You don't need everyone immunised against measles, but if you keep vaccination rates up above 70% you will create herd immunity in the country and stop it spreading to those it may kill. To do that for a disease with no vaccine you have to let the illness just rip through the country, "taking it on the chin" and just letting enough people get it to stop it spreading any further. I suppose in principle you could lock all the most vulnerable people away somewhere separate from this viral tsunami, such as in nursing homes perhaps, to prevent them getting it. (Hint: that won't work). 

The problem with a new disease that has a mortality rate of about 1% means that the estimates for the deaths this policy would cause were in the region of 250,000 to 500,000. These numbers came from modelling by Imperial College London published on March 17th. At that time the WHO advice was for countries to act aggressively and speedily in order to halt the virus spread. Other scientists were voicing concerns at the British policy. On March 13th Professor Devi Sridhar of Edinburgh University and chair of Global Public Health stated "the UK government is getting it wrong...Other countries have shown speed is crucial".

Meanwhile over the weekend of March 10th in Britain almost 200,000 spectators attended the Cheltenham Festival, and on March 11th around 3000 Spaniards arrived in Liverpool to see a Champions League game between Liverpool and Atletico Madrid. On 12th March hundreds of German fans came to Ibrox to watch Rangers vs Bayer Leverkusen. Two days later the Spanish government imposed a national quarantine as their national death toll approached 500 from COVID-19. At this stage the British government advice was for us to wash our hands while singing God Save The Queen, advice Boris Johnson was simultaneously telling us not to bother with as he spoke about "there were actually a few coronavirus patients, and I shook hands with everybody you will be pleased to know.

On March 12th government policy changed from "contain" to "delay", later admitting this was due to insufficient resources being available to test all new cases and quarantine contacts. The new advice was for symptomatic people to self-isolate at home for 7 days, and the rest of us to continue using hand-washing and handkerchiefs. The government press release of that date specifically states that "in the coming weeks we will introduce further social distancing...If we introduce this next phase too early, the measures will not protect us at the time of greatest risk." The only justification for this delay was if the policy remained at this stage to let a large proportion of the population get infected, and later immune, thus speeding up the exit from the inevitable lock-down. In effect we were prioritising restarting the economy over preventing deaths. On 26th March the weakness in the government's cunning plan was plain for all to see, when the Health Secretary, and the Prime Minister managed to contract COVID-19, Boris Johnson eventually ending up seriously unwell in ITU. One further example in a long list of people in positions of power in this crisis who failed to believe their own advice, or heed it.

As Professor Sridhar and others said at the time, this delay was wrong. On 26th March Richard Horton, editor of The Lancet, said on BBC's Question Time programme "we knew in the last week of January that this was coming. We knew that 11 weeks ago, and then we wasted February". No social distancing was imposed until 18th March, and from 23rd March gatherings of more than two people, travel restrictions and unnecessary outdoor activity were forbidden. The Scottish infection rates began climbing a week or so behind the UK figures. The first confirmed case in Scotland was March 1st, in Dundee, and the first death was on 13th March, at a time when 85 cases had been confirmed. Scottish policy appears to have been in step with UK-wide advice, following the same general programme of actions. However the impression is that First Minister Nicola Sturgeon is at each stage slightly forcing the hand of the UK government by enacting policies when they are proposals in England, eg announcing a ban on gatherings of 500 people on 12th March (meaning the Rangers vs Celtic game planned for 15th March was cancelled), announcing school closures on 18th March. Unfortunately no separate policy was taken on ramping up testing capacity, establishing teams of contact tracers or planning for increased testing and shielding of vulnerable adults in care homes. As of today, 6th May, 2795 deaths have been recorded in Scotland with COVID-19 mentioned on the death certificate as a contributing factor, 1703 of those deaths with a confirmed test for COVID-19 as we still struggle to extend testing beyond those admitted to hospital. The confirmed deaths for the whole of the UK is now over 30,000, with many more deaths suspected as being due to the virus.

Unfortunately we are just at an early stage in this outbreak, as it may yet be another year before an effective vaccine is developed. As it is a new illness it is not yet clear how much immunity is retained by those exposed to the virus who only develop mild symptoms, and as we emerge from lock-down, all the modelling predictions expect an increase in infection rates to develop. We maybe did not have the geographical distancing that have enabled Iceland, New Zealand and the Faroe Islands to be examples of good practice, but Vietnam, and South Korea appear to have managed it with densely populated countries (recorded deaths in Vietnam is zero, and South Korea, population 51 million, is 255). What about a European neighbour that I know quite well, Greece? The first case in Greece was on 26th February, in the northern city of Thessaloniki, where I worked in a hospital as a student. Fearing that their health system which was stretched before a decade of severe cuts, would not cope with a widespread outbreak, the country acted early to minimise spread of the disease. After three cases were confirmed in the country, all large events were cancelled. On March 10th with 89 cases in the country and no deaths, all educational institutions were closed, three days later all cafes, bars and shopping centres were closed. On March 16th two villages with cases were quarantined, and all religious ceremonies stopped. From 22nd March non-essential movements were banned. If you were going out, a central number had to be texted to justify your actions before you ventured out, health systems were changed to allow prescriptions to be sent as text messages. These strict measures are now beginning to be stepped back. A country of 10 million people, with a similar geographical population spread, has now recorded 147 fatalities from COVID-19. This country with twice the Scottish population had its first case 5 days before we had a case in Scotland. At present their total fatalities from COVID-19 are 5% of the Scottish numbers (which are terrible, but are better than the figures in England). 

The one thing the Greeks did was "follow the science", the advice that was there from WHO for everyone to decide whether or not to follow.