Comprehensive testing for coronavirus — including the identification of contacts — was part of Britain’s initial effort to contain the outbreak, but it was abandoned on March 12 when NHS chiefs decided to stop testing people with mild symptoms of the virus. 

Since then, testing has been restricted to those sick enough to enter hospital and only now is it being extended to NHS staff and key workers. As a result the Government has essentially been “blind” to the progress of the disease, relying on the daily reports of “confirmed” cases and the sad death toll that follows. Owl has previously reported on the difficulty of using these because of the inconsistency in the way they were  reported early on.

The Covid-19 symptom tracker app, the subject of this post, rapidly deployed by Professor Tim Spector, is an interesting example of quick thinking. A pragmatic use of science that has been producing valuable evidence of how Covid-19 is spreading, and now declining, where the hot spots are etc. Note there is a lag between symptoms being detected and serious Covid cases needing hospital treatment.

But it didn’t come out of SAGE and Owl gets the impression that “follow the science” may be trying to be too “scientific”, making the best the enemy of the good [follow also the debate on masks] .

[Current Covid-19 symptom tracker results for East Devon indicates symptom rates are down to of 0.5% of population. Owl recalls it being 3.6% and that would not have been the peak]

Jonathan Leake, Science Editor www.thetimes.co.uk

The coronavirus was spreading in the UK weeks before the first case was detected, according to a leading epidemiologist.

Professor Tim Spector has collated reports of people falling ill with “classic symptoms” of the disease from the start of January.

It suggests the disease was well established before two people from China became the UK’s first confirmed cases on January 31.

Spector, professor of genetic epidemiology at King’s College London, gathered the reports through the 2.6m people signed up to his team’s Covid Symptom Tracker app, where they report their past and present health status.

So many of those using the app have reported having symptoms in January, Spector said, that it is highly likely the disease was circulating soon after new year. Some have even reported symptoms in late December. “What’s impressive is the sheer volume of the reports,” he said. “We’re getting hundreds of the people using our app telling us that they developed something soon after the new year.”

Spector and his team have found that Covid-19 victims can suffer any or all of 12 key symptoms, with the commonest including a fever, persistent cough, loss of taste or smell and mental confusion.

Each of the symptoms can occur in other diseases too, but a combination, or their occurrence in people who have been close to victims, strongly suggests Covid-19. “The reports I am getting are from people who were ill from early January onwards and strongly suggest they had Covid-19 but were not recognised as such,” Spector said.

He cautions that retrospective and subjective reports of symptoms of illness are hard to substantiate, but the sheer volume is powerful evidence — and could be confirmed by antibody tests when they become available.

The app, developed by Zoe Global, a London biotech firm, includes questions about previous exposure to Covid-19, including any symptoms experienced and their dates.

Spector’s team, which is backed by the Royal College of Physicians, Royal College of Surgeons and other medical bodies, uses the data to estimate the size and geographical spread of the epidemic. It suggests that 376,000 people around Britain have Covid-19 symptoms this weekend, with hotspots around Walsall, Lichfield and Nuneaton in the Midlands, Boston in Lincolnshire, Blaenau Gwent in south Wales, Pendle in Lancashire and Inverclyde in Scotland. The app reports also have some good news, suggesting that the number of symptomatic cases peaked at 2.1 million on April 1 and has declined steadily since then.

Spector and his team are publishing a paper in Nature Medicine this week suggesting that a wider range of symptoms should be included in diagnosing Covid-19. At the moment the government-recommended key diagnostic signs are fever and a persistent cough. This means people with any of the other symptoms who call 111 may not be recommended to self-isolate and so will spread the disease.

“The number of real cases clearly vastly exceeds those recorded by the government, because testing has been reserved for those sick enough to be in hospital,” Spector said. “In most cases people recover at home and so are never tested.”

The UK’s earliest cases could include people such as Daren Bland, 50, who was skiing at Ischgl, Austria, from January 15 to 19. On his return he became ill and passed the infection to his wife and children in Maresfield, East Sussex. Bland’s illness fitted the Covid-19 profile of symptoms but was never confirmed by tests.

Ischgl has since become infamous as the location of one of Europe’s biggest clusters of Covid-19, with 600 Austrians infected and 1,200 visitors from other countries including Germany, Norway, Iceland and the UK thought to have taken the virus home.

Such European travellers are in addition to the tens of thousands of people who flew to the UK from China in January. There were about 17 direct flights from Wuhan alone between new year and January 24.

Scientists in other countries have also seen evidence that Covid-19 was circulating for weeks before it was first detected.

In late March a study in Lombardy in northern Italy found that the virus might have been circulating in the region for more than a month before it was detected in the town of Codogno on February 21.

In America the first officially reported death occurred in Washington state on February 29. Last week, however, three people who died in Santa Clara County, California, between February 6 and March 6 were confirmed as Covid-19 deaths after post-mortem examinations. Since the time taken from infection to death is usually 2-4 weeks, this suggests the virus was also spreading in the US in mid-January.

Passengers arriving at British airports and ports will be placed in quarantine for up to a fortnight, under plans for the “second phase” (see below) of the Government’s response to the coronavirus pandemic.

By Edward Malnick, Sunday Political Editor 25 April 2020  www.telegraph.co.uk 

Officials are drawing up a scheme that mirrors the 14-day “stay home” notices currently issued to Singaporean citizens returning to their country from abroad. It could be rolled out as early as next month, and include large fines for those who fail to remain at the address given to authorities as their place of isolation.

The radical plan, being overseen by Priti Patel, the Home Secretary, and Grant Shapps, the Transport Secretary, is intended to stop the transmission of Covid-19 from abroad, when the Government launches its “track and trace” strategy to identify and isolate cases of the virus in the UK. It would apply to both British citizens and those from abroad.

The disclosure comes as the Covid-19 death toll exceeded 20,000 for the first time on Saturday, as 813 more deaths were reported in the previous 24 hours.

In other developments:

• The Sunday Telegraph understands that Downing Street is preparing to ditch its current “stay at home” slogan for the “second phase” of its response, with Isaac Levido, the Australian strategist who masterminded the Conservatives’ election win, working on a new appeal to the public…….

As part of plans for a “new normal” for businesses, the Government is drawing up separate plans to introducing strict social distancing in workplaces that re-open, with employers told to provide hand-washing facilities or sanitiser. A cabinet minister said Mr Johnson was expected to focus on decisions about the “very gradual opening up of shops, workplaces and public spaces”, before deciding when to begin re-opening schools.

The plan to quarantine passengers arriving in the UK would involve authorities requiring travellers to fill out a specific landing card which would ask for information about the individual’s health, as well as details of the address at which they will self-isolate.

Officials are planning a worldwide communications campaign to warn passengers of the measures that they can expect if they come to the country. It would be likely to dissuade many of those already in the country from travelling abroad, on the basis that they are unable or unwilling to self-isolate for two weeks, as well as deterring travellers from abroad.

The Government is considering possible exemptions for essential workers such as lorry drivers bringing vital supplies to the UK.

A Government source said: “A stringent, Singapore-style approach at our ports will help the UK manage the risk of travellers entering the country and reduce the possibility of a second peak.

“We are looking at deploying these measures at the right time, in line with the scientific advice and when community transmission has been significantly reduced.”

Singapore introduced 14-day “stay home” notices on March 18, for everyone landing in the country.

The Government has faced criticism for allowing travellers to continue coming into the UK without imposing health checks or quarantines. But officials insist that the high rate at which the virus was spreading within the UK meant that banning flights or imposing quarantines would have been relatively ineffective before bringing transmission under control.  

On Friday, Chris Whitty, the chief medical officer, said that the infection rate had fallen low enough to start thinking about lifting some of the lockdown restrictions, amid growing concern about the collateral damage.

However the second phase of the Government’s response is likely to involve some tougher measures in other areas, such as those currently being considered for the country’s borders..

Ministers believe the measures can be carried out under powers in Mr Johnson’s Coronavirus Act allowing authorities to assess and isolate “potentially infectious” travellers. When the legislation was introduced last month, the Government said the provisions “look to fill existing gaps in powers to ensure the screening and isolation of people who may be infected or contaminated with the virus and to ensure that constables can enforce health protection measures where necessary.”

Authorities would be able to check whether those asked to quarantine have remained at their stated address.

Ministers have asked officials to draw up proposals for enforcing the planned measures, with the potential for large fines and even legal proceedings for those who are found to have broken the rules. The plans were discussed at a meeting of ministers and officials on Wednesday.

On Saturday, the latest official figures showed that 20,319 people had died with Covid-19 in UK hospitals – an increase from 813 on Friday. Last month, Sir Patrick Vallance, the government’s chief scientific adviser, had said that keeping the number of deaths below 20,000 would be a “good outcome”.

Ms Patel said: “As the deaths caused by this terrible virus pass another tragic and terrible milestone, the entire nation is grieving.”

During the Government’s daily press briefing, Ms Patel praised the “spirit of national unity” during the coronavirus outbreak, urging  the public to “not lose sight” of the fact their efforts are saving lives.

A No10 spokesman declined to comment on the plans to quarantine travellers.

Britain’s public health sector has told the Government that the emergency £3.2 billion support package for local authorities may not be enough to avoid an “uncontrollable” second wave of coronavirus.

By Tom Morgan 25 April 2020 www.telegraph.co.uk

A letter sent to Professor Chris Whitty, England’s chief medical officer, and Professor John Newton, the official in charge of testing, also suggests a national “one-size-fits-all” strategy cannot beat lockdown.

Maggie Rae, the president of the Faculty of Public Health, and David McCoy, professor of Global Public Health at Queen Mary University, are among 20 experts calling for more powers regionally to put local teams “at the heart” of the response.

“The last decade has seen the capacity of local public health teams eroded by a combination of budget cuts and disorganisation to the health and social care systems,” says the letter, seen by The Telegraph.

“And while the injection of £3.2 billion of new cash to support local governments through this current crisis was welcome, further efforts are needed to give local structures the resources and mandate to enable the country to release the current lockdown measures and restore the economy without risking an uncontrolled second wave epidemic.”

The epidemic and the effects of lockdown “cannot be effectively mitigated through a centralised and one-size-fits-all approach”, the letter says.

More detailed local plans would enable authorities to tailor to “the specific local and contextual factors of different parts of the UK”. Contact tracing would also be achieved easier, and co-operation would be improved between public health, social care, primary care and hospital services.

In a separate interview, Ms Rae told The Telegraph that the UK will eventually need an “awful lot more” testing than the current 100,000 a day target by the end of the month. The Government accepts that it may eventually need capacity for 250,000 a day when lockdown measures are reduced.

“As we’ve seen from other countries and the successes they’ve had, we will probably need an awful lot more especially if we want to get to a plan where we can lift lockdown…as the testing capability and capacity grows, we need to stand for testing, tracing and isolating.”

Amid attempts to assess the possibility of relaxing lockdown in areas less affected by the virus, Public Health England set up a team at Porton Down in February to establish a “national surveillance programme”.

The team of scientists are currently analysing 5,000 samples from potential sufferers and Rae says establishing a clearer idea of how it is spreading across the country will be a huge help.

“My understanding is that we’ll be able to see the hotspots,” she added. “You do have people in the highlands of Scotland asking, ‘Why are we on lockdown when we could probably move about without putting anyone at risk?’, as long as they stay on the island. That’s a logical way the public will behave. At the moment we need everyone to follow the guidance.”

A spokeswoman for Public Health England pointed out that a letter had been sent out to local authorities and regional public health officials on Friday. There were also meetings held in the past week in which the Government pledged to involve local agencies, the spokeswoman added.

Regional directors of public health “are absolutely critical to the response”, the PHE spokeswoman said, adding that the “public health community will be at the heart” this going forward.

At the moment the Government seem to be putting their faith in Deloitte. The press is full of stories such as the person who drove many miles to Worcester for a booked test; arrived at 3 pm, was told there was a two and a half hour wait and advise to re-book as the site would close at 5 pm. regardless.

Allyson M Pollock, professor of public health, Newcastle University, and barrister Peter Roderick, principal research associate, Newcastle University www.theguardian.com

Perhaps, the most surprising aspect of the British Covid-19 crisis is the extent to which the Scottish, Welsh and Northern Irish governments, and the English regions, have allowed strategy to be decided by Westminster.

Health and social care are devolved, and this national epidemic is not homogenous. It is made up of hundreds, if not thousands, of outbreaks around the country, each at a different stage . England had its first confirmed case on 30 January, Wales on 28 February and Scotland on 1 March. Some areas – such as Rutland, Hartlepool, Blackpool, Isle of Wight, Tyneside, Durham, Orkney, Western Isles – had no reported cases until late March, and some even now have relatively few cases.

Contact tracing and testing, case finding, isolation and quarantine are classic public health measures for controlling communicable diseases. They require local teams on the ground, meticulously tracking cases and contacts to eliminate the reservoirs of infection. This approach is recommended by the WHO at all stages of the epidemic. It was painstakingly adopted in China, Singapore and Taiwan, with a high percentage of close contacts identified and many housed in hotels. Germany has traced contacts throughout. The leaked UK national risk register proposes it.

Yet Public Health England, the agency responsible for communicable disease control in England, stopped contact tracing on 12 March, having reportedly only contacted 3,500 people, of whom about 105 were found to be positive. It’s now about to resume. But why was it stopped, and how will it be resumed?

We’ve not seen an official explanation for its stopping. But lack of both resources and effectiveness are usually mentioned. Resources are essential, just as they have been for increasing acute care capacity, and the potential pool of contact tracers is vast. There are thousands of environmental health officers in local authorities and other sectors who have the necessary skills and experience. Singapore used its army. Teachers and barristers have volunteered in Ireland. Centralising control and management of the pandemic through NHS 111 has also left 7,500 GP practices underused, and the potential for real-time knowledge of new cases, results of swab tests and insight into the geography of spread has been lost. Yes, it’s true that contact tracing is insufficient, but that’s not the same as ineffective. It should have been supplemented, not replaced. Look at Germany.

We think there are more fundamental reasons. The system of local communicable disease control was established in the 19th century. After the NHS was set up in 1948, it was supported in England and Wales by national, regional and more than 40 local public health laboratories. But since local medical officers of health were abolished in 1974 – replaced by community physicians at different levels of the NHS – the system has been gradually but relentlessly eroded, fragmented and centralised.

Communicable disease control was centralised in the Health Protection Agency in 2003, and local public health laboratories transferred to NHS hospitals. Public health was then carved out of the NHS in England in the 2012 Health and Social Care Act, which abolished local area health bodies, created Public Health England to fulfil the government’s duty to protect the public from disease and charged local authorities with improving public health – but with limited proactive scope for infectious disease control and woefully inadequate resources.

Then came austerity. Local authorities suffered a 49.1% real terms reduction in central government funding from 2010 to 2018. Numbers of community control teams and consultants in communicable disease control have decreased. PHE made “savings” of £500m over five years in the name of “efficiency” and now has nine regional “hubs” serving 343 English local authority areas.

With further waves of the epidemic likely, resumption of contact tracing is critical. Each of the four nations needs to institute scores of locally led, nationally coordinated and funded teams to trace, find and test contacts. Caernarfon isn’t Cardiff, Gairloch isn’t Glasgow, London isn’t Lulworth. Teams in England and Northern Ireland would be based in local authorities; in Wales and Scotland they would be in local health boards. Their composition should be locally determined, drawing on a range of expertise, especially among directors of public health, field epidemiologists, environmental health officers, GPs, local NHS laboratories, NHS 111 and test centres, plus volunteers if required.

Widely used apps with robust data protection could play a supportive, but not framing, role. In addition, the apparently strategy-free plans for 50 mass drive-in test centres need to be decisively directed to support local contact tracing, as well as strategically targeting the most at-risk groups.

We would expect rigorous implementation of these measures now to make an overdue but significant contribution to controlling the epidemic. Restoring and updating local communicable disease control is an integral part of properly funded, publicly provided health and social care.

Revision 30 April 2020. The Devon Clinical Commissioning group have pointed out that the use of the phrase “no gowns” in the title (taken from an early edition of the Sunday Times, later revised) is inaccurate. The call for substitutes for gowns was a precautionary advertisement. Stocks have now improved and none of the advertised items has been issued to NHS staff.

In Devon, the request for alternatives to gowns included boiler suits, lab suits and painting suits in a tender notice titled, “Urgent help needed re provision of PPE for NHS staff.”

Rosamund Urwin, Andrew Gregory and Caroline Wheeler –The Sunday Times April 26 2020

The call came as the severity of the shortage of gowns, masks and gloves was laid bare to the cabinet in a 90-day forecast for the government by the consultancy firm McKinsey.

In Devon, the request for alternatives to gowns included boiler suits, lab suits and painting suits in a tender notice titled, “Urgent help needed re provision of PPE for NHS staff.”

Fears have been raised not only over the quantity of PPE but the quality. “Every day we run out of something, the advice is downgraded and we are now running at standards lower than [recommended by] the International Red Cross and the World Health Organisation,” said a senior Whitehall insider.

“We have always been so smug about ourselves as a developed country, but now we have nations we send aid to watching us in horror.”

An NHS employee, who works on procurement, said: “The government has said that the CE mark [indicating conformity with safety standards within the European Economic Area] can be waived so we can get stuff from other countries or that’s made locally.

“The doctors on the front line don’t have time to check the medical journals to ensure that what they are being provided with is safe.”

Of particular concern were visors, because many 3D-printed designs had gaps that would allow aerosols and splashback to enter and put the medic at risk. More than 100 NHS and care workers are estimated to have died after contracting the disease, according to data collected by the online platform NursingNotes. NHS staff have repeatedly raised concerns about supplies.

Two NHS doctors are mounting a formal legal challenge to the government’s PPE guidelines. Meenal Viz, who is pregnant, and her husband Nishant Joshi, have treated patients with Covid-19, and argue that the government’s guidance is not protecting frontline staff.

Joshi said: “Matt Hancock said [on Friday] that the guidelines are based on the use of our ‘precious resources’. That admits the government is basing its guidelines on supply, not safety. It raises the question: has the government knowingly exposed healthcare workers to potential risk?”

Doctors and nurses have been asked to reuse gear that is usually single-use, and to wear flimsy plastic aprons instead of full-length gowns that had run out.

The NHS uses an estimated 150,000 gowns every day. Public Health England had previously said that the gowns should be worn for all high-risk procedures.

According to data collected by the Doctors’ Association UK, hundreds of doctors have gone without masks, eye protection and gowns, including medics carrying out aerosol-generating procedures that present a greater risk of catching the virus.

The survey of 1,197 doctors by the NHSPPE.com app, launched to report shortages, found that 38% who responded over a fortnight were without eye protection, including 23% of doctors carrying out aerosol-generating procedures.

The Doctors’ Association UK is calling for a public inquiry into the government’s failure to provide PPE.

Vanessa Crossey, interim deputy director of nursing at NHS Devon CCG, said: “We are leaving no stone unturned in our work to bolster national PPE supplies for our NHS and care staff”
The department of health and social care said: “Ware working night and day to ensure our frontline health and social care staff have the equipment they need to tackle this virus.”