On Covid-19, a century and a half of expertise in infection control has been squandered

The John Snow memorial pump on Broad Street, London

Dr. Carl Iwan Clowes, former medical director of NHS Wales, board member of Public Health Wales 2009 -2018

Pounding the streets of London may not, at first glance, seem an obvious way to tackle an infection but that was exactly what Dr John Snow did in 1854 when, faced with a cholera epidemic, he walked the Broad Street area of the city and identified a common feature of all the infected patients.

Dr. Snow worked around the clock to hunt down when the outbreak began and from where the victims drew their water supply. The tracking took him to hundreds of cases of cholera in schools, restaurants, businesses and pubs and he noted that the families all got their water supply from a pump on Broad Street.

On 7 September 1854, Snow took his research to the dubious town officials and convinced them over time to take the handle off the pump, making it impossible to draw water. The cholera outbreak abated almost immediately.

The significance of this intervention was far-reaching. An outbreak of cholera in the county of Glamorgan in 1848/49 had resulted in the deaths of over 3,000 people. The intervention was urgent and by 1872 almost £100,000 had been invested in drainage and water supplies in Cardiff alone.

Modern-day epidemiology was born. Schools of Public Health flourished, notably in London, Liverpool, Edinburgh and Cardiff. Their influence was widespread, influencing the health and well-being of populations throughout the world.

 

Tracing

Wales entered the field of public health education very early and established one of the first Chairs in Preventive Medicine. In Cardiff a Medical School was opened in 1893 and 1931 saw the creation of the Welsh National School of Medicine and it was here that Archie Cochrane, a world-renowned doyen in epidemiology and a pioneer of Randomised Controlled Trials, chose to establish his research in 1948.

Almost from its inception, there was close collaboration between the Medical School and the municipal authorities. The School was allowed to use the public health laboratory of Cardiff Corporation for teaching purposes and in 1900 it established a Department of Hygiene and Public Health.

The importance of a potable water supply for health and well-being was, by now, well established. In the early part of last century Cardiff became one of the world’s leading centres of Public Health or social medicine. The challenge of a potable water supply remains today for much of sub-Saharan Africa, South-east Asia and parts of South America where morbidity and mortality from gastroenteritis, cholera and typhoid are all too common.

The importance of a potable supply in contemporary Wales was highlighted in 2005 when 231 cases of Cryptosporidiosis developed in north-west Wales following an infection in the mains water supply. Tracing the common point source for all infections of this nature is vital to understand where best to intervene and curb the problem.

The principle of tracing an outbreak of disease back to its source was tested to the extreme in Clwyd in 1989 when the county saw over 600 cases of Salmonella poisoning, the largest outbreak in Europe last century. The point source was eventually traced to a wholesale supplier of meat in the region and the outbreak was brought under control but not before many miles had been pounded by researchers on the ground.

Within the same period, an outbreak of the potentially fatal botulism occurred in Clwyd and adjacent parts of England when a yogurt became contaminated by an affected supply of hazelnut puree. Widespread distribution of the yogurt, through direct sales and cash-and-carry outlets proved a significant challenge to the county’s Public Health team. There were no short-cuts. There were long hours and shoe leather wore thin.

Outbreaks of this nature involve a huge commitment to piece together the spread of a disease in an attempt to bring it under control. Many hours of work coordinated by the Health Authority’s lead on Public Health was the key to success. Expertise in analysis was forthcoming from the Welsh Office and the University in Cardiff and the county’s Department of Environmental Health played a hugely significant role, deploying resources to trace all the likely contacts, before treating and isolating them.

Resources

A pattern of infection control has been well established in this country for well over a century. Experience has shown the value of local coordination across agencies, with specialist input from the Centre, as being the formula for controlling widespread outbreaks of disease.

So, what has gone wrong in the case of controlling the spread of Covid-19 in this country?

When the first patient in Gwynedd succumbed to Covid-19 in March, the obvious first question was how best to follow recent contacts. The stark reply was that resources didn’t allow that. But, hold on a minute. How could that be? The numbers were still few and other agencies’ resources were still to be tapped.

When the WHO first announced a pending pandemic of coronavirus in February there were just 82 cases worldwide outside China with no deaths. Why didn’t we mobilise then? Why didn’t agencies coordinate resources at that point?

Instead, here we are, three months down the line, looking to contact trace on a far wider scale, with almost 2,000 thousand preventable deaths in Wales in the interim.

Our legacy of a well-tried and tested system of contact tracing going back over a century, and pioneered for much of the rest of the world to follow, has been squandered.

What a travesty.

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Tudor ReesdaniElspeth WdbbHuw Daviesj humphrys Recent comment authors
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Plain citizen
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Plain citizen

Really good points. Why didn’t PHW tell Drakeford or why didn’t he listen? The author makes it clear there was no lack of resources.

John Lumley
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John Lumley

There was no profit element in the existing system so was considered inefficient being public sector managed.

Robin Lynn
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Robin Lynn

This deserves wider circulation. Could I suggest that Dr. Clowes edits a bit of the history and submits to the Western Mail and a London daily. PHW is not the only culprit.

The Bellwether
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The Bellwether

Interesting article but the words ‘stable’ and ‘door’ spring to mind.
The author is clearly a very senior and respected authority in ‘contact tracing’ and health matters. My question is why has this article only now been written and published. Surely someone of such eminence would have realised and known what to do early on. Does he have no influence in his field? Didn’t he know who to contact and warn right at the beginning? If he did why wasn’t he listened to?

max wallis
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max wallis

An excellent article, we await the sequel, a critique of the way the Chief Medical Officer etc. have behaved since that first case (didn’t he arrive from California?). Why write it only now, asks The Bellweather? Carl like other Welsh specialists had left it to the professionals, but become increasingly frustrated that the Welsh CMO did not pull together independent experts in an advisory group – instead forming a united front with the other 3 CMOs, meeting in London. Maybe Carl is especially frustrated at those who defend the Welsh response to Covid on nationalism grounds. Even if the Welsh… Read more »

Ann Owen
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Ann Owen

It’s absurd for Max Wallis to spin that Dr Carl Clowes’s frustration somehow comes from “nationalism” requiring loyalty to the Welsh lockdown. Nothing could be further from the truth! Continued lockdown in Wales is extremely widely supported by the Welsh public as opinion polls show – the deniers are very few and mostly right wing British nationalists as can be seen from social media! The lockdown support is based on preventing the infection spreading. After all, at the moment lockdown is all we have in the absence of a cure, medication or vaccination. As Dr Clowes states, no effective Testing,… Read more »

j humphrys
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j humphrys

Yes. Adam and Co have tried hard from the get go.

Ann Owen
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Ann Owen

Critical that we get an effective test, trace, isolation regime in place NOW – Dr Clowes makes it clear we missed the opportunity to get this in place early on when cases were very low. Indeed for a reason that no-one can really fathom, Wales abandoned the concept a week after setting it up! Was it really the readily parroted “we rely on the science”, was it lack of test kits or was it indeed Public Health England’s “bags me, I take it all” approach. It’s shameful that we have ignored and undervalued our proud pioneering tradition of public health… Read more »

j humphrys
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j humphrys

At 35,704 cases, UK now second on world list, their tactic is now to attack Wales. Expect more of such.

Huw Davies
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Huw Davies

Now chasing the proverbial hopping frog that has well and truly escaped. But, and a big but, some effort is better than nothing, and right now there is a lack of serious effort. The whole thing stinks of debacle from delays/failure to secure adequate PPE fit for purpose, test &trace and a wholly data rational approach. Willingness of the public to self isolate and lockdown have saved the day so far but we can’t shut down for ever so some coherent battle plan needs to be created and communicated effectively otherwise the mightily pi**ed off public will break ranks eventually.

Elspeth Wdbb
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Elspeth Wdbb

One of the biggest body blows to our public health system was the 1994 Health Commissioning Act
When the Welsh Assembly decided, rightly, to scrap the purchaser/provider split, they at that time should have started to rebuild the public health system we lost.
Public Health Wales is no substitute for teams that were embedded into the fabric of their local health boards

dani
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I have no expertise in this and so am to some extent speculating. March 11th a man from Caerphilly was the first community transmitted example identified. By that time they were pretty sure that they suspected the country was riddled with the virus. A vicar told me that he was having to take an increase of funerals for people dying of Pneumonia. Maybe this was a secondary infection or maybe this was misdiagnosed. And this was happening months before Betsy Cadwaladr health board confirmed that they had any cases. There is quite a bit of anecdotal evidence of people assuming… Read more »

Tudor Rees
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Tudor Rees

The article by Carl Clowes is authoritative and gives us a road map about what can be accomplished by total community mobilization in Wales in the face of a real Public Health threat. This was seen in the 1962 Smallpox outbreak in Cardiff and the Rhondda. Through a joint effort involving the Cardiff and Glamorgan Local Authority Health depts, The Welsh Board of Health, the Welsh National School of Medicine, and the support of the public, it was brought under control. The tracing of possible contacts was a key element. Everyone played their part, such as the Prof of Bacteriology… Read more »