Dr. Eilir Hughes, GP
A clear strategy is essential for the remainder of the pandemic as we approach six months since the Prime Minister’s lockdown announcement. The lack of a clear pathway out of the emergency is the biggest criticism of the Government, and will be told by historians of the future for generations to come.
From the moment lockdown was introduced work should have started on the strategy to overcome the pandemic. Yet, it seems we are six months into the biggest public health crisis in a century with an approach which neither stops the infection from spreading nor enables immunity to develop within communities.
The lockdown for the SARS-CoV-2 epidemic in the UK came in on the 23rd of March 2020. The reasoning for this was clear – this virus posed a very real danger to the lives of many people, and it being highly contagious meant drastic action was needed in order to contain its spread. There were justified concerns about the NHS’s capacity to deal with the sickest of patients if the virus was allowed to spread further.
The lasting memory of dread for me personally as the number of hospitalisations increased was a conversation I had one Sunday evening in late March with a very good friend who works as an intensive care specialist in one of the largest units in Wales. He’d just finished working his fourth long day in full PPE.
He warned me: “This is serious. Take no chances out there in the community. We have the kit to protect us, but you’ve got nothing. This is no time for heroics.”
The need then for a lockdown was clear and a strategy was formulated.
But locking down society was the easy part in dealing with the pandemic – opening up and releasing again was always going to be the biggest task. Unlocking requires clarity of policy and a strategy to follow.
The apparent lack of strategy after lockdown bothered me tremendously; to such an extent I managed to convince a journalist to pose the question directly to the Welsh First Minister Mark Drakeford on the 26th of June 2020.
I set the scene, explaining that there are three main ways out of the pandemic:
- Keeping the infection rates low until an effective vaccine or treatment becomes available.
- Eliminating the virus through aggressive test, trace and isolation along with long term restrictions on people.
- Achieving herd immunity by a controlled spread of the virus by community transmission. He asked The First Minister which of the three best matches his government’s strategy.
Mark Drakeford responded by saying: “Well, it’s not the third. It’s a combination of the first and second ways. We are very determined to keep infection rates low.
“Everything we are doing is designed to keep the rates of circulation in Wales falling.”
But subsequent decisions made by both UK and Welsh Governments left me with little doubt that the only realistic strategy to bring the country out of the COVID-19 crisis was by achieving widespread immunity in the population – known as herd immunity.
Decisions such as promoting foreign travel and mixing of urban and rural populations were incompatible with viral elimination. Indeed, such decisions made elimination much harder to achieve as it was inevitable that the movement of people would at least allow the virus to remain in circulation, and, as became evident, led to increases in cases.
Sadly, it seems that UK politicians’ fears of taking responsibility for the perceived consequences of the phrase ‘herd immunity’ have led them to adopt a half-and-half strategy that is neither one thing nor another.
Yet, the increases in cases have not led to increases in the number of hospitalised people with COVID-19 or in any rise in the number of deaths. This is explained by what we’ve learnt during the pandemic, which is the virus rarely causes serious illness in children and young people.
The recent observed increases in case numbers have come from within the younger age groups. The concern is that this wider community transmission will seep into the older population and those who are deemed to be particularly vulnerable to a serious illness.
Community or herd immunity is a scientifically sound approach to take- just think of chicken pox parties that parents hold for children in order to “get it out of the way”.
Although it could have been applied without introducing lockdown, the triggering of lockdown was to protect NHS capacity so that the very ill could be offered inpatient medical care within the NHS.
This success in suppressing the virus due to the lockdown then led to the second possibility, which was of eliminating the virus.
Elimination, which is stopping new cases of an infectious disease from occurring whilst the majority of the population remain vulnerable to being infected, could have occurred if the interventions that came with the advent of lockdown had been extended for longer and relaxed more gradually:
- Limited travel distances
- Avoiding mixing of different populations such as urban and rural
- Social distancing
- Hand hygiene
- Widespread facemask use
- Limited gathering of people indoors
All of these could have been employed for the purpose of driving down the number of infected people. With these in place, those areas prioritised by society, such as schools, workplaces and public transport, could have reopened gradually with the risk of resurgence kept low.
The extended lockdown we had in Wales compared to England gave a slightly better hope for elimination, but rapid easing that eventually came meant this wasn’t a strategy Cardiff were willing to pursue either.
It must be noted that measures such as lockdowns have an expiry date. The longer they last the more disgruntled and frustrated people get and there were plenty of people who felt like this in Wales by the end of June!
Understandably the huge negative impact of lockdown on the economy also had a bearing on the decisions made by government during the summer, too, helped by aggressive lobbying by the hospitality and leisure sector in particular.
Tourism was opened, with “staycations” actively promoted. Restaurants, cafes and pubs were allowed to open whilst following regulations issued by the government in order to limit the risk of transmission of the virus within their establishments.
These locations were then termed “COVID-secure”, although very little vetting and compliance checks have occurred. This has inevitably gone against any policy government may have had to bring about the elimination of the virus – the so-called Zero-COVID approach.
Now, however, achieving Zero-COVID is now practically impossible since the virus is widespread. It would be incredibly hard – people’s movements would need to be severely limited, and foreign travel would require prolonged restrictions, as the reintroduction of Covid back into the UK from other countries will remain a very real possibility for many months to come.
What we’re left with is a perpetual yo-yoing between a tightening and relaxing of restrictions which are going to be incredibly unsettling for both society and the economy. Following the economic and psychological burden the first lockdown had on society’s mental well-being, which we are yet to fully understand, any further lockdowns is invariably going to cause a great deal more harm and despair for large sections of our society.
Compliance with the regulations will become harder when people will have to make a choice between being compliant with the law and putting food on the table.
More recently, numbers of cases have risen in certain areas of the UK. This has not been a surprise. It has led the Government to introduce local lockdowns, where further tightening on people’s liberties have been implemented in order to limit further spread of the virus.
In Wales, the County Borough of Caerphilly was the first area to have such an intervention placed upon it on the 8th of September 2020 when case numbers rose to 55.4 per 100,000 people within the previous seven days.
A few days later, the case number per 100,000 people within the previous seven days for the whole of Wales reached 20. The First Minister reported to the media that this was their threshold to reverse some of the unlocking that had happened in Wales over the summer months by limiting the number of gatherings within an extended household to six people when indoors. In addition, face coverings became compulsory in indoor public areas.
The Welsh Government has made it clear that further increases in cases within particular areas will necessitate local lockdown measures similar to those introduced in Caerphilly. And so they’ve now been introduced to Rhondda Cynon Taf.
Since the time when Government decisions steered away from a strategy of elimination, I sense it leaves them with only one option to bring about a resolution to the crisis which would limit the ongoing economic and psychological harm that the pandemic has so far inflicted upon us.
This is to allow the careful spread of the virus through the young and healthy population, where we know the risk is much less. Whilst a vaccine remains unavailable, the alternative is a prolonged and arduous epidemic.
The policy of aiming for herd immunity has received a lot of negativity in the media, but it is a viable strategic option. Those people within the at-risk groups would have to take extra precautions and take some responsibility from avoiding others whilst the virus is in general circulation.
So what do recent decisions tell us about the Welsh Government’s current strategy? Clearly they do not like rising numbers of cases, regardless of the clinical status of these individuals.
Currently, for a case of COVID-19 to be recognised, having a positive PCR test result is the only criterion. Professor Carl Heneghan, director of the Centre for Evidence Based Medicine at the University of Oxford and the editor of BMJ Evidenced-Based Medicine explains why it is important to consider the implications of this:
“In any other disease, we would have a clearly defined specification that would usually involve signs, symptoms, and a test result.
“We are moving into a biotech world where the norms of clinical reasoning are going out of the window. A PCR test does not equal COVID-19; it should not, but in some definitions it does”
It seems the goalposts have shifted since the beginning of the outbreak where only symptomatic people admitted to hospital were being tested. Now cases are counted for people who have a positive result, regardless of symptoms.
This has a huge bearing when it comes to threshold points for introducing measures that directly affects people’s freedoms.
The case numbers rising again so early in the Autumn is causing a great deal of anxiety and fear. It is easy to see why some governments would prefer to take a cautious approach as this would be welcomed by a significant proportion of society.
Another consideration for policymakers is the sensitivity of PCR tests for detecting SARS-CoV-2. The technique can pick up a single strand of viral RNA. This does not necessarily equate to someone being infected or infectious. We don’t currently understand what importance should be placed on identifying such a small amount of genetic material in a person, especially if it isn’t interpreted in the context of symptoms or viral load.
Some of these people may have had an active infection some weeks ago and are still carrying the RNA in their airways. It is very possible that these swabs are not picking up evidence of a live virus.
In Wales, such low levels of detected RNA material are reported by the laboratories as “low titre positive”. My understanding is that these cases are included in the case counts. in my view, they should not.
They should instead be reported as “indeterminate”, prompting a retest 48 hours later. Clinical experience has often shown that retesting low titre positive often lead to a negative test.
If government policy remains to protect the NHS capacity, then it would be smarter to count the number of symptomatic people. There is evidence that the higher the viral load an individual is exposed to the more likely they are to become unwell with the virus.
Exposure to low viral loads is likely to induce a milder illness yet obtain an immune response that would infer protection when exposed to the virus in the future.
If the intention of government is to protect NHS capacity then implementing the current policy of including each and every positive PCR test in its decision-making process is ill-judged. Instead, this approach suggests the goal is to keep positive cases at their minimum, regardless of clinical condition.
This approach goes against that of achieving herd immunity. Obtaining immunity depends on exposure to the virus either by infected individuals or an effective vaccine.
The UK government’s Chief Medical Officer Professor Chris Whitty has himself admitted that a vaccine will not be available until early 2021 at the earliest.
We have to remember that the reason for increased community testing is to inform the test and trace policy. Test and trace is an accepted method in infectious disease management where possible exposed individuals are traced and provided instructions in order to prevent further spread of the virus. This is a process that is compatible with disease elimination.
However, it seems that the intelligence gathered by this process is leading to panic and over-reacting. More attention should be paid to hospital admissions and cases with symptoms. PCR testing should drive the test and trace strategy, which should be separated from a strategy on restrictive measures in order to avoid severe illness.
Wales’ test and trace system is already showing signs of causing distress and uncertainty. This isn’t more evident than the effect it is having on welsh schools currently. After months of schools being closed, they have opened again for the new academic year at the beginning of September. Yet within a week cases were seen in staff and pupils.
Such events have led to entire bubbles, often the whole class to which the affected individual belonged to being instructed to self-isolate for two weeks, effectively suspending education again. There is no saying how often this can occur for a given class. A cynic would argue that if a positive swab is picked up in one of the pupils in a class of 26 pupils every fortnight, then the class could be closed for an entire year. And of course, someone has to take time off work to look after them, further harming the country’s productivity.
When an index case has been identified in a school, the reaction has been one of deep sorrow, reminisce to a bereavement. In response to a positive test in a primary school pupil, the county council’s chief executive officer said:
“All our thoughts and best wishes are, of course, with this young pupil the family and the entire school community at this difficult time.”
This further amplifies the fear, worsening the insecurity and worries of the community.
The universities will be opening soon. We should expect positive test results in these institutions too. Should they close down when they happen? Empty the lecture halls, vacate the halls of residence, dash the hopes of bright-eyed freshers hoping to taste some normal experiences following the A level fiasco?
Clearly society views a positive PCR test result as a significant risk to life, whilst the reality suggests this is to be far from the truth.
Lockdown, and the nature of how it was implemented seeded a deep fear in the nation’s psyche – something of a mass existential crisis. It has forced what is a largely irreligious Western society to face up to its own mortality.
This requires careful management for the medium to long term. History has shown us that the largest cost inflicted upon society by a pandemic is that of its ill effects on mental health. The current policy should reflect genuine attempts at mitigating this.
As individuals, we need to learn to live with the risk of contracting SARS-CoV-2. Psychologically we are very far from this. Government has given the public the impression that it has tried its hardest to rid us of the virus. But only by eliminating the virus through stringent rules, gradual lifting of restrictions over the last six months and an effective test and trace policy could have achieved this.
Instead, with the autumn and winter months ahead, it is inevitable that the virus will continue to spread. The colder climate suits the virus. Its biochemical structure is more stable, less UV light, and the darker evenings lead to the prolonged congregation of people indoors.
The public need to be informed that the risk will remain throughout winter, and they need to be taught about effective ways to mitigate the risks within their environments.
Government has been slow to accept the growing body of evidence about the nature in which SARS-CoV-2 can travel from person to person. Throughout the crisis, emphasis has been placed on droplet transmission, and aerosol transmission has often been discounted.
However, it is irrefutable that aerosol transmission does indeed occur and this has a huge bearing on what happens over the winter months (see http://www.freshair.wales/). Promoting the ventilation of indoor spaces is essential, as well as widespread mask wearing and strong messaging to discourage loud talking/shouting is needed so that viral loads remain as low as possible so that when people are infected they are exposed to the minimum amount which would then equate to a milder illness.
The greatest challenge of course remains in the care setting where frail and vulnerable individuals are cared for indoors in the same building, where close contact to their caregivers is unavoidable. I have very little doubt that aerosol transmission was a huge contributory factor in the number of people in care who became seriously unwell/died during the first wave, since mitigating factors for this were not implemented. They really should be for the Winter.
Policy to mitigate this is urgently needed to avoid a second wave of deaths of people in care. It would help if the people who live in such institutions are thought of as living within a “household”.
Contact within households is also thought to be responsible for roughly 70% of SARS-CoV-2 cases. Currently, track and trace relies on voluntary compliance with the advice on isolation. Yet despite people’s best efforts, they often turn out to be inadequate. Within households, interaction between individuals is likely. Gathering at mealtimes, sharing a bed, vehicle and facilities such as bathrooms often continue.
We know that transmission is more likely to occur indoors than outdoors. Government should promote ways to prevent household transmission – such as the wearing of masks within quarantined households. Indeed this is currently advised by the WHO but not recommended by public health organisations in the UK.
Other measures that could reduce risk would be disinfecting shared facilities, staggering meal times, and ensuring sufficient circulation of fresh air through the home.
Indeed members of a household that cannot self isolate safely at home could be accommodated in special isolation facilities such as hotels (as is seen in Italy, Finland and Lithuania), or indeed the rainbow hospital sites (as was done in the field hospitals in China). Community hospitals could be sacrificed for the purposes of such isolation policy for positive cases found in nursing and care homes in the community in order to safeguard the rest of the home.
Such measures could only be useful if rapid testing is made available. Given that we know the virus is particularly dangerous to the frail and vulnerable as is the case for people necessitating residential care, rapid testing should therefore be prioritised for these groups.
In an attempt to better understand the prevalence of illness caused by the virus in our community, GPs should be brought into the system. So far, GPs have been completely cut out of the surveillance process. They currently don’t even receive PCR test results for people registered at their practice.
This means the information is not added to their official medical records that could inform future care as well as any future complications of COVID-19, including long-Covid. Often when a GP has a clinical suspicion of COVID-19 they advise the patient to call the track and trace service on 119 or book online to secure a test.
Testing is offered in very few locations in Wales- only two in north Wales- Llandudno and Deeside. These are unacceptable to many people in Wales as they’re too far from the communities in which they live in. Indeed, it is off-putting for many and they effectively discourage engagement with the track and trace process.
Track and trace should be an easy process to follow in order to encourage engagement. Participation in such a process yields very little benefit for the individual, so motivation to engage with the system is less. It would be far better if smaller testing units such as one in each primary care cluster could be established, and that GPs can refer clinically suspected cases to these community testing centres so that a much clearer understanding can be gleaned of the local transmission of clinically relevant cases.
This is particularly pertinent for the months ahead as other seasonal viruses including the flu will begin to pick up, and clinically may be very challenging for community clinicians to differentiate from COVID-19. No one within the health service knows communities better than GPs and current policy is cutting this important cog out of its COVID fighting machine.
Paradoxically, despite actions taken at preventing the crisis from overloading the NHS, the current situation has seized large portions of the NHS into a standstill. Hospital-based specialist-led clinics are finally restarting after a prolonged period of closure. The fear the public have of entering hospital buildings is causing record-high numbers not attending their appointments. Operating theatres are functioning at less than 50% capacity.
The NHS in general had 12% of its nursing roles vacant prior to the outbreak. As a health service, we’re fighting a pandemic crisis with the health service in an existing staffing crisis. And the people who suffer the most are those from deprived backgrounds and long-standing ill health.
The lack of follow up in hospital clinics for patients with complex and chronic conditions inevitably means that they are contacting their GP reporting deterioration in their condition. Additionally, the mental health burden of the pandemic has begun to rear its head with a surge in the number of presentations to GPs and reports of increased suicides.
In addition, patients who did not contact their GPs during the lockdown in an attempt to avoid burdening the health service are now presenting and some have very concerning symptoms that should have warranted earlier action. It is fair to say this winter will be the hardest ever seen in the NHS, regardless of what happens to the coronavirus.
Policy to jump-start secondary care is urgently needed to oil the engine that has reached a standstill. Additional sessional working incentives for consultants would go some way to get more out of the limited workforce. Making better use of the space available to the health service would also be wise, such as hosting clinics and simple interventions at other sites such as the rainbow field hospitals.
Ensuring the NHS drainage system, which is the social care system is flowing smoothly is more crucial this winter than ever. Yet it seems community capacity for care is less than it has ever been.
There is a shortage of home carers, particularly in rural areas. Care homes remain very nervous of accepting new residents. Some insist on illogical repeated PCR testing in a desperate attempt to prevent the virus from entering their home. Some continue to refuse new residents, often beyond the threshold that the loss of income is jeopardising the viability of their business.
If there was ever a pressing need for a joined-up health and social care approach, then this winter is it. Over the shielding period it is reasonable to assume that older and vulnerable individuals, unbeknown to services, may have advanced in their frailty. At some point these people will hit crisis, necessitating a wrap-around care package that ideally keeps them in the community and away from the acute healthcare system. However, many will become acutely unwell necessitating admission to hospital.
Whilst being treated medically, assessments of need should start immediately by social care colleagues so that once medically fit for discharge these people’s discharge from the health system is minimally delayed. If the capacity isn’t available, local authorities should seriously consider the acquisition of suitable accommodation in the community, whilst also “ramping up” the care sector staff numbers with an unprecedented recruitment drive and rapid training of a new army of carers. Clinical medical beds should be used for those in clinical need. This should be a government priority this Winter.
One of the most upsetting aspects of the last few months, where it is argued that people’s human rights have been breached, is the barring of family members from visiting poorly relatives in hospitals. Loved ones hospitalised for many weeks if not months, unable to see relatives, and some eventually die. The psychological distress that this policy has caused is yet to be understood.
It is in the gift of decision-makers in hospitals to provide safe visiting protocols for relatives. A rapid turnaround swab test, a well-ventilated visitors area within hospital grounds or even wheeled outside by staff, ensuring PPE is given, and those visitors who come into contact with loved ones with COVID-19 instructed to self-isolate for 14 days.
Sooner or later, we as a society must accept the virus isn’t going away. We must learn to live with it, learn behaviours and good practices to reduce the risk, and accept that the virus won’t cause serious illness in a great many of us.
Whether an effective vaccine is developed, or the virus somehow loses some of its lethality, we have to accept it isn’t going to go away any time soon. Diseases of despair, those conditions linked with prolonged economic hardship is on the rise, including drug use, alcohol abuse and suicide.
Society now faces a big question – what will cause us the least amount of harm? Is it the gargantuan task of keeping the number of Positive PCR tests that identify the genetic material of the virus to a minimum?
Or is it accepting the risk of developing serious illness from being infected by the virus and managing it responsibly?