The Covid-19 Files (2): Briefing Boris

I just had the very depressing thought that if the opposition parties hadn’t given into Boris by allowing a General Election in December, and instead forced another extension to the Brexit transition period, until say the end of this month, the whole Brexit process would have been overtaken by coronavirus events and maybe never completed.

And Parliament might be more effectively holding the government to account over their approach to the pandemic itself. Literally a fatal mistake.

That prompted me to get on with this post!

Regular readers will know that I rarely keep my promises of future posts. But for once I am! Well, it was an implicit promise in the title “The Covid Files (1):…“.

Below is a letter I posted to the PM on 28th February (so it was mainly written the previous day).

My annoyance (now transitioned into cold rage!) back then at apparent (and perhaps actual) government complacency in the face of the Covid-19 threat comes across in the irreverence of point 2. At least I didn’t mention the Queen!

I see now that some of my points have been actioned (7, for example), and others moot (e.g. 10), but my lockdown advice (3, 24 and 25) has not yet been taken. I now believe the reason for that is because, instead of the “contain, eradicate outbreaks and contain again” strategy I had implicitly assumed, the UK’s plan (published on 3rd March), throws in the towel seconds into Round 1 and aims only to “fail to contain, delay and mitigate”, with mitigate in fact meaning “make do and mend”. More on this later, though I’ve already explained why it won’t work.

Needless to say, I’ve had no reply yet, though I didn’t expect one. Or want one (yet), in the sense that No 10 should be fully engaged on stopping the UK’s Covid-19 epidemic.

Oh, just one thing more before I finish my breakfast. Because I know everything about everything myself I don’t normally plug other analyses, but, besides this blog, Tomas Pueyo’s article “Coronavirus: Why You Must Act Now” is a must-read.


COVID-19 Response

Dear Prime Minister,

I am very pleased that the government recently gave the go-ahead to HS2.  It will eventually provide additional travel options from London to Newcastle, a journey I often make to visit my elderly mother.  To increase the chance of her living long enough for the new railway to be of benefit for such trips, I urge you to show the same decisiveness in dealing with the threat to the UK of the COVID‑19 pandemic.

Over the last few weeks I have watched with mounting horror the pathetic response to the spread of the Wuhan novel coronavirus by authorities in most countries outside China, and particularly in Europe, including the UK.  Since we have been following similar procedures, it is only by luck that the most serious COVID-19 outbreak in our region so far has occurred in Italy and not in this country.

I would like to make a few observations and suggestions:

1.       COVID-19 is not comparable to normal flu.  Rather, it is a highly infectious viral pneumonia.  The overall mortality rate is usually quoted at around 2%.  That is around 50 times that of the 2009 swine flu pandemic and comparable to that of the “Spanish flu” of 1918 which killed an estimated 50 million people.  2% of the half of the UK population who might be infected in a full-blown COVID-19 epidemic is in excess of 500,000 people.  

2.       COVID-19 is far more serious for the elderly.  A mortality rate of 15% for over-80s has been widely quoted.  This would, for example, render moot any political initiative to reduce the number of members of the House of Lords, should Westminster not miraculously avoid the pandemic. 

3.       The UK’s higher proportion than China of elderly people would tend to increase the overall mortality rate.

4.       The mortality rate will also tend to increase wherever the health service is overwhelmed.  China has relocated tens of thousands of health professionals to Hubei province.  Presumably the care they are providing is saving lives.  It’s not clear that we could mobilise a comparable number of doctors and nurses. 

5.       Serious COVID-19 cases (an estimated 5% of those infected) require intensive care, including respiratory assistance with equipment in limited supply.  Medical staff must wear protective clothing and follow strict procedures in order to prevent themselves from becoming infected.  Any epidemic in the UK of more than a few thousand cases would overwhelm the NHS.  It may still be possible to avert such a scenario, but, if it occurs, it would be necessary to lock down potentially the entire country.  There is nothing particularly Chinese about the way they have handled their epidemic – they were forced to adopt the lockdown approach they have – though, with their long history of mobilising vast numbers of people in response to threats (such as river flooding), they may be better at this sort of thing than we are. 

6.       The incubation period of COVID-19 is up to at least 14 days.  Any lockdown to prevent further spread must therefore be initiated as early as possible in an epidemic because of the number of people already infected but not yet symptomatic.  Such people may travel and spread the disease more widely.  The global health community has not yet got ahead of what is now an incipient pandemic.  Case detection and isolation is of course critical to limiting the spread of the coronavirus.

7.       The World Health Organisation should immediately declare a pandemic.  I suggest that the UK seek a resolution of the UN Security Council urging them to do so in order to enable the most effective possible global response. 

8.       It may not now be possible to stop the COVID-19 pandemic in its tracks, but we can buy time whilst effective antiviral drugs are identified and vaccines developed.  Spread of the virus might slow in summer because its survival time on surfaces should theoretically drop from hours to minutes with higher ambient temperatures (which suggests a heat cycle might be an inexpensive way of disinfecting aircraft, trains and buses, for example).    

9.       It beggars belief that travel is still permitted to the UK from China and other areas with active COVID‑19 epidemics.  We have already had one case of an arrival from China with the disease since the seriousness of the Chinese epidemic became clear.  If she has passed on the virus to even one other person, for example on public transport, we could soon see a growing cluster of cases.  It seems infected individuals have also recently travelled here from Tenerife, Italy and Iran and passed through UK airports.  COVID-19 has a relatively long incubation period (weeks, compared to days for flu) and contact-tracing and testing takes time (and is not perfect).  We should therefore assume any overseas epidemic is far worse than the number of detected cases might suggest, and apply the precautionary principle accordingly.  We should not at present be accepting untested travellers from at least China, Iran, Tenerife, Korea, Japan or northern Italy including Milan and nor should other countries – apparently the case in Nigeria travelled from Italy just 3 days ago (when it was already clear Italy had a problem).   

10.   In a world of death-cult suicide-bombers and hostile states with murderous secret services the possibility of deliberate spreading of the coronavirus should not be discounted.

11.   It seems COVID-19 can easily spread on public transport, so it is no surprise to see cases appear seemingly at random in various countries around the world.  I personally went down with (what must have been) swine flu on 7th June 2009, very early in that epidemic.  It is highly likely I was infected on the Piccadilly Line (which, of course, serves Heathrow) at a time (I now learn) when an entirely ineffective attempt was being made to screen arrivals from Mexico who should surely not have been travelling here at all.

12.   Public Health England (PHE) has apparently been deliberately withholding details of the movements of the UK’s known COVID-19 cases in order to protect patients’ confidentiality.  This makes contact-tracing more difficult, since people who have shared transport with them, for example, have not been prompted to come forward.  This is in stark contrast to the situation in China (and elsewhere in Asia) where “big data” has been used to identify incidental contacts (such as those sitting nearby on public transport) of identified COVID-19 cases.  The UK approach should be reviewed by government.  Other countries are publicising, for example, information about flights taken by infected individuals.  I repeat: the later it is detected, the more widespread any COVID-9 epidemic in the UK will be; and the more widespread the epidemic the more severe the subsequent lockdown will be.  The cost to the economy of the lockdown of major cities would be astronomical.  

13.   Compared to pandemics in previous eras we now have much more convenient means of detection of the pathogen itself.  Testing needs to be carried out to the maximum extent possible and not just of people known to have been in contact with other cases.  A week or more ago Singapore announced they were testing all pneumonia patients, whether or not COVID-19 was suspected.  I was led to believe the same was happening in the UK.  Yet this is apparently not yet the case (or more tests would be being carried out) and it seems that at least some cases are only being detected in other countries (e.g. France, US, Italy and Iran) when patients are tested when the disease is well-advanced, sometimes after days of treatment and in some cases around the time of death.  This is reprehensible since the spread of the coronavirus in hospitals will not only create a local epidemic but also infect vulnerable patients with other conditions and reduce the operational capacity of the health service.  Even more importantly, it seems precious days may have been lost, at least in Italy, allowing the epidemic to spread further before preventative measures were taken and contact-tracing attempted.  All patients presenting with symptoms compatible with COVID-19 should be tested as soon as possible after arrival at hospital (as well as as many as possible of those presenting at GP surgeries or via 111). 

14.   It could help in tracking any epidemic if a test for antibodies to the coronavirus were deployed in addition to the existing test for the virus itself.  This would allow detection of individuals who have recovered from COVID-19 (so test as negative for presence of the coronavirus), but may have transmitted the virus when infected.  

15.   Only a few hundred COVID-19 tests are currently being carried out in the UK per day.  Our capacity was boosted to 1000/day about a fortnight ago.  It seems tests may not be being carried out because of the risk of contamination of health workers (and the need to disinfect ambulances).  To maximise our chances of detecting clusters at an early stage we should not only be utilising our full existing COVID-19 testing capacity, but also increasing it further.

16.   There seems to be an absence of the application of logic in the design of COVID-19 testing protocols.  What we should be trying to do early in the epidemic is maximise our chances of detecting any isolated cases before they turn into rapidly growing clusters of hundreds, as in Italy and South Korea.  Reasonable precautions against infection should of course be taken, but a small per-test risk to health professionals is surely tolerable when only say 0.01% of patients are infected (low risk, high reward for detection), whereas it wouldn’t be if the figure was 50% (high risk, relatively low reward). 

17.   It is a welcome development (at least for those with a car), though maybe too late, that drive‑through COVID-19 testing is to be rolled out.  Is there any reason, though, why samples could not simply be dropped off by, or on behalf of, patients themselves, e.g. at GP surgeries?  Having, on reaching a certain age, been required by the NHS to give myself an enema prior to colonoscopy bowel-cancer screening, I’m fairly confident I could competently carry out a procedure as simple as taking a cheek-swab (as is done by millions for ancestry DNA tests), wiggling a cotton-bud in a nostril and sealing the two samples in a correctly labelled resealable plastic bag.

18.   The quarantine arrangements applied for those exposed to the coronavirus on arrival in the UK (and elsewhere) are also baffling.  Mercy-flight returnees have been housed for 14 days at significant public expense and inconvenience to themselves.  14 days is considered the maximum incubation period of the virus (though several reports suggest that may not even be true).  But, given we can test for the presence of the coronavirus, why not detain the exposed individuals for just the period after possible infection until it becomes reliably detectable?  This must surely be known by PHE now, and is probably no more than a couple of days.  A second test could be conducted a day or two later for more certainty of non-infection.  Something like this procedure seems to have been followed in the case of the BBC’s Nick Robinson.  Obviously, if we can’t test for the presence of the virus (e.g. due to resource constraints in a lockdown scenario), at least 14 days isolation is necessary. 

19.   The preceding observation suggests the necessary draconian travel restrictions could be mitigated by quarantine arrangements for those whose travel is deemed essential (e.g. to attend funerals of COVID‑19 victims).  Arrivals could be quarantined for just days, rather than weeks, while COVID-19 testing is carried out.  Since travel restrictions may need to be in force for several months, or even longer, the government should secure facilities near all major air- and seaports and Eurostar terminals to enable essential travel to continue.

20.   Ideally the protocol for travel restrictions should be agreed internationally.  However, the UK should retain the right to unilaterally ban all unquarantined and/or untested arrivals from any territory not demonstrably free of the coronavirus or not themselves restricting (or certifiably quarantining and/or testing) arrivals from infected regions.  

21.   Pre-departure isolation and testing of travellers would be even more effective than following the procedure on arrival in the UK and could be mutually agreed with trusted international partners. 

22.   Special procedures need to be instituted for frequent testing of flight and ship crew, not to mention disinfection (and maybe even swab-testing) of aircraft, ships, trains, road vehicles and perhaps even some classes of freight.  Unfortunately, no travel is risk-free.

23.   Obviously, sufficient COVID-19 testing capacity is a precondition for a strategy of isolation and detection to be applied to travel to the UK. 

24.   Any COVID-19 epidemic in the UK must be closed down as quickly as possible, by lockdown of the affected area accompanied by contact-tracing and testing of both known contacts of cases and those with symptoms, as has been done in China.  This is also the least-cost solution.  The more widespread the epidemic the greater the area of the country that will have to be locked down and the longer it will take to return to normality. 

25.   Lockdown preparations need to begin immediately, since the streets will clear anyway and it is far preferable for the process to take place in an orderly manner.  Employers need to be told to prepare for as many staff as possible to work from home and educational institutions to gear up to provide online teaching.  An indication needs to be given as to the measures that will be taken: for example, all schools, universities, restaurants, pubs, cafes, cinemas, theatres, sports facilities and other social venues will have to close for the duration.  To provide some predictability to economic actors, thresholds for initiation (and removal) of measures should be announced.  A business continuity plan needs to be prepared, e.g. a loans scheme for distressed businesses, tax deferral arrangements etc.  Public transport service provision should be maximised, to reduce crowding, but used only for necessary journeys, with all staff and passengers wearing face-masks.  Note that the main value of face‑masks is to reduce spread of the virus from the wearer to others in the vicinity and to surfaces in the environment.  They are not a very effective means of protecting oneself unless part of a full hazmat suit.

26.   COVID-19 is exposing existing weaknesses in infectious disease control (I can’t not mention GP and A&E waiting rooms), but the crisis also suggests technology and procedures that could be applied to counter other emerging threats, in particular antibiotic-resistant so‑called “superbugs”, which are predicted to kill tens of millions a year globally, within a few decades.  Broadly, we need to apply the new technology of pathogen detection (in 10 years I expect our phones to tell us within minutes what microbes we have become infected with, or identify those present in the environment) with the old technologies of isolation (or quarantine) and disinfection.  I was born not so many decades ago in a repurposed orphanage, the local maternity ward having been closed for “deep-cleaning” due to the apparent presence of an infectious agent.  It amazes me that we now tolerate hospital-acquired infections, when we have the technology to hunt the bugs down and eliminate them.       

Strong leadership, coordination between government departments and the mobilisation of resources are needed to deal with the COVID-19 crisis.  COBRA should be meeting regularly. 

Prime Minister, this could be your Churchill moment!  Or, if we experience a serious epidemic and decimation of the UK’s grandparents, it could be this government’s Black Wednesday, seeing it limp through the parliamentary term until a loss by default in 2024.   

Yours sincerely,

Tim Joslin