Covid-19: How can we safely exit lockdown?

Loosening the lockdown too much now will not do our health, the economy, or people’s livelihoods any good, argue KK Cheng and Wenjie Gong

The British prime minister Boris Johnson announced the UK government’s plan to relax social distancing and ease lockdown measures on 10 May. There has been widespread criticism of the government’s confused approach and messaging to easing lockdown and there remain serious concerns in several areas. But a cautious approach to exiting lockdown is welcomed.

Simplistically speaking, if it took Wuhan 76 days before they reopened, then exiting by the seventh week seems risky, especially since the restrictions in Wuhan were more stringent. Other European countries (e.g. Italy, Spain, and France) that are ahead of the UK in the pandemic are also only beginning to slowly loosen restrictions. Germany relaxed its social distancing measures last Wednesday when the effective reproduction number (Rt) was 0.65. It went duly up to 1.1 within a few days. The government has said that it will only consider easing lockdown once the country has passed five tests. Let’s use the tests to look at the government’s decision.

The first test was to make sure that the NHS can cope and does not become overwhelmed. Although the NHS has avoided the meltdown seen in other countries with similar number of cases, there are pressing needs to restore non covid-19 work as soon as possible as patients seem to be staying away, raising concerns that the NHS will face a backlog of non covid related cases and that urgent care is being missed.

The second test was to see a sustained and consistent fall in daily deaths. The number of deaths is falling steadily, but daily deaths still hover around 600, with clear excesses in all-cause mortality compared to previous years, including excess in deaths for which covid-19 was not stated as a cause of death. With the UK now recording the largest number of deaths from covid-19 in Europe, what level of mortality is considered “acceptable” is contentious. 

The third test is to see a decrease in the rate of infection to more manageable levels. If the government found the trend in the first two areas mildly reassuring, then it is likely to be very concerned by the prevailing rate of infection. The number of known new cases is still approximately 6,000 daily but, the real number of new infections is probably closer to 20,000. The effective reproduction number (Rt) is also too close to 1 for comfort. Transmissions in nursing homes and hospitals are fuelling the epidemic. The problems caused by covid-19 in care homes are especially concerning. A number of measures are needed for better control: regular and repeated testing of all staff and residents with rapid reporting of results; strict segregation of residents into hot and cold zones; moving some residents away from homes to reduce density; appropriate personal protective equipment for staff working in hot areas; and finally all staff (and residents who can comply) should wear masks all the time. Directors of public health have been put in charge of the local management of care home testing. However, with 30,000 tests a day earmarked for a care home population of 400,000 and a workforce of almost 1.5 million, quite how the needs for testing can be met or rationed is unclear. Unless the risk of infection among care workers can be reduced, continuing and growing community transmissions are inevitable. 

The fourth test was to ensure appropriate levels of personal protective equipment and testing. Testing is closely related to the government’s plan to “Test Track Trace.” Much attention has been paid to tracking using the new NHS app which is being trialled in Isle of Wight. Capacity for manual tracing is also being established, which is sensible because no country seems to have succeeded without the traditional “feet on the ground” approach. A tracking system that is very likely to work is an absolute prerequisite for anything more than mild loosening of restrictions. One curious omission from the Test Track Trace plan is the safe isolation of cases. There is anecdotal evidence of household transmissions arising from failed isolation in high density living households. Together with intergenerational living and vulnerable household members, the implications on the number of new cases and deaths seem underappreciated. We previously raised the possibility of repurposing the Nightingale Hospitals to house patients with mild conditions to prevent household transmissions. Should these transmissions become an important contributor to an escalating Rt, serious consideration should be given to this option. 

The shortage of proper PPE for health and social care workers has been widely discussed. Logistical challenges are immense and the fact that almost every country has experienced big problems does not provide much consolation to staff and grieving families. Failure to make further improvements as we exit will lead to unacceptably high number of casualties to NHS staff and further damage staff morale. 

Many of the above factors have obvious bearings on the fifth and final test of whether exiting the lockdown will lead to a second peak of infections that could overwhelm the NHS. There are two additional important considerations. First is the quarantine for people arriving from other countries. Failure to introduce this in January to March was the primary reason for the pandemic on British isles. Second is the wearing of face coverings in public, especially public transport. Despite the positions of more than 70 countries (including Scotland and a working group of the Royal Society, the intransigence of the UK Government on this point until today’s announcement is likely to compromise initial uptake by the public and limit its effectiveness. 

The decision to enter an unprecedented lockdown might have been easier than working out how one exits. The patience of the public is not unlimited. Delaying the exit would have massive economic consequences, which we have not covered here. To date, the government has been hesitant in providing the public with quantitative arguments on these opposing dynamics. As poverty also kills and results in ill health, there are difficult ethical dilemmas. Lockdown also results in significant mental health issues

The stakes in making the right decision cannot be higher. However, the data on covid-19 mortality show that it is not “just a flu.” Some previously healthy patients also face complicated recovery after acute infection. The UK has made some progress in controlling the pandemic since it entered lockdown on 23 March. However, a system of testing, tracing, and isolating is still not in place. Adequate provision of high quality PPE is not secure. Transmissions in care homes, hospitals, and households are far too high. Of course, the Government needs to balance health, wealth, and public acceptance of lockdown in making decisions. In this case, however, the health implications are so overwhelming that loosening the lockdown too much now will not do the economy and people’s livelihoods any good. 

For those who are still not convinced that a cautious approach to easing lockdown is required, it is worth noting that the Rt in Wuhan at this stage of lockdown was below 0.2.

KK Cheng is Professor of Public Health and Primary Care and Director at the Institute of Applied Health Research, University of Birmingham, UK. 

Wenjie Gong is Associate Professor at the Xiangya School of Public Health, Central South University, China.

Competing interests: None declared