Serious weaknesses in the UK’s current plans for suppressing covid-19 risk a second major outbreak

The Faculty of Public Health believes we need concerted action now to reduce infections, to enable us to return to something approaching normal life as soon as possible.

Several countries—notably New Zealand, Taiwan and South Korea—have managed to reduce the daily number of new cases to zero. That enables them to respond quickly and effectively to any fresh infections. With powerful mechanisms for surveillance and control in place, their populations are now able to enjoy the economic, social, and health benefits of largely returning to normal life.

There are obvious similarities between the public health strategies in these countries, including strict social distancing, handwashing, extensive testing, comprehensive contact tracing and quarantining at ports of entry.

The critical difference between their approaches and the UK’s is that none of these countries started to relax their control measures until the number of new cases was low and falling. England has begun to relax its “lockdown” when the number of new daily cases is falling, but is still high.

We believe the urgent priority for the UK is to learn from the success of these countries by setting an objective of having no new community cases of covid-19 as quickly as possible.

Health and economic modelling needs to inform this objective, so that we can all understand how long it would take to achieve and what the short term economic and social costs and long term benefits would be. The public need to be given the facts and projections and participate in the debate. In particular we should seek to protect people aged over 60, in whom over 95% of the deaths occur. 

When the government raised the prospect in mid-May of relaxations to the lockdown, the five tests which it had insisted would have to be met in advance of any changes did not seem to have been fulfilled.

The supply of personal protective equipment (PPE) was not secure, the contact tracing system was not operational, testing capacity was insufficient to give a reliable estimate of daily new cases, public transport capacity was insufficient to allow social distancing, outbreaks in many care homes were not controlled and the R value was estimated to be only slightly below 1. Scotland, Wales, and Northern Ireland, looking at similar data, decided not to relax their lockdowns significantly. Several local government leaders in England, notably in the North, expressed concerns.

The government hoped to be able to allow some additional economic activity and some return to schooling without allowing an increase in the R value. As part of the message that the easing of lockdown restrictions is measured and cautious, the government has given repeated assurances that if there is a new spike of infections or an increase in R, controls will be tightened. However, information on how progress will be monitored and what would trigger tighter controls has been vague.

If the country is to prevent a second epidemic it needs a robust early warning system. There is an urgent need to make public the range of metrics which will underpin an early warning system—presumably run by the new Joint Biosecurity Centre—and the specific trigger levels for action. Until now a lot of modelling of the pandemic has focused on hospital admissions. Waiting for hospital admissions to rise is a dangerously slow way of spotting and controlling an outbreak.

A reliable measure of the number of new daily cases is key to robust early warning. This requires local public health teams with the capacity to actively investigate all likely contacts of a new infected person.

Alongside this, weekly longitudinal studies of a representative population could provide a reliable estimate of total symptomatic and asymptomatic cases. The government should publish in advance how this data would be used to trigger action and the infection levels at which that would happen.

In the early days of the pandemic, keeping the NHS within its capacity was judged as a measure of success. While preventing the NHS being overwhelmed is of course desirable, a promise to avoid a second peak which overwhelms the NHS implies we can accept another wave of the around 50,000 deaths. This promise is not reassuring.

In addition to an effective early warning system and strict measures for triggering action, further action is needed to ensure that we are focused on prevention including quarantine controls at borders as well as the suppression of outbreaks. 

Like everyone else we are longing for restrictions on our lives to be lifted. But evidence from around the globe shows that the way to achieve this is not to merely suppress covid-19, but to systematically reduce its incidence. We believe that robust, concerted action now will be the surest way to achieve this. 

Maggie Rae is the President of the Faculty of Public Health.

Ellis Friedman is Treasurer of the Faculty of Public Health.

Competing interests: None declared.