Author: Lt General Louis Lillywhite CB, MBE, OStJ
As the UK emerges from lockdown, we need to consider the potential resurgence of the disease and how best to respond, carefully balancing both benefits and harms. Covid-19 cases continue to increase globally and, in some countries, such as in Germany and Australia, it has re-emerged. The cases arising in some food preparation sites, which are kept at a cold temperature, reinforces a view that the winter may see a re-emergence of the disease in the UK.
In preparing, we need to be aware of the gaps in our knowledge, taking care not to learn false lessons which may perpetuate or lead to more harm. These gaps cover the whole spectrum – our knowledge of the virus, its impact on the human body, the optimum treatment, which institutional response is the most successful, and the fine balance between the benefit and harm of those institutional responses.
Covid-19 is a Coronavirus. Coronaviruses cause the common cold and have been responsible for two previous major outbreaks of respiratory disease (SARS and MERS) which spread internationally. MERS is contained within the Arabian Peninsula whilst SARS has completely disappeared. We do not know the future of the Covid-19 virus. Is it stable or will it mutate, potentially rendering any vaccine of limited value? How does it spread - other than via respiratory spread - and how long will the virus survive outside the body? How is its survival affected by the surface on which it lands (e.g. plastic versus cardboard)? How is it affected by environmental conditions (e.g. heat and humidity)?
Its impact upon humans remains intriguing. It mainly causes a minor or no illness, but sometimes causes severe illness with disproportionate impact on males, BAME, the obese, those with pre-existing disease and the elderly. However, the contribution of each factor, and the interaction between them, is not known. We are unsure of the time between contracting the virus and the onset of disease nor how many in the populations of affected countries have had the virus unbeknown to them, and the extent to which these symptomless individuals spread the virus. Why, so far at least, does Africa appear to have been mainly spared serious cases and why did one African study conclude that women are more significantly affected than males? We know that children are rarely seriously affected, and whilst children contract the virus to the same degree as adults, it seems very young children may not be good carriers, unlike our experience of other viral illnesses.
The impact of the disease on body processes, in addition to the lungs, such as on blood clotting and brain damage have been recognised but the cause, scope for prevention and treatment is unclear. Consequently, we continue to adapt our treatment in the light of experience. Various drugs have been claimed to improve the outcome or shorten the disease, but so far only two (Remdesivir and Dexamethasone) have been proven to have a significant impact. Matters are complicated by rapid publications of small clinical trials or without full peer review, leading to later retraction, for example by the Lancet (its findings on alleged harm from Chloroquine) and the New England Journal of Medicine (involving ACE Inhibitors). We know that there are likely to be long-term impacts on those who have recovered after serious illness but are unclear on the long-term impact on those recovering from milder infections. We do not know whether the virus will cause protection from future attacks, and if so, for how long.
Much has been written about the response by various States. It is alleged that some have “locked down” too soon, or too late, whilst some have not locked down at all. In fact, we cannot conclude which is the optimum approach and will not do so for some time for several reasons, and indeed it might depend on what one counts. Without widespread testing we cannot tell the rate of infection of one country compared to another and without that we cannot compare the overall Covid-19 mortality rates. There is also an argument that we should instead measure the overall excess death rate. Which is better - to minimise the number of deaths from Covid-19 but suffer a significant excess of other deaths (eg untreated cancers) or have a higher Covid-19 death rate but an overall lower excess death rate? There is also a question of timing; Sweden which has not imposed a lockdown currently has a higher death rate from Covid-19 compared to its neighbours but has hitherto argued that when the epidemic is over, their policy will be found to be equally valid in terms of disease but superior in avoiding many of the harms (including excess non-Covid-19 disease) of lock-down.
And whilst the economic consequences of lock-down are still being calculated, we have not measured the adverse impact in terms of mental health, emotional distress, increased poverty leading to adverse ill health, increased domestic violence and the healthcare that has not been provided (eg treating cancers and undertaking hip operations etc). Critically for our future generations, we can only estimate the impact on our children of social separation and sub-optimal education and the potential for a disproportionate impact on the children of the already disadvantaged.
So how might we respond to a major resurgence of the disease this coming winter? Perhaps the most important action is to put in place an effective system for testing, tracing contacts, and isolating those infected. The basics are there, but there is a danger that with cases reducing during the summer months that impetus and focus will be lost.
At the strategic level, we urgently need to debate the benefits and harms of re-imposing a near total lockdown. However, even without a near total “Lock-down”, there may still be the need for local restrictions and employers need to revisit their resilience planning. We will need to decide whether, as in some countries, education should continue regardless of other measures and if so how. Decisions are required on how to address the major backlog of untreated, but often life-limiting, cases noting that whilst it is relatively easy to provide the real estate (e.g. Nightingale Hospitals) radical measures may be needed to address workforce capacity.
At the tactical level we need to address our processes within healthcare facilities and care homes. Separating Covid-19 patients from their loved ones reduces transmission but can cause significant distress. We need to consider what mitigation can be put in place to reduce the mental and emotional impact of forced separation of patients from their loved ones, including in their own homes. We also need to understand both why so many care homes seem to have been so severely affected, but why so many were not affected at all, and ensure that appropriate, and humane, infection prevention and control measures are implemented.
An in-depth review of how we responded to Covid-19 will be required, but this is for the future. Now, we need to address how we respond to a resurgence this autumn/winter and how to address the major backlog within the NHS of untreated cases. Importantly, as all options will have both benefits and harms we need politicians, workers and the public to be active participants in the debate.