In this article there are two messages:
• Our risk of contracting Covid-19 relates to the number of people with whom we are in close contact, the duration of such contacts, and our personal hygiene actions;
• Our risk of serious consequences of infection relates to the efficiency with which our Governments prepare and support the NHS to cope with the inevitable increase in cases over the following weeks and months.
We are thus active participants in a test of both governmental competence and population compliance such as has not been seen in the UK since 1939.
Many readers will be familiar with the feeling of relief when during an illness you meet a doctor who examines you carefully and gives a clear explanation of the diagnosis and proposed management, even when the news may not be good. At the very least, you know what to do yourself and what the healthcare team will do to aid your recovery or to ease your symptoms. Less satisfactorily, some of us will be aware of the anxiety when the doctor clearly doesn't know what to do and gives an unhelpful explanation – anxiety that makes the symptoms less easy to bear. Multiply this experience by 66 million and you will understand how the Government can manage or mismanage an epidemic that appears to threaten the whole population.
My previous article (4 March
) noted the apparent stumbling initial UK Government response as the epidemic threatened to reach these shores and pointed out that this was a job for experts, not politicians. The latter should confine themselves to stating clearly how they are going to apply the advice of experts, obviously taking into account mitigation of any social or economic consequences.
Absolute openness is essential as the public is already conditioned to disbelieve politicians because they have adopted a culture of 'spin' and sometimes frank dishonesty. This message had already reached those who advise the Prime Minister, and the appearance of Professor Chris Whitty alongside him showed the public that we are now in capable hands, so long as his advice is taken. Our own First Minister, as expected, has been measured in her response throughout and the other devolved nations are now also showing leadership including close cooperation across the island of Ireland.
Who are the experts?
Experts are not people uniquely gifted with wisdom. They are people who have studied problems deeply, have practical experience of what they are talking about, and crucially, understand the evidence on which to base their advice. Professor Whitty is one such. Behind him, in this particular epidemic, are teams of specialists and researchers trying to fill in the gaps of evidence, to provide answers to questions about the effectiveness of various measures, the problems that might arise and the likely length of the event and the risk of recurrence. With a new virus, there are many unknowns and intensive study of the outcomes in the earliest stages of the epidemic are necessary to reduce uncertainties.
We are now about three months from the start of the Covid-19 epidemic and thanks primarily to the remarkable activities of the Chinese and the WHO we know much more than we did a month ago. This is guiding our responses in the UK and across Europe generally, and is a continuous process. As the epidemic spreads, so we learn more about its effects and behaviour and that in turn informs the advice we receive.
In this case, the experts are epidemiologists and virologists. The latter understand the virus and its behaviour, method of causing harm and possibly its susceptibility to various medicines. Their findings are the basis of preventive measures, including producing a vaccine and possibly even a treatment. Professor Sir Patrick Vallance, the Chief Scientific Advisor to the UK Government, is a medical scientist expert in drug development.
Epidemiologists study patterns of diseases and their determinants in populations, measure the associated risks, and use their data to make predictions of the course of the epidemic and how it would be likely to respond to various interventions. This is analogous to the medical process with which many are familiar – doctors examine the patient, make a diagnosis and then a prognosis which can be altered by treatment. To do this requires data and such data are now available from China, cruise ships, Korea, Japan, and increasingly from over 100 countries. Most data however are still unreliable since they depend on measuring accurately the numbers of people infected and this is not possible in most countries, so what is increasingly known is the number of deaths, the numbers ill enough to be detected, and the overall population of the country or area affected.
The present epidemic
This is a new virus (now named SARS-CoV-2; the disease is called Covid-19) that attaches itself to receptors in lung cells. Nobody had specific immunity to it although natural resistance to its effects is present in a proportion of the population to varying degrees. It is now clear that the young are relatively resistant, and few develop severe symptoms when infected. It is suspected that many have none. The elderly have very little resistance and are at high risk of severe symptoms and even death if infected.
The risks rise sharply over age 70. This has meant from the beginning that it will infect many people, that most will recover quickly if they get any symptoms, that a small proportion will fall very ill, and some will die. Moreover, in the severely affected group, recovery is likely to depend on the health services available to the population; whether such services can cope depends on the demand placed upon them at any one time, since many patients simultaneously place great demands on staff and intensive care equipment.
In the UK at the time of writing, 1,551 people have been diagnosed and 51 have died so far. These numbers have risen from 162 infected and one death a week ago. In Scotland, roughly one tenth as many can be expected (153 and one death so far). As searching for cases accelerates and the virus spreads, many more will be found. Italy and South Korea, with roughly similar populations to UK, illustrate possible extremes of the effect of the epidemic: Italy has so far recorded 27,980 cases with 2,158 deaths and South Korea has recorded 8,236 cases with 75 deaths. This difference shows starkly how a Government can influence the outcome and we shall soon see how ours measures up. Norway and Denmark, with populations similar to Scotland's, are running at 1,312 cases (three deaths) and 932 (three deaths) respectively. Of 3,700 mostly elderly passengers on Diamond Princess, 696 (19%) were infected of whom seven died.
Epidemic management: The Government's role
Management of an epidemic can be viewed as being the responsibility of two parties, the Government and individuals. Government devises the strategy and tactics, and the people take action to protect themselves and those with whom they interact. The epidemic takes its course, modified by the actions taken to influence it and eventually most people survive, usually with some immunity to future attacks by that virus. When many people become immune (so-called herd immunity), the harder it is for the virus to keep hold and thrive, but this immunity will only occur after about 70% of the population has been infected or vaccinated; it is therefore not likely to be relevant for curtailment of this epidemic.
Many scientists are working hard to find a vaccine to prevent a future attack by SARS-Cov-2, but again, this is likely to take a year or more before one becomes available.
The management of this epidemic requires the Government to go onto the war footing of the 1940s, to act decisively, and the people need to be as compliant as the British population was then. One of us lived through this and we do not exaggerate. Within a week or two, we can expect the NHS to be overwhelmed unless spare capacity is found, and different ways of working are urgently implemented. Hospitals need to create capacity for Covid-19 patients and all non-urgent care needs to be passed elsewhere or postponed.
It is obvious that private hospitals and those which focus on elective surgery (which have oxygen facilities and ventilators) and their staffs should expect to be requisitioned for this purpose within days and certainly those who work between private and NHS sectors should expect to focus fully on acute NHS work. Money needs to be spent on ventilators and other equipment for the front line; the UK Government already has spoken of the mechanical and military manufacturing industries refocusing on manufacturing vital medical equipment.
Doctors and nurses will expect to be redeployed and retrained as necessary, and senior students in medicine and nursing likewise can expect to take up vital roles in supporting the delivery of healthcare. Indeed, we hope these actions will have been taken by the time this is published and that money will flow to all appropriate health authorities for use designed to meet local needs.
The public's role
This is crucial. The Government's advice is now well known and readily available with appropriate information provided
. The principles behind it are worth noting; they underpin all preventive medicine:
• The risk of harm from a toxic agent relates to the amount you are exposed to and the duration of exposure.
• Exposure may be reduced by avoiding the agent or by protecting the individual from being contacted by it, and by reducing the duration of exposure.
In the case of this viral agent, absolute protection of the population is impossible in practical terms until a vaccine is developed. Therefore, risks must be reduced. Knowledge of the behaviour of the virus shows that it is transferred to and from the respiratory tract by droplets in breath and by coughing and sneezing. The virus can transfer directly to another person in close proximity and be either inhaled or transferred to the eyes or mouth by hand movements. The virus is also deposited on surfaces, where studies have shown it can survive for up to three days although susceptible to strong alcohol cleaners and to soap and water. Studies of washing have shown this requires vigorous rubbing with soap, and a good lather for at least 20 seconds. Hand-drying is best done with disposable paper towels.
Coughs and sneezes should be caught on tissues and all paper should be disposed of safely to bins. Hands should be kept from the face as far as possible. It follows that exposure is likely to be dependent on social interaction. Simple 'respiratory droplet precautions' comprising fluid repellent surgical masks, plastic aprons and gloves with regular hand hygiene are the standard protective measures advised for healthcare workers when assessing or caring for those both suspected of or proven to have COVID-19.
Eye protection is used on a case-by-case basis based on a risk assessment, whilst specially fitted masks (and gowns) are reserved for procedures where there is higher risk of aerosol generation as in the intensive care unit. There is no proven value of mask wearing outside of the healthcare setting and this may in fact encourage hand transfer of virus to the face when adjusting or removing them without the appropriate hand hygiene. For both healthcare workers and the general public, hand washing or disinfection with soapy water or alcohol gel is the mainstay of protection against transmission of this virus.
What must we do as individuals?
The virus is now distributed widely in the population and anyone may harbour it, including us. The epidemic is progressing as predicted and very many will be infected in time. The Government's strategy is to accept the inevitability of many cases but to take action to reduce the rate at which new cases occur. Thus, fewer will occur at the peak of the epidemic and the NHS and social services will be better able to cope, though ultimately the same number of illnesses may occur over a more prolonged period but with lower mortality supported by better resourced and prepared healthcare. There is evidence that vigorous action early may have this effect, but it is too soon to be confident of this.
The tactics are where there is more room for uncertainty, but if you follow the principles above it is obvious that social isolation and avoidance of contact are the most important measures. Hence, the no hand-shaking/kissing and regular hand-washing advice. The more people you spend time with, the greater the risk that one will have the virus, so avoiding crowds, parties, conferences, health clubs, etc, is in our view essential for those at higher risk.
There is one proviso; children and younger adults usually only suffer a mild illness and will provide a group with immunity after recovering, essential for continuing the economy. This, along with the problem that large numbers of elderly people will be involved in caring for children if schools are closed, makes this a serious problem to which there is not yet a clear answer. No touching, frequent hand-washing and social distancing are now essential for all of us, especially the elderly and those with pre-existing health conditions.
Importantly, we must assess our own risks. If you are young and fit, you can work and live with these simple hygiene procedures, but if you socialise, keep your distance. Remember that if you reduce the numbers of people you meet, you will reduce your and their risks proportionately. Many companies are already encouraging employees to work from home, utilising electronic communication whenever possible. This has extended to medical conferences which have been urgently reconfigured to allow virtual attendance with delivery of content over the internet.
If you are over 65, you should stay mostly at home until it is over and take care with your activities, though walking or cycling with a friend or two is good and low-risk. Shopping should be planned and a simple dash in, buy it and out, washing hands on return. Public transport should be used at quiet times whenever possible. If you are older, ask your family to avoid visiting but keep contact by phone. Each of us must make our own risk assessment; advice on this is available from the NHS
. This includes advice for owners of businesses, schools and other organisations.
What if you fall ill?
There is now clear advice, altered as we were writing. Anyone developing a raised temperature or a new cough that persists over a day or two should self-isolate at home for two weeks with others in the house. If it gets worse or you become breathless, you should call 111 for advice. Do not go to hospital or the GP's surgery. The advice may be to attend a local assessment centre or hospital or to continue at home, depending on the circumstances. Please be patient, as staff will be under great pressure. Even if you have the illness, you are still likely to see it out at home with simple symptomatic medicine, if you are not in a high-risk group.
Government has now gone much further, and its advice to all of us essentially follows that given above, perhaps making it easier by specifying the avoidance of places where numbers of people congregate. Since advice will change, it is necessary to keep in touch with the Government websites and other media sources.
Finally, remember that we are now in good hands, but our cooperation is essential to ease the burden on the NHS as the numbers of cases increase, and on which the management of serious cases depends. Keep up on the latest advice from the experts. Do not be alarmed as the numbers of diagnoses rise; this is expected. But do your best to keep the pressures on the NHS manageable by acting on the advice, even if in time it becomes more restrictive. Protecting the NHS is the key to minimising the serious consequences.
Anthony Seaton is Emeritus Professor of Environmental Medicine at Aberdeen University
Andrew Seaton is Consultant Physician in Infectious Diseases in NHS Greater Glasgow and Clyde and an Honorary Associate Clinical Professor at the University of Glasgow (@raseaton66 on Twitter)
The views expressed here are those of the authors and do not represent the views of their affiliated organisations or employers