This article examines the course of the COVID-19 pandemic as it has affected the UK and particularly Scotland. It notes that after five weeks of lockdown, the rate of discovery of new cases and of deaths had shown no reduction, indicating reservoirs of new infection. It draws attention to the large differences between the rates of death in the UK and Scotland, and in Finland and Norway, and to the need to examine the reasons for these. In looking forward to a point when rates start to fall, it examines the ways in which lockdown could gradually be eased and points to the vital importance of re-introducing strong public health measures for detecting cases and identifying and managing contacts. In view of regional differences, it suggests that an independent pro-active approach would be appropriate in Scotland.
The first article of this series (4 March
) noted that China appeared to have started to control the COVID-19 outbreak within about two months of it starting, probably as a consequence of extremely rigorous restriction of people's activities. The second article (18 March
) drew attention to the influence of political decisions on both spread of infection and on subsequent mortality, pointing to the importance of expert advice. At that time, different outcomes were appearing in different countries and the article mentioned some with similar populations to Scotland, notably the Nordic countries.
It was apparent that the outcome in the UK and Scotland would depend on the actions taken to prevent spread and manage the illness when it occurred, and that this would be a critical test of both Government competence and public compliance. On 23 March, the UK Government supplemented its general hygiene and social distancing advice with the introduction of a severe lockdown policy and the public in general complied well, with some publicised exceptions.
Similar policies were enacted in Finland, Norway and Denmark. In contrast, in Sweden the social distancing policy alone was relied upon. With respect to medical preparation, while the Government took relatively early action to increase the availability of staff, ventilators and intensive care facilities within the NHS, the need to ensure adequate provision for virus detection and personal protective equipment does not seem to have received the same degree of attention – either within the NHS or especially the social care sector.
The situation in the UK and Scotland
The first death from COVID-19 was reported in the UK on 6 March and by 12 March, with the number of cases increasing, efforts at contact tracing were abandoned. A one-day peak of 8,700 new cases was reported in 10 April and by mid-April total cases had reached 100,000. As of 26 April, roughly 4,000-5,000 new cases are being reported daily across the UK.
In Scotland, the first deaths occurred on 17 March and continued to increase rather slowly through March but took off in early April. Since then, deaths in Scotland have fluctuated and are now averaging around 50-60 daily with no evidence of reduction since lockdown began. This suggests that reservoirs of new infection are present in the population and the obvious sources are the NHS itself, the social care sector, recovered but still infective patients, and those occupations recognised as essential where isolation of large numbers has been impracticable. This reservoir effect is supported by the daily numbers of newly diagnosed cases in Scotland which has averaged about 320 daily throughout April without showing any significant downward trend.
These figures do not take full account of the additional deaths outwith hospital that are associated with, but only in part a consequence of, the infection. Some of these deaths are ascribed to other causes but COVID is also mentioned on the death certificate. National Records of Scotland publishes weekly data on all COVID-19-related causes of death and compares them with averages over the previous five years. By 19 April, 1,616 deaths related to COVID-19 had been registered and in 25% of these there was another cause, usually dementia or cancer, suggesting that deaths from these diseases had been brought forward by the infection. Of the 1,616, 563 COVID-19-related deaths had occurred in care homes and 163 at home. 90% of deaths have occurred in the over-65 age group, mostly in the over-75s, and 0.5% among those under-45.
COVID-19 remains a disease primarily of the elderly and most fatalities occur among older people with other significant health risks. Already some clues are appearing; obesity, heart disease, high blood pressure, kidney disease and, most unfortunately, BAME status. Being a female offers a small measure of risk reduction and youth a large measure. The most important question to be resolved is why some people do not catch it; perhaps they do but report no symptoms? All these issues present important opportunities for research.
The Nordic countries: some comparisons
You will have noticed our Governments' emphasis on the scientific evidence, the importance of which has been stressed in these articles from early March. As time has passed, it appears that some of the public and media are beginning to question this. The relevant sciences are epidemiology and virology, one to investigate the risks to life and health and to attempt to predict the consequences of preventive actions, the other to understand the behaviour of the virus and to assist in providing a cure or a vaccine. The epidemiologists have to work with numbers: of deaths, diagnoses and positive tests. All are, to a degree, unreliable unless defined clearly. While death seems clear enough, the cause is rarely clear cut, especially in the elderly who usually have several chronic diseases that contribute to a fatal outcome. Diagnosis depends on the reliability of the criteria and tests used.
Methods of ascertainment of COVID-19 differ between and within countries, making the number of cases difficult to compare across them. However, deaths thought to be COVID-19-related, expressed as a proportion of the country's population, give a rough indication of how different countries are managing the pandemic. From Scotland's point of view, how are we doing compared to other countries with similar populations and climate?
I have chosen to watch the Nordic countries. Up to 25 April, Finland (population 5.54 million) had recorded 31.9 deaths per million, Norway (pop 5.37 million) 37 deaths per million, Denmark (pop 5.79 million) 69.6 deaths per million, and Sweden (pop 10.23 million) 210 deaths per million. In contrast, Scotland (pop 5.45 million) has recorded 217.2 deaths per million and the whole UK (pop 66.67 million), 293.5 deaths per million. The UK figure does not include many deaths outwith hospital and is likely to be much higher; all these figures will rise, and different means of recording deaths may make direct comparisons difficult.
However, the almost seven-fold difference between Scotland or Sweden and Finland or Norway at the same stage in the epidemic is food for epidemiological thought and perhaps soul-searching, something that is now happening among Swedish epidemiologists and may well be in deliberations in the SAGE committee. The UK as a whole is even worse than Scotland; how we got into this sad situation must be relevant to how we get out of it.
How do we get out? Test, identify, and isolate
The last article in this series started to address the issue of getting out (14 April
), making the point that we should by now have the examples of other countries to assist us, as well as our own experience. Our UK and Scottish experience to date is that there must still be large reservoirs of cases causing the new infections that are occurring despite five weeks of lockdown. Our obvious failure had been to drop the antigen testing and contact tracing that we started, presumably because we did not have the facilities to pursue this. Moreover, doubts have been raised about the reliability of the antigen test we had chosen to use, and this must be resolved.
The contrast with Finland is stark; their Government introduced lockdown at the same time as the UK but continued extensive testing for the virus and contact tracing, and proposes to intensify this while cautiously lifting their restrictions. They were able to do this because they were much better prepared than we were for the pandemic in terms of medicines and supplies. It is good to hear that UK Governments are now saying that they will re-start widespread testing and contact tracing, since this is essential to keeping the epidemic damped down. The experience of Singapore is relevant here; they controlled their epidemic initially but, when restrictive measures were relaxed, they suffered a rapid resurgence from unidentified sources among enclosed groups of immigrant workers.
In Scotland, new case numbers are small enough to make contact tracing feasible. To test, identify cases, and isolate/treat is old-fashioned public health that works and can be achieved without electronic wizardry; there is an army of unused volunteers to help achieve this. Once contact tracing and testing are running and cases are reducing significantly, the questions of relaxation of restrictions and regeneration of the economy arise. They are inter-related and because of local differences there is a strong case for different administrations, especially Scotland, making different decisions.
Sadly, for those of us over 70, it is likely that we shall all be very restricted in our activities for a long time, since we are the ones who are most likely to end up in hospital and cause a repeat of what has been happening over the last two months.
We have discovered that many activities can continue with the workforce largely at home, and these should continue. School and university education can return in a selective manner with a similar large contribution also from home, but research and productive industry requires attendance in laboratories and factories. These must be re-introduced into the economy in a staged manner as the workplaces adapt to comply with the Health and Safety at Work Act's provisions adapted to COVID-19. Here it may be remembered that risks from infective particles are likely to relate not only to the numbers of viruses in the immediate environment, but also to the duration of exposure. Thus, limiting hours/days of work is a preventive measure.
Shops, restaurants and bars, public transport, and other personal services are essential parts of the economy; again, all must eventually re-open while taking account of the continuing need for hygiene measures, distancing and limitation of numbers in any one area. It is here that the wearing of masks becomes relevant.
The issue of masks has become unnecessarily controversial. The priority for protection from inhaled virus lies with health and social care workers. Those most exposed, working in intensive care and similar environments where aerosols are generated, need full PPE and the most efficient respirators available. Consideration of powered air filtering respirators (PAFR) in such circumstances is urgently needed, but for now the uncomfortable face-fitted disposable filtering respirators (FFP 2 and 3) which give about 95% protection are essential. Facial hair nullifies their effect. For lesser exposure situations such as admission units, general practice, social care and accident and emergency, surgical masks with face protection and appropriate gowns and scrubs are probably adequate. Patients and suspected patients should be issued with surgical face masks.
As the public is released from lock-in, some advice on masks should be introduced. Here the purpose would be to protect the public from infection by the wearer rather than to protect the wearer. High-quality disposable masks are unnecessary for this purpose, since infection mostly occurs from large wet droplets generated by cough or sneeze, and any reasonably tight-knitted material across nose and mouth will prevent most of these particles escaping and can be washed and re-used. Thus, for example, it could be advised or even made compulsory for such masks to be worn in public places, transport, shops, bars and so on, both by customers and staff. There is some evidence from the Far East that such measures can reduce risks of outbreaks and that they are acceptable to the public.
One measure little discussed is the use of mobile phones and social media. Apps on mobile phones are an adjunct to contact tracing and are being used successfully in some countries. This is something, along with the use of volunteers for contact tracing, that Scotland could try even if the rest of the UK does not. Another measure is the use of so-called 'influencers'. Such individuals have access to many people who do not use other traditional media. Finland has used them successfully in persuading the population to comply with its strict isolation measures, and they could be used to amplify messages about contact tracing, use of masks and compliance with quarantine.
Immunity and a cure
It appears that Sweden pursued a policy aimed at allowing the epidemic to take its course towards herd immunity, its preventive measures relying initially on hygiene, social distancing, and its excellent health services. The relative inefficacy of this, as of the UK and Scotland's measures, is now apparent. We still do not know the strength of the immunity of recovered patients, though it is reasonable to assume that they are at least quite well protected from the same virus for a few months. However, whole-population protection can only be expected from the deployment of a vaccine. Quite literally, never has the safety of so many depended on the efforts of so few – the virologists who are developing the vaccines. We should not expect this to be available before we take action to come out of lockdown.
A medicine to treat COVID-19 is even less likely in the short term, but possible. It is likely to be too expensive for most countries to afford unless produced by national consortia. History suggests that one effective medicine alone is unlikely to be solve the problem as the virus would probably become resistant, and several effective ones may be necessary, as with tuberculosis and HIV. It is worth repeating that only one infectious agent has ever been beaten – smallpox – in that case by an effective vaccine and a huge international effort by WHO over many decades.
When a politician says, 'We'll beat this virus', look at the faces of the scientists; they will know that these are empty words. It is probable that the best we can hope for is to co-exist relatively peacefully as we do with influenza, unless the virus by good fortune mutates into benignity.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own.