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UK’s alternative scientific advisers put public health first

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2056 (Published 27 May 2020) Cite this as: BMJ 2020;369:m2056

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  1. John Middleton, president
  1. Association of Schools of Public Health in the European Region
  1. John.middleton{at}aspher.org

A good start and cautious welcome for new Independent SAGE

The Independent Scientific Advisory Group for Emergencies (iSAGE) published its first report on 12 May.1 Chaired by David King, former chief scientific adviser to the UK government, the group includes experts in public health, epidemiology, virology, intensive care, primary care, mathematical modelling, and social and health policy. It was set up to address concerns about the absence of key disciplines from the government’s pandemic scientific advisory group (SAGE), its apparent reliance on modelling and behavioural science, and perceived interference by political special advisers.2

The group’s recommendations are strongest on public health measures and emphasise the World Health Organization’s criteria for easing lockdowns,3 including evidence that covid-19 transmission is controlled; that sufficient public health and health system capacity is available to identify, test, and isolate all cases4; that quarantine should last 14 days (not seven); that control and testing strategies should target vulnerable groups and settings, such as nursing homes and prisons; and that a quarantine policy is in place with a diverse range of community facilities.

Pandemic planning should move away from top-down procurement of services led by private companies with little experience, and the private “lighthouse laboratories” capacity should be assimilated into existing laboratory services run by Public Health England and the NHS. Real time, high quality data at local authority and electoral ward level are called for to support action led by local public health and primary care professionals.

iSAGE stresses that testing is only one component of an integrated prevention and infection control response. Even so, the group seems uncritical of the limitations of testing, including the risk of false negative PCR test results (particularly in health and care workers), and false positive serological test results, which overestimate population exposure and immunity.5

Five criteria

The UK government has repeatedly said that relaxing restrictions depends on five criteria6: protecting the NHS’s ability to cope; a sustained and consistent fall in daily death rates; the rate of infection decreasing to manageable levels; confidence in our capacity to provide tests and personal protective equipment; and confidence that relaxation measures will not risk a second peak of infections.

These criteria have clearly not been met, so lockdown should be maintained until daily infection rates are low enough to be manageable with a strategy to test, trace, and isolate. iSAGE concludes that lockdown reduced the spread of covid-19 even in the absence of a test, trace, and isolate policy. Others agree that we are nowhere near satisfying the government’s criteria for relaxing lockdown.7 The R value remains too high (in Wuhan R was just 0.2 when relaxation of measures began).8 There were 545 deaths in the UK on 19 May, and the Office for National Statistics estimates that between 27 April and 10 May, there were 148 000 infections in the community alone.9 Any contact tracing strategy is likely to fail without substantially increased resources. Germany plans to open all schools before the summer holiday, comparable with the proposed UK timetable, but has much lower circulating levels of infection. As yet, the UK has no quarantine policy or isolation facilities.

Mixed messaging

Among western countries, the scientific advice is fairly consistent, and criteria for relaxing restrictions are broadly similar.31011 The major problems have been how the UK government has interpreted the science and been ambiguous in media briefings. iSAGE and others have been particularly critical of the shift from “stay at home,” to “stay alert,” a message that only England is adopting. The prime minister’s announcement about returning to work was catastrophic, leading to crowding of public transport and employers unprepared for safe working arrangements.12 A leak to the press ahead of that announcement13 led to large gatherings on VE day; this was an act of political negligence or incompetence.

Efforts to revive the economy are vital, but no one contributes to the economy if they are dead. Countries that entered lockdown early and stayed with it longest during the 1918 flu pandemic improved their economic performance more quickly than those that did not.14

Clarity, action

The new group has done a service in highlighting the need for clarity and decisive action in the public health response. Will its report influence policy in the UK? Possibly—its members called for locally driven action and border controls ahead of their report, and, coincidentally perhaps, local directors of public health were then given a leading role in testing and contact tracing measures.

It’s not yet clear how influential iSAGE will be or should be. But influence is possible, even without all the resources of governmental scientific machinery. The group is extensively networked within the UK and globally, and should have no problem accessing data and advice to inform recommendations. It is not yet more diverse than SAGE, and has, of necessity, omitted some clinical expertise. But it is more transparent in both deliberations and reporting. Critics may question the new committee’s authority, but its first report is a good start, and any drive to put public health back into the heart of the UK government’s pandemic responses should be welcomed.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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References

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