Moving quickly in pandemics
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2730 (Published 09 July 2020) Cite this as: BMJ 2020;370:m2730Read our latest coverage of the coronavirus pandemic
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Dear Editor
We read with utmost interest your article ‘Moving quickly in pandemics’ and agree to undertake aggressive measures to break the chain at different settings.
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The mode of transmission of the disease, whether by large droplet as fomites through surface, short distance aerosol borne or long distance airborne by small particles is still not known. The understanding, however, is extremely relevant both in the community setting and in the hospital setting for breaking the chain of transmission. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon.
The principle behind the containment is to prevent susceptible hosts from getting infected with the virus. The strategy was applied at Wuhan,1 during the beginning of the pandemic, with success, and the whole world followed. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread faster. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings.
The infectiousness of a disease is determined by the ability of the primary case to cause secondary cases in a susceptible population. It is based on Susceptibility – Infectivity-Recovery/Death (SIR) model and is quantified by the reproductive number (R0). The R0 is dependent on the proportion of susceptible population in a given cohort and its density and reduces with decongestion.2 The initial R0 for SARS CoV 2 at Diamond Princess, a cruise ship with close environment, was 14.8 and was lowered to 1.78 with disembarkation of passengers and prevented almost 2000 extra individuals from getting infected.3 In another example, Dharavi, world’s largest slum, with a population density of 2.27 lakh square km, has recorded around 2400 cases and 215 deaths since 01 Apr 2020. Inspite of the impossible social distancing, common public toilets and inadequate health care system, authorities have pulled off a miracle by ‘chasing the virus’. The number of cases peaked in end May and presently has fallen sharply. The public health system was strengthened by the authorities and extensive contact tracing (24 contacts for each case) and aggressive testing were carried out. Quarantine facilities were created near-by and mild and moderate patients were shifted there. Severe cases were admitted to make - shift hospitals, thereby decongesting the containment zones inside.4 The Dharavi model has been emulated in other densely populated areas with increasing success.
Contact tracing data have found the contacts to be located mostly near the cases and did not spread to the rest of the population in the 2.2 square km slum area. Moreover, such transmission zones are comprised of only asymptomatic, mild or moderate cases, who have low viral load. High level of infectiousness in clusters of close quarters of susceptible hosts explains droplet and short distance aerosol transmission as has been endorsed by World Health Organisation (WHO) in their recent statement.5 In the hospital setting however, high viral load in severely symptomatic patients and aerosol generating procedures may be accompanied by airborne transmission. This has been emphasised by several studies and endorsed by WHO.5 A negative air pressure isolation facility alongwith HEPA filters and UV lights in hospitals is an essential requirement for robust infection control in airborne diseases.
Future control and mitigating measures of building healthy residences and hospitals with proper ventilation, enough exhausts in bathrooms, multiple air exchange air conditioning system and negative pressure isolation wards should accordingly be undertaken.
References
1. Prem K, Liu Y, Russell TW, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study [published correction appears in Lancet Public Health. 2020 May;5(5):e260]. Lancet Public Health. 2020;5(5):e261-e270.
2. JK Aronson, Jon Brassey, KR Nahtani. When will it be over? An introduction to viral reproduction numbers (R0 and Re). Available at https://www.cebm.net/covid-19/when-will-it-be-over-an-introduction-to-vi.... Accessed on 14 Jun 2020.
3. Zhang S, Diao M, Yu W, Pei L, Lin Z, Chen D. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: A data-driven analysis. Int J Infect Dis. 2020;93:201‐204.
4. World Health Organisation. Transmission of SARS-CoV-2: implications for infection prevention precautions. https://www.who.int/news-room/commentaries/detail/transmission-of-sars-c.... Accessed on 11 Jul 2020.
5. Coronavirus: What is the Dharavi model being praised by WHO chief Tedros Adhanom. Available at https://www.indiatoday.in/india/story/what-is-the-dharavi-model-being-pr.... Accessed on 11 Jul 2020
Competing interests: No competing interests
Dear Editor,
The need for speed and local capacity to use relevant information available in an appropriate form emerges yet again with the Leicester covid-19 lockdown pandemic1.. The lockdown continues to expose even wider and still neglected policy failings along with inadequate national, regional and local capacity relating to information, surveillance and inspection of workplaces. This is important in controlling SARS-CoV-2 and dealing with clusters yet the UK Health and Safety Executive (HSE) was almost entirely absent from UK Government press briefings at the height of the pandemic.
Several months ago, the high-risk categorisation of manufacturing workers as well as meat and poultry industry workers exposed to SARS-CoV-2, was flagged and information from a six nation Asian study identified how vulnerable such workers were to covid-19 2,3. In addition, much evidence has been presented about the greater vulnerability to the virus of BAME workers, those experiencing the highest levels of socio-economic deprivation, and those exposed to higher levels of air pollution both where they live and through occupational exposure to dust, fumes and gases. In the textile industry workforce in cities like Leicester, all the above factors frequently applied4. The pandemic there is running alongside multiple syndemics including ones created by occupational ill-health with entirely foreseeable consequences in terms of morbidity and mortality5.
This information should have informed regulatory planning and action at a very early stage of the pandemic in UK workplaces where such workers were known to be employed. It apparently did not. It should have been integrated into ‘local capacity’ leading to earlier precautionary interventions as well as the later reactive ones during the Leicester lockdown. It did not. The HSE has been weakened in terms of policy, inspections, enforcement and staff over decades of cuts and, in many respects, went missing during the pandemic. According to a recent House of Commons Work and Pensions Select Committee covid-19 report, HSE received thousands of contacts from people concerned about safety at work during the pandemic. The Committee recommended HSE look at how it could improve its reporting detail and transparency “to send a clear message to the public that raising concerns with HSE does result in action against employers where necessary”6. HSE issued only one ‘covid-19’ improvement notice across all sectors by late June and required no employer to close. HSE did not inspect a single care home for example between 10 March and late June 2020. This is remarkable because HSE was advising employers and workers about PPE needed to work safely yet its own staff felt so unsafe they did not apparently visit key workplaces during the height of the pandemic.
The occupationally-caused and occupationally-related covid-19 cases in the UK show, as illustrated by the latest Leicester lockdown, that fully staffed and resourced regulators with necessary powers need to move much more quickly and effectively both before and during a pandemic to improve workplace health and safety. Prevention of future pandemics will also require much better workplace sick pay and support schemes as well as urgent actions on low pay, long hours, night working and welfare conditions.
References
1. Gill M, Sridhar D, Godlee F. Lessons from Leicester: a covid-19 testing system that’s not fit for purpose. BMJ 2020;370:m2690doi:10.1136/bmj.m2690
2. Landrigan P. 24th Collegium Ramazzini Statement: Prevention of Work-Related Infection in the COVID-19 Pandemic. Published online ahead of print, May 19. J Occup Environ Med. 2020;10.1097/JOM.0000000000001916. doi:10.1097/JOM.0000000000001916
3. Lan FY, Wei CF, Hsu YT, Christiani DC, Kales S. Work-related COVID-19 transmission in six Asian countries/areas: A follow-up study. PLoS One. 2020;15(5):e0233588. Published May 19. doi:10.1371/journal.pone.0233588
4. Bland A. Leicester factory put lives at risk during lockdown, claims garment worker. Guardian 11 July 2020. https://www.theguardian.com/uk-news/2020/jul/11/leicester-factory-put-li...
5. Marmot M. Challenging health inequalities—implications for the workplace. Occupational Medicine 2010; 60(3), 162-164.
6. UK DWP Select Committee report on the coronavirus outbreak. The Health and Safety Executive. The Health and Safety Executive and the coronavirus pandemic. 22nd June 2020 https://publications.parliament.uk/pa/cm5801/cmselect/cmworpen/178/17814...
Competing interests: No competing interests
The title, 'Moving Quickly in Pandemics', possesses a terrible ironic ring about it.
The awful reality is a NHS that has moved too slowly.
Another problem has been mixed messages.
Lockdown was late, and remains partial. A few weeks ago, people were being told to 'stay at home'. Now they are being allowed to travel abroad for 'holidays' on packed planes to sunbathe on crammed beaches. For the moment, all countries are making a mockery of their lockdowns if they do not stop the international travel that produced an instant pandemic.
Politicians and medical officers who lectured us on coronavirus uniformly were stricken with it themselves.
Face masks were initially dismissed as irrelevant. Now we cannot go into the open without them.
There are echoes of a poisonous farce about this whole Covid crisis.
Let us, the same as Florence Nightingale, examine the statistics.
Britain has the third highest death toll in the world.
Britain has the highest death toll in Europe.
Britain has the second highest death rate in the world.
Britain's death toll and death rate are much higher than in so-called Third World Countries such as Pakistan and Columbia.
This pandemic has revealed the catastrophic inadequacy that defines the NHS.
References:
News Coronavirus. World Update. Pg.15.
Competing interests: No competing interests
Re: Moving quickly in pandemics
Dear Editor
Deployment to Covid19 wards is often regarded as a diversion from the curricula learning of final year undergraduate, Foundation and Specialty trainees. But it may have been an intense period of immersive, hands on clinical learning that not only met but often even exceeded the benchmarked Learning Goals of not only medical students and trainees but allied health care professions.
It would not be onerous or take long to identify the knowledge, skills and attitudes of the Covid19 ward experience and map them against the curricula and syllabi of the various stages and specialities of learning.
This would enable the 'signing off' of a range of competences for the present cohorts and identify a 'Covid19/Pandemic Curriculum' that unfortunately may need to become part of the core curriculum for future cohorts.
Yours faithfully,
Sue Roff
(formerly Scottish Lay member of Postgraduate Medical Training and Education Board 2005-2010, serving on its Curriculum and Assessment Committees. Currently Part Time Tutor, Centre for Medical Education, University of Dundee)
Competing interests: No competing interests