Covid-19: England must aim for “zero tolerance” to avoid 27 000 predicted deaths, experts say
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2749 (Published 09 July 2020) Cite this as: BMJ 2020;370:m2749Read our latest coverage of the coronavirus pandemic
The UK government should take a “zero tolerance” approach to covid-19 to prevent thousands more deaths, a group of experts from across England, Scotland, Wales and Ireland have warned.1
The panel, which included members from the Independent Scientific Advisory Group for Emergencies (iSAGE), the former health secretary for England, Jeremy Hunt, and advisers from across the nations, met to discuss a covid-19 elimination strategy. They raised concerns over the number of covid-19 deaths occurring in England and the government’s lack of a policy to reduce deaths.2
The call came after England’s chief medical officer, Chris Whitty, said at the final Downing Street covid press conference on 23 June, “I would be surprised and delighted if we weren’t in this current situation through the winter and into next spring.”
Given that currently more than 100 people are dying each day, iSAGE estimated that this would mean around 27 000 deaths in England by March 2021, even without a second wave. “It is the view of Independent SAGE that a death toll from covid-19 of this magnitude is not only preventable but is absolutely unacceptable,” the group said. “The UK government must fundamentally change its approach.”
Recommendations
The group laid out its proposals in a paper that recommends that the government “replace their failing NHS Test and Trace system with a fully fledged and locally controlled system of Find, Test, Trace, Isolate, Support.”1 This would include providing “all the resources necessary to enable adherence to the regulations on notification of infectious disease.”
England’s NHS Test and Trace system, which is run centrally by private companies, with local public health teams handling the complex cases, has been criticised for missing potential cases, not reaching all the cases in the system, and not being transparent with data.3 Experts have also said that, instead of spending money to create a completely new central system, the government should have invested in local public health teams, especially as they do most of the tracing.4
However, Hunt said that while he has advocated for a localised approach he would not now tear down the centralised system. “I would like local authorities to have control of the testing in their areas, so they can integrate it better into the tracing programme,” he said. “If we are going to catch 2000 to 3000 people every day who are not being picked up by the test and trace system, I think you need some kind of mass testing system in the places that are most likely to have the highest levels of prevalence.”
The paper also recommended slowing down the easing of lockdown measures, restricting travel into, out of, and within the UK, and implementing “well designed and scientifically based plans” to quickly contain and suppress local flare ups.
It said, “Combine all these measures with a systematic public information campaign stressing that things are not ‘back to normal’ yet, that premature removal of restrictions in the midst of a deadly pandemic threatens to squander all the sacrifices of lockdown, and that strict compliance with restrictions now will make a full return to normality come sooner.”
Zero tolerance
During the panel discussion on 7 July Gabriel Scally, visiting professor of public health at the University of Bristol and a member of iSAGE, said, “Northern Ireland and Scotland are having days in a row without any deaths and a small number of positive cases. Wales had its first day of no deaths yesterday, and similarly their number of cases is falling. In England, however, the level of positive cases remains high, and the government strategy appears to be maintaining cases at their current level and dealing with any outbreaks. That is inadequate.” He added that iSAGE has “seen no evidence that the government has a considered strategy for the next stages of handling the pandemic [in England].”
Originally iSAGE had proposed aiming for a “zero covid UK,” but after the discussion members agreed that a “zero tolerance approach” would work better. Proposing this, the Scottish National Party health spokesperson Philippa Whitford, a breast surgeon and MP for Central Ayrshire, said, “[With zero covid UK] you’re kind of setting up to fail because you [still might have] one or two cases. Using zero tolerance for covid-19 means we are not accepting it and saying, ‘100 deaths a day is acceptable.’ It doesn’t mean no cases ever; it means absolute constant battle against the virus.”
Inequality and support
To achieve as few cases as possible, the experts emphasised the importance of ensuring that people were able to isolate themselves and follow covid-19 guidance, regardless of their background and circumstances.
“We need to think about this as an inequality issue,” said Vittal Katikireddi, member of iSAGE and the Scottish covid-19 advisory group. “We need to be getting the messaging right and reaching all communities in terms of knowing what they are expected to do, understanding the symptoms, and having the trust in the contact tracing systems to engage with them. I’m not sure we have met these challenges yet, but I think they will be essential.”
Whitford added, “It’s very hard for people to be asked to stop working, taking themselves out of society, isolating away from family. There are groups of people who have had no support in the last few months. We need to be certain that people will be supported to isolate . . . People need to know that if we ask them to stop working for two weeks, they will be able to feed their families.”