Editorial
At the date of writing this editorial, there is now agreement amongst
experts that the first wave of the United Kingdom’s (UK) COVID-19
pandemic is in decline (1). The number of deaths reported each day is
now around 1% of the cumulative total and falling. In general, the
approach to predicting pandemic policy has been through a comparison of
inter-country performance in managing this crisis. While all countries
are paying a high price in economic slowdown and lives lost, the health
consequences in terms of cases and deaths have varied considerably.
Countries with lower relative mortality and infection numbers have shown
a more structured logical approach to pandemic management.
While there will be an inevitable public enquiry in due course around
the UK government’s response to the pandemic, there is a very real
urgency to learn lessons immediately given the pressure to reduce the
home confinement policy as soon as possible. While this is a challenging
time for policy makers, public health messaging is often emotive around
concepts such as ‘being at war’ with the virus, and other similar
statements. We propose that a more rational approach to moving forward
is required to avoid a second wave. Understanding this rational approach
can be found through an evaluation of not only how other countries are
approaching this challenge, but also from history.
We considered the consolidated latest mortality and test data (2) from
national sources, which provides a summary of current progress in
managing the pandemic. Using this data, we have explored the UK’s
performance against European neighbours and created a mortality ratio
for each of the major countries as the overall number of deaths against
the vulnerable group with age over 65 (3) (Figure 1). To show the
differences in disease management more clearly, we have grouped
countries into four equal-sized classes based on the total number of
reported tests as a percentage of the total population.
While there are some issues about the comparability of data across
countries (for example, due to different diagnostic and reporting
frameworks), this analysis demonstrates the wide variation in relative
mortality rates, with some being an order of magnitude lower compared to
others. This variation is likely to be due in part to differences in
levels of active intervention including testing, along with another
critical factor of active protection of vulnerable groups. The most
effective approach to achieving this is likely to involve a mix of
targeted testing, earlier case detection, isolation, and segregation
within the care environment. These factors are what seem to separate
effective pandemic management from less effective management.
There will no doubt be ample opportunity in due course to evaluate the
rights and wrongs of the wave 1 pandemic management but our concern is
how to ensure we are fully prepared for wave 2. An optimal solution
would, of course, be a vaccine. However, this is unlikely to be
available until next year (4), which leaves a large window in virus
terms for a new wave of infection. Optimising our approach early is
therefore critical.
An example from history which could inform this optimal approach is
where the science of epidemics began with the physician John Snow, who
identified in 1854 the source of a cholera outbreak in London, which
killed 616 people, to one water pump (5). He traced all victims’
movements back to a common factor as evidence that eventually led to the
offending water pump being decommissioned and the handle removed.
However, reminiscent of the events at the root of the current global
outbreak, government officials did not initially believe him and delayed
acting while people continued to die.
With more than 28,734 UK residents dead from this first wave (1) we must
learn the lessons not only from other countries but also from history.
Rather than speak of ‘war’, we need to speak of ‘water pumps’ and the
lessons learnt that success is gained from a careful methodical approach
whereby all cases are identified as exactly and early as possible, while
at the same time the more vulnerable amongst us are also identified and
protected.
Perhaps then we will reduce future waves of this virus and achieve some
form of, if not normality, stability for the economy and the NHS / Care
sectors. A disciplined rational approach as we describe will only serve
to enable a strong recovery across all sectors as we go forward to what
will be a different landscape in many ways from the world we knew.