The Westminster government has announced the reopening of more venues, the end of shielding for vulnerable individuals and the reduction of the safe distance from two metres to ‘one metre plus’. Are these the right measures and is this the right time?
A recently published study (The Lancet, 1st June 2020) has shown that reducing the distance from two metres to one will double the risk. The risk is relatively small in each individual exposure, but the overall risk across the country is still significant.
Reducing the minimum safe distance may help to restart the economy, but it will require counterbalancing measures such as the generalised use of face masks. Both the World Health Organisation (WHO) and the US Centres for Disease Control and Prevention (CDC) endorse the use of face coverings in the community. This is how the lockdown exit risk is managed in Italy: one-metre distance but compulsory use of masks inside shops and other enclosed spaces.
Why has the Westminster government been so late in recommending the use of face masks and made it mandatory only on public transport?
When the Covid-19 outbreak started there was evidence of the benefit of masks from mechanistic models, but no studies had yet been done with this new virus. However, as Coronavirus was known to be transmitted via respiratory droplets, masks were recommended for all healthcare workers. Absence of evidence is not evidence of absence (of a protective effect) and both The Lancet (16th April) and the British Medical Journal (25th April) advocated the use of face coverings in the community. This recommendation was based on the precautionary principle and some evidence from Influenza studies.
Better evidence is now available. A study published in BMJ Global Health (28th May) showed that wearing masks reduces the risk of Coronavirus transmission in households, whereas the study in The Lancet, that showed an increased risk at a distance of one metre, also showed that wearing face masks gives a considerable degree of protection.
Face masks work in two ways: they protect those wearing them, although not completely, but they also significantly reduce the risk of transmission from those wearing them. The latter is important as transmission can occur from asymptomatic individuals.
A real problem with our Coronavirus rules is that they have been changed many times and are now so complex that many people no longer know for sure what is expected from them. Confusion has been compounded by cynicism. Hasn’t Dominic Cummings shown that the rules can be freely interpreted?
Testing anybody who has symptoms and tracing their contacts, if they have a positive test, is another critical control strategy. However, our Test and Trace is anything but world leading. Many symptomatic patients do not seek testing and some of those who test positive cannot be contacted. Compliance with the recommended period of self-isolation also seems to be poor.
The leader of the opposition asked this very question in parliament: why is Test and Trace reaching only a third of those estimated to have the infection?
Part of the problem is that Test and Trace has been set up in remote call centres with unqualified staff not working as part of a local public health teams. In Italy Test and Trace is a local service largely provided by nurses and doctors, so that those with the infection can get advice and support and are, therefore, more likely to be tracked down and to comply with the self-isolation requirements.
The delayed implementation of the lockdown has resulted in the UK having the largest number of deaths in Europe. We have repeated the same mistake by starting the lockdown exit too early when our infection and death rate were higher than in other countries. It is safer to relax the lockdown rules when the risk of infection is lower.
A timely and carefully executed lockdown exit, that reduces the risk of a recrudescence, is the best safeguard for the economy.
Although the transmission of other respiratory viral infections is reduced during the Summer, the new Coronavirus has such a high transmission rate that further outbreaks are likely (as is currently the case in the USA) unless we keep in place adequate control measures. However, a significant second wave is more likely to occur in Autumn or Winter.
Public health bodies such as the European CDC have put emphasis on these two key messages: ‘This is a marathon, not a sprint’ and ‘We must not drop our guard’.
The choice we have is not between saving lives or saving the economy. During the influenza pandemic of 1918, the communities with more deaths also experienced greater damage to the economy. With coronavirus the damage to the economy seems to be more limited in countries that have taken more effective control measures, though it is too early for a definitive analysis. Death is bad for business.