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Following the science? Early failures of test and trace

Following the science? Early failures of test and trace

A decision was taken in March to stop testing even those with symptoms. Was this based on science or lack of resources? Who in government argued for herd immunity over lockdown and on what basis – and was that goal ever really abandoned?

Should the UK have known better? Should it have done better?

Exercise Cygnus, a 2016 government simulation of a flu outbreak, was a warning sign. War-gaming a flu pandemic affecting up to half of the population and causing as many as 400,000 excess deaths, the UK was deemed to be underprepared.

“The lack of joint tactical level plans was evidenced when the scenario demand for services outstripped the capacity of local responders, in the areas of excess deaths, social care and the NHS.”

Exercise Cygnus Report, 2016

So should the government have performed better in 2020?

How did the UK, which by 2019 was judged the best-placed country in the world to rapidly clamp down on a pandemic, end up having one of the worst coronavirus death rates?

The wrong pandemic

The country had planned for an influenza pandemic in such detail that it refused to throw away these preparations in the face of a new challenge, Chris Cook reported for Tortoise in October.

One variant of this plan was to aggressively test people at borders to hold off the virus, as the UK successfully did with Sars in 2003. However, the UK’s 2011 Pandemic Preparedness Strategy concluded it would be “a waste of public health resources and capacity” to halt a new pathogen as flu would spread too quickly.

As a result, millions of people were flying into the UK without being tested as late as March, when the UK was already well into the first wave of the pandemic.

The variant of the plan that was implemented relied on the so-called FF100 process, based on monitoring and studying early cases. It is designed to slow the spread, not stop it.

“Containment strategies to prevent a [flu] pandemic spreading in the UK are unlikely to be effective as simultaneous, multiple importations would be expected.”

Pandemic influenza: Guidance for infection control in hospitals and primary care settings, 2007

This may have achieved some success early on, according to the Scientific Advisory Group for Emergencies (SAGE):

“The effectiveness of this contact tracing is not yet known. By reference to other infectious diseases it is probably preventing at least 30% of potential transmission from these cases.”

Recommendations on the continuing use of case-identification / contact-tracing / case and contact isolation (CCI) management, SAGE, February 2020

But the same document hinted at danger ahead:

“We recommend that a reasonable ceiling is to enhance current capability 10-fold [to 8,000 contact traces per day]; but also advise that any further provision above that level would probably not be justified.”

At this point, in February, the UK’s total contact tracing capacity amounted to 800 new contacts a week, equivalent to just five new infections. Once the proposed new capacity of 8,000 traces per week was breached, with no vaccine and no proven treatments, the official advice from SAGE was that there would be no further point in contact tracing.

“When there is sustained transmission in the UK, contact tracing will no longer be useful.”

Addendum to the eighth SAGE meeting on Covid-19, 18 February

On 12 March, the government announced that it would stop all community testing for Covid-19.

“By that stage, we were already in a situation where there was a big risk that we were missing cases in hospitals, we were not able to treat people and we were leaving people in ITUs without being diagnosed and so on. There were multiple things that the capacity had to be used for .”

Chris Whitty, Chief Medical Officer for England, oral evidence, 21 July

Testing failures and missing cases

By mid-March, the UK was able to test much less than more successful countries.

“Our key message is: test, test, test.”

Tedros Adhanom Ghebreyesus, WHO head, 16 March

“We have the best scientific labs in the world but we did not have the scale… My German counterpart, for instance, could call upon 100 testing labs ready and waiting when the crisis struck, thanks in large part to Roche, one of the biggest diagnostic companies in the world.”

Matt Hancock, Health Secretary, 2 April

Hancock failed to mention that many of the private laboratories used for testing in Germany were associated with medical facilities rather than with business. This in turn was partly a function of different levels of healthcare spending:

“You cannot just turn public health and the response to it on and off. You invest in it over many years… Frankly, since SARS 1, public health around the world, including in the UK, has been neglected.”

Jeremy Farrar, Director, Wellcome Trust, oral evidence, 21 July

In these crucial early weeks, the UK did not ramp up testing, focusing its resources on those taken to hospital.

“I urge people who think in view of what we’re saying about their potential symptoms that they should stay at home, not to call 111 but to use the internet for information if they can.”

Boris Johnson, Prime Minister, 11 March

“My sense, looking across Germany and the UK of why we have potentially suffered more, is that, first, people stayed away from the NHS when they were having minor to moderate symptoms instead of coming in immediately. Some of the places that kept their mortality quite low, like South Korea and Germany, immediately triaged at a very early stage.”

Devi Sridhar, Global Public Health chair, Edinburgh University, oral evidence, 21 July

The government was missing hundreds of thousands of cases – and spreaders of the virus.

Herd Immunity

The phrase “herd immunity” was first used publicly by officials as the first wave of infection approached its peak.

“There’s going to be a point, assuming the epidemic flows and grows as it will do, where you want to cocoon, to protect those at-risk groups so they don’t catch the disease. By the time they come out of their cocooning, herd immunity has been achieved in the rest of the population.”

David Halpern, CEO Behavioural Insights Team, 11 March

“Our aim is to try and reduce the peak, broaden the peak, not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity.

Patrick Vallance, Chief Scientific Adviser to the UK government, 13 March

The government denies it was ever planning for herd immunity, but a proposed computer simulation of the impact of “targeted herd immunity” was in an NHS planning document seen by the Guardian that emerged towards the end of March. The plan would have involved only isolating the most vulnerable people. And SAGE minutes from 13 March “noted that full suppression of the virus was not advisable because it could result in a second peak”. Any measures short of a substantial lockdown would have been a disaster for the NHS, according to the models of epidemiologist and former government advisor Neil Ferguson.

Too little too late?

On 2 April, two weeks after the end of the initial contact-tracing, the government released a mass testing strategy aiming for 100,000 tests a day by the end of that month.

On 17 April, a fortnight later, the health secretary announced government plans for a new national test-and-trace programme.

“The government said that it had not made basic decisions about a ‘test and trace’ programme, like whether it would run contact tracing at a local or national level.”

Sarah Nickson, Institute for Government researcher, September 2020

In practice, testing capacity did not increase significantly until May.

By the time the test-and-trace system was up and running, nearly 40,000 people had died.

By October, the new test-and-trace system was on the verge of collapse after failing to contact nearly 250,000 people, or 40 per cent of contacts, over a four-month period.