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The lost month: what happened in February?

The lost month: what happened in February?

Britain first went into national lockdown on 23 March. Italy’s lockdown started two weeks earlier. By that time images of overwhelmed Italian hospitals dominated the news in the UK. Italian doctors said they lacked ventilators, intensive care beds and protective equipment, and on 7 March three critical care specialists wrote to the European Society of Intensive Care Medicine with a simple message: “Get ready!”

Lockdown was imposed on Italy’s northern provinces on 8 March and extended nationwide the following day.

Was there time to prevent a similar spread of the virus in the UK? Were there signals that should have prompted action but did not? Why did the government wait?

When should alarm bells have rung?

Two months elapsed between the UK’s first COBRA meeting on Covid and its first national lockdown. In that time other European countries recorded their first cases of community transmission and first deaths. The global death toll passed 10,000 and the WHO declared Covid-19 a pandemic.

In the UK, the government advised against all but essential travel to mainland China. It declared the virus an imminent threat to public health and invoked powers to curb freedoms – but proved reluctant to use them.

What was the UK’s strategy?

The Government’s coronavirus action plan, published on 3 March 2020, had three phases:

  • “Contain: detect early cases, follow up close contacts, and prevent the disease taking hold in this country for as long as is reasonably possible.”
  • “Delay: slow the spread in this country, if it does take hold, lowering the peak impact and pushing it away from the winter season”
  • “Mitigate: provide the best care possible for people who become ill, support hospitals to maintain essential services and ensure ongoing support for people ill in the community to minimise the overall impact of the disease on society, public services and on the economy”

The plan was based on the government’s previous work on preparing for pandemic influenza and experience handling outbreaks of other infectious diseases.

Here’s how each phase played out:

Contain: 22 January – 12 March 2020

22 January
SAGE meeting on coronavirus. Advises against temperature checks at UK airports for arrivals from Wuhan because of the likelihood of high false positives and false negatives.

24 January
Government trying to track down 2,000 passengers recently arrived in the UK from Wuhan for testing.

29 January
Travellers returning to UK from Wuhan made to quarantine for 14 days.

2 February
Government issues hand-washing advice.

4 February
Advice to the government from the Scientific Pandemic Influenza Group on Modelling (SPIMO) says that it is “unclear” if isolation and contact tracing can contain the spread of the virus. If most asymptomatic cases are infectious such policies are “unlikely” to contain it, they advised. Additional documents state that once cases are widespread contact tracing is “not practical.”

11 February
SPIMO advises government that the “direct impact” of stopping mass gatherings on infection levels will be “low” and that stopping leisure activities would have a “much larger effect” on the spread.

13 FebruarY
SAGE meeting concludes that “neither travel restrictions within the UK nor prevention of mass gatherings would be effective in limiting transmission.”

14 February
Government advises people who have travelled through China, Hong Kong, Japan, Macau, Malaysia, Republic of Korea, Singapore, Taiwan and Thailand to self-isolate “as you would with the flu” if they develop Covid-19 symptoms. Self-isolation not made mandatory.

26 February
SAGE advises UK government that ceasing social contact outside home/school/workplace could reduce peak of infections by 50-60 per cent.

28 February
Boris Johnson offers his condolences after the first British national abroad dies from Covid-19; says the “best single piece of advice we can give” to prevent the spread is to “wash your hands for 20 seconds or more”.

3 March
Papers prepared for SAGE meeting on this date cite research from China which found that if interventions such as travel restrictions, school and business closures and the cancellation of social events had been applied three weeks earlier in China, case numbers would have been reduced by 95 per cent.

4 March
Government launches hand hygiene ad campaign.

Delay: 12-16 March

12 March
Government announces it is moving from “contain” to the “delay” phase of the outbreak to delay a peak in infections. UK’s community testing and contact tracing programme will end, and testing will take place in hospitals for people with severe symptoms only.All others with symptoms are asked to self-isolate.

Johnson says his government is considering banning large public events but that scientific evidence suggests that “banning such events will have little effect on the spread”.

Mitigate: 16 March – end lockdown

16 March
Paper presented to SAGE by Imperial College London shows that limiting Covid mitigation measures to social distancing of the elderly and self-isolation for infected households would lead to 250,000 deaths and to intensive care surge capacity being exceeded 8 times over.

UK bans gatherings of more than 1,000 people.

Elderly and vulnerable people are advised to begin shielding for 12 weeks from the weekend.

Johnson advises against all “non-essential contact with others” including in pubs, clubs and theatres and urges people to work from home if they can. 

18 March
Johnson says schools will close from Friday 20 March.Retired healthcare workers are asked to return to help the NHS.

20 March
Leisure venues advised to close.

23 March
UK lockdown announced.

What would have happened if the UK introduced mitigation measures sooner?

On 19 February the WHO’s daily situation report on the coronavirus highlighted research by Chinese researchers which showed the impact of the Wuhan travel ban on 23 January on transmission rates. Their models found that other mitigation measures were also necessary:

“According to these models, travel restrictions alone are projected to have only a modest effect on the progression of the outbreak; they would need to be combined with other public health interventions, such as early case isolation, other forms of mobility restrictions, social distancing and population-level behavioral changes to be effective.”

Days later, graphics from these reports were showing an exponential growth curve in transmission of the virus outside of China.

It was known from analysis of historical pandemics that early intervention is critical to prevent the spread of viruses. Comparisons of interventions by different US cities in the 1918 influenza pandemic show that introducing social distancing early prevented a peak in deaths:

Well-timed interventions were emphasised in high-level UK meetings. A SAGE document from 3 March 2020, produced by scientists at Imperial College London, said that:

“Timely implementation of control measures will have a greater impact on the COVID-19 epidemic.”

Evidence presented at this meeting also cited research which showed that if travel restrictions and social distancing had been introduced earlier in China, the number of cases would’ve been much smaller: 

And the number of cities affected by the virus – 308 – would have likewise been reduced:

Advice from the WHO at this time stressed the need to use a range of measures to contain the virus:

“Our message to countries continues to be: you must take a comprehensive approach. Not testing alone. Not contact tracing alone. Not quarantine alone. Not social distancing alone. Do it all.”

Dr Tedros Adhanom Ghebreyesus, 13 March 2020

Peer countries that locked down when they had fewer daily infections have seen lower overall death rates than the UK:

Only Belgium and Spain had higher rates of daily infection than the UK at the point they went into lockdown.