July 3, 2020
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Getting back on track: fighting Covid-19 outbreaks in the community

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  1. Peter Roderick, Researcher1,
  2. Alison McFarlaneProfessor2
  3. Allison M PollockProfessor1
  1. 1Institute for Health Sciences, University of Newcastle, Newcastle upon Tyne, UK

  2. 2School of Health Sciences, City, University of London, London, UK
  1. Compliance: R Roderick peter.roderick {} on newcastle.ac.uk

Peter Roderick, Alison McFarlane and Allison M Pollock argue that there’s still time to change the tactics of using a special UK system to track, test and track contacts covid-19

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Historically, the English system of combating infectious diseases was based on close collaboration between local health services and the authorities. The key role is played by general practitioners, health services and health care providers, as well as local public health officials, backed by legal notice requirements.

This local system has gradually collapsed over several decades. (box 1) But instead of setting priorities and rebuilding this system at the beginning of this epidemic, the government has created a separate system that distracts patients from general practitioners, avoids local authorities and relies on commercial companies and laboratories to track, test and link the trail. The special parallel system in England consists of three components:

Box 1

Erosion of Local Communicable Disease Control in England

At its peak, the fight against local infectious diseases was supported by more than 60 national, regional and local public health laboratories. Service was strengthened from 1977 to 2002 by the establishment of the Colindale Infectious Disease Surveillance Center.

Erosion began after the reorganization of the State Health Service in 1974 and continued when the Council for Serving Public Health Laboratories was abolished in 2003, and its local laboratories were transferred to the trust management of the NHS, while the control of infectious diseases was centralized in the Agency for health protection.

In 2012, the Health and Social Assistance Act abolished local governments in England and excluded public health functions from the National Health Service. England’s public health service was created as an executive body to fulfill its government responsibility to protect people from disease, with only nine laboratories and eight regional centers. Local authorities have been accused of improving public health. Each local government, acting in conjunction with the secretary of state, had to appoint a director of public health to be responsible for performing the functions of a public health authority.

BACK TO TEXT

  • The Covid-19 Primary Care Program, which until May 29, 2020 did not include information on the need to notify local authorities of suspected cases

  • A central testing program that relies heavily on private companies

  • A centralized contact tracking system that uses commercial call centers and can use the mobile phone application in the future.

We wonder why the government created this special parallel system when a simple, albeit weakened, system already existed. In addition, we are concerned about the obvious flaws of this parallel system. The notification system (table 1) was apparently not handled right from the start, and as a result, many suspicious cases will be missed. Outsourcing private testing services received the bulk of public business without clear public health standards. There is also no clarity as to where the results are sent.

Table 1

Summary of legal requirements for notification of diseases to be notified in England, Scotland, Wales and Northern Ireland

Suspected Case Notification

SARS-CoV-2 was declared a serious and immediate threat to public health on February 10, 20201, but covid-19 was added to the list of diseases to be notified only on March 5. From the very beginning, the notification system was inadequate.

The NHS 111 covid-19 call centers were urgently created. Patients with symptoms were advised to stay at home and not contact their therapists or NHS 111 at the beginning of 3, and then contact NHS 111 online. This would prevent prompt reporting of suspected cases. The Covid-19 Clinical Evaluation Service was also established to receive and possibly reclassify referrals after the NHS 111 hexadecimal, using retired general practitioners and local or session doctors instead of general practitioners. It is not known whether registered health workers working for NHS 111 or the evaluation service have notified any suspected cases.

NHS4 management did not warn general practitioners of the need to inform local authorities of suspected cases. He advised GPs to inform Public Health England (PHE) of symptomatic cases, and then only under certain conditions or in unusual cases. The manual also mistakenly implies that the requirements for diseases to be registered only apply to confirmed cases. These flaws were only partially corrected in the new manual of May 29, 2020. PHE management erroneously implies that local authorities should not be notified of suspicious cases.

Centralized and commercial tests

A public health approach to testing requires a clear goal, systematic delivery and data flows, informed participation, quality assurance, fairness and ethical control to build trust. Decisions must be protected from political and commercial interference 7. The test program announced by the government on April 4, 2020, with its “five pillars,” lags far behind what is required.

Instead of focusing on building capacity in PHE and NHS laboratories that report PHE results through their second generation surveillance system, the government has identified these laboratories as “pillar 1” for people with clinical needs and health and healthcare workers and has created a separate, centralized and commercially reasonable “Pillar 2” for a wider population.

The daily number of tests for component 1 has leveled off, and the number of tests for component 2 now generally exceeds the number of tests for component 1.9. These include personal tests that are counted when samples are taken at test stations in about 50 regional locations and mobile test units. controlled by the army. Test kits sent to people at home and elsewhere are taken into account when sending10, and it is not known how many of them are actually used. The numbers have risen sharply in some cases, when the government tried to achieve the set goals for testing.

The president of the Institute of Biomedical Sciences has called the creation of this new complementary structure “perverse,” competing with and freezing NHS laboratories.

Support 2 is based on contracts with commercial companies. Very few appear on the government contract search website. From the list of data handlers 13, which changed frequently, it is clear that testers at regional sites are provided by Sodexo and Boots; some sites are run by Deloitte. Serco, G4S and Levy provide facility management. Randox provides home test kits for which Amazon provides logistics.

Second-level samples are analyzed by four new “lighthouse laboratories” involving AstraZeneca and GlaxoSmithKline (Box 2), although both claim that “diagnostic testing is not part of any company’s core business”. 1516 Randox analyzes samples from his home. test sets with a contract of £ 133 million (€ 150 million; $ 165 million) .17 This is comparable to £ 86.9 million provided by PHE for infectious diseases, surveillance and outbreak control in 2018-1918 years. to be sent to the USA for analysis due to lack of capacity, but 29,500 results were invalidated and need to be redone. nineteen

Box 2

Beacon Laboratories14

  • Milton Keynes– Managed by UK Biocentre, the largest UK company for the storage and processing of biological samples. It is a trading unit of the charitable British Biobank.

  • Alderley Park This is a science campus with a dedicated covid-19 analysis lab led by Medicines Discovery Catapult, which was founded as a limited company with the support of Innovate UK to support pharmaceutical companies, contract research organizations, and health care diagnostic companies. sector

  • Glasgow-The laboratory is led by the University of Glasgow at Queen Elizabeth City University Hospital. He is supported by the Scottish government, BioAscent Discovery (a comprehensive drug detection service provider) and Dundee University

Cambridgecollaboration between AstraZeneca, GSK and the laboratory of Anne McLaren of the University of Cambridge

BACK TO TEXT

According to the government, 13 non-Randox test results are sent to the National Pathology Exchange (NPEx), hosted by Calderdale and the Huddersfield NHS Foundation Trust. NPEx associates them with registration for testing and passes the results to NHS Digital and the NHS Business Services Authority, which sends the results to those who have passed the test. The government also states that Palantir analyzes anonymous data.

The strategy has three more pillars. Pillar 3 – Mass Antibody Testing. Pillar 4 is a serological and smear testing program for national surveillance supported by PHE, the Office of National Statistics, the UK Biobank, universities and other partners. The aim of Pillar 5 is to create the British diagnostic industry with the short-term goal of supplying other supports.

Feedback on the results

It is not clear what happens to many of the test results, in particular whether they return to the doctors of individual patients. It is reported that several hundred thousand tests were not related to NHS records, skipping confirmed cases. 20 There is also no indication of whether the results are provided to employees performing local contract tracking. It is reported that the chief medical officer of England apologized to the local authorities for the lack of detailed test data conducted by Deloitte21. It is unclear whether the PHE has timely access to test results.

Additional problems have arisen in connection with the reporting of the number of tests and results in national statistics, which caused two letters to the Secretary of State for Health and Social Affairs from David Norgrow, chairman of the UK Statistical Office. 223 The second suggested that statistics allow understanding of the epidemic and help manage the testing program, but indicate that “statistics and analysis are not good” and that the main goal seems to be to get as much as possible tests.

Centralized and commercial contact tracking

Contact tracing is a local activity. Local authorities know their community, and it takes feet to the ground to search. But the tracking program announced by the Secretary of State on April 23, 2020, 24 is centralized using call centers managed by Serco and other companies, with thousands of newly recruited call handlers. Perhaps the program will not be fully operational until September 25th. The NHS Covid-19 app, which was touted as a key to contact tracing, was abandoned.

It is not clear how the contact tracking program will work, as outbreak plans have not yet been developed. Government guidelines do not mention general practitioners or local health directors26. It is not known whether suspicious cases will be reported, and to whom. Inefficiencies, data quality problems, difficulties accessing local data and unnecessary costs are inevitable.

Data such as full postal codes, as well as the age and sex of suspected and confirmed cases, are important for monitoring outbreaks in the local government area and identifying clusters. However, local governments do not have direct access to this information and instead send aggregated data. This approach, coupled with refusals to require notification of suspicious cases and community testing, made monitoring the outbreak even more difficult. Instead of restoring local data streams, the government is trying to establish a population surveillance system through the new Joint Biosafety Center27. The center will receive data from numerous sources, including NHS data, through the NHSX covid-19 data warehouse reference library portal. Over 50 datasets are integrated and harmonized by private data companies Palantir and Faculty to create a “single source of truth.” 28

Make it work

Immediate steps must be taken to ensure that registered NHS 111 practitioners, covid-19 assessment services and general practitioners notify local authorities of suspected cases. Outbreak management plans should put local public health directors under the control of contact tracking, coordinated, not led by PHE. The NHS 111 covid-19 call center capabilities and assessment services should be immediately reintegrated into primary care and the methods dedicated to resuming care. The official guidelines for individuals with Covid-19 symptoms should be changed to refer them to a general practitioner or NHS 111.

These steps, however, are corrective. They are not a consistent and adequate public health response to the epidemic in England. This response requires that local authorities, NHS, and PHE laboratories have sufficient resources to take the lead in contact tracing and testing, as well as common practices to ensure patient support with central coordination. Parliament has empowered the Secretary of State to make this happen, and we urge him to use them.

In the longer term, the government’s terrible reaction to the epidemic has underscored the need for legislation to restore and reintegrate a strong local system for communicable disease control.

Key messages

  • England’s local infectious disease control system has been destroyed for several decades

  • In response to Covid-19, the government created a parallel system that distracts patients from general practitioners and relies on commercial companies to test and track contacts.

  • Many suspicious cases will be skipped due to improper handling of the notification system.

  • NHV 111 Covid-19 Call Centers and the Covid-19 Clinical Evaluation Service should be immediately reintegrated into primary care and into methods dedicated to resuming care.

  • Contact tracking and testing should be carried out by local authorities and coordinated at the national level.

  • England must rebuild and reintegrate its local infectious disease system

Footnotes

  • Authors and sources: PR has more than 30 years of experience as a lawyer, co-authored the NHS Restoration Bill, and wrote a lot about the Health and Welfare Act. AMP has 30 years of public health policy research and NHS privatization and long-term care research. She is a member of the Independent SAGE; the views expressed here belong to her. AM is a perinatal epidemiologist and statistician with over 40 years of public health and public health policy research experience. PR researched regulations. All authors examined the operation of the notification system in practice and the testing program. AM and PR examined the history of the fight against local infectious diseases. PR wrote the first draft of the article, and all authors were involved in further development and editing. We are grateful for helpful discussions with several local public health practitioners and general practitioners during the preparation of this article.

  • Competing interests: We have read and understood BMJ’s policy regarding the declaration of interests, and we do not have the relevant interests to declare.

  • Провенанс и рецензирование: не заказано; внешне рецензируемый.

This article is made freely available for use in accordance with the terms and conditions of the BMJ website for the duration of the covid-19 pandemic or until the BMJ determines otherwise. You can use, download and print the article for any legal, non-commercial purposes (including extracting text and data), provided that all copyright and trademark notices are preserved.

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