With more than 146,000 people now dead from Covid-19 in the UK, it seems unthinkable that this scale of mortality and suffering – driven by an unseen, silent killer – could return in our lifetime.
But one year on from the anniversary of Britain’s first lockdown, at a time when many are reflecting upon what has been lost since the onset of this crisis, the threat of another pandemic remains high as ever – irrespective of the devastation wrought by coronavirus.
As globalisation, urbanisation and deforestation brings man and the dark side of nature into closer contact, the chances of infectious spillover continue to rise.
“We will see more outbreaks” in the years to come, warns Professor Sarah Gilbert, the scientist behind the Oxford vaccine.
Experts have told The Independent that now is the time to start preparing for the “next big one” and ensure future generations are better equipped to dealing with these outbreaks.
“My fear is that the perception and impressions, lessons people think they’ve learned during this pandemic, will subside quite quickly,” says Professor Christopher Dye, a former director of strategy at the WHO. “After this experience goes away, these could be forgotten. We cannot allow this to happen. We have to remember, learn and prepare.”
Heed ‘big lessons’ of test and trace
As the UK wrestled to stay on top of infections throughout last year, only 60 per cent of close contacts were regularly reached each week – well below the 80 per cent figure needed for effective test and trace system, according to Sage.
Building a new, centralised operation alongside Deloitte and Serco proved fatal. Experienced local health “teams have been underused during this pandemic, with very expensive private sector consultants being employed instead”, says Dr Michael Head, an expert in global health.
Having been starved of £800m in funding since 2012, Public Health England (PHE) had 300 tracers for the whole of England at the start of the crisis, which meant the agency was capable of processing only five new infections a week due to the network of close contacts linked to each case.
But instead of pumping money into existing health networks to scale up tracing teams and integrate university-based and NHS laboratories for testing, resources were channelled into a centralised network that was part-run by contractors will little experience of infection control.
“If a fraction of that was put into those structures that already exist, then of course that’d have been a better response to what we had with all the outsourcing,” says Professor Deenan Pillay, a virologist at University College London.
“Those are some of the big lessons” which need to be carried forward as part of future preparations, says Prof Dye, adding that it is “absolutely” vital that investments are made for sustaining local health networks and joining the dots between different features of test and trace.
“It needs to have the plans ready in place to scale up dramatically,” says Professor Gabriel Scally, a leading public health expert.
The tracing team in Leicester, which has struggled with high case rates all year round, provides some clues as to what the future might hold. On 14 July, the city took matters into its own hands and set up its own tracing system. It works alongside NHS test and trace, taking over local cases that the national system’s call centres struggle to reach, and tracking them down on the phone, or by visiting homes.
By November, this approach was reaching 90 per cent of close contacts. Jo Atkinson, a public health consultant at Leicester council, explains that it’s the small details which have made the difference. “We get better responses if people can see a call that’s coming from an 0116 number [Leicester’s dialling code]. They are more likely to answer it rather than one they don’t recognise,” she says.
As soon as cases are uploaded, which be done within 12 hours of a test, the team are able to start tracing on the same day, having previously waited 72 hours to access such data.
But despite this, there are early signs that the government hasn’t learnt its lessons. After the chancellor allocated an extra £15bn to the centralised test and trace service, it was announced that spending on critical local health services, which includes local tracing teams, will rise by just 1.4 per cent from next month.
‘Morale will be at an all-time low’
The burden of this pandemic has largely rested on the shoulders of our country’s healthcare workers, who have been pushed mentally and physically to the edge. It is yet to be seen whether the NHS will ever get the funding it requires to not only repair the damage done by coronavirus but also prepare for future outbreaks.
A report from the Institute for Public Policy Research (IPPR) has shown that a £12bn “booster shot” is needed to get the NHS and social care back on its feet. Research from Health Foundation has meanwhile projected that the NHS workforce gap will double over the next five years and exceed 475,000 staff by 2034. If these holes cannot be filled, the NHS will undoubtedly be overrun by any future disease that comes close to matching the threat of Covid-19.
Although Ucas reported a 32 per cent rise in applications to British nursing courses last autumn, health chiefs remain fearful of a huge “brain drain” among doctors at the end of the pandemic.
“Once we are through this I fear that morale will be at an all-time low and many will say enough is enough and either leave their role, retire early or go abroad,” says Dr David Wrigley, wellbeing lead at the British Medical Association. In the words of one frontline doctor, this “equates to a lot of future trouble for health services in this country”.
‘Reduce inequalities in health’
The tragedies that unfolded in the care home sector must not be repeated. “It was a serious error to let people leave hospital untested and go back into care homes” and one of Downing Street’s most “fundamental mistakes”, says Sir Mark Walport, a former government chief scientific adviser.
A report by the National Audit Office revealed that 25,000 untested people were moved from hospitals into care homes between mid-March and mid-April, potentially accelerating the spread of the virus among one of the UK’s most vulnerable groups.
The degree of protection required for this population was foreseen in Exercise Cygnus, the 2016 operation into the UK’s pandemic preparedness, but not acted upon. One scientific adviser to the government told The Independent that Downing Street was “distracted” from the threat posed to care homes during the first months of the crisis.
For now, more investment is needed to ensure adult social care workers – many of whom don’t earn the living wage – are properly paid and trained, says Sir Michael Marmot, an expert in health inequalities.
“These people, along with refuse and delivery drivers, supermarket workers, frontline NHS staff, they have kept society going,” says Sir Michael. “But no priorities were made into conditions they work in.” Many of those in social care face are part of the gig economy, he adds, and are therefore underpaid and face “appalling working demands”.
“We need a proper trained workforce for adult social care,” says Sir Michael, adding that there is a “good argument” for integrating the sector with the NHS and establishing a coordinated, connected “health and social care system” that can respond as one to the next pandemic.
Such inequalities need to be addressed throughout wider society, he continues. Those living in poverty and deprivation, in cramped households, unable to work from home, exposing themselves on a daily basis to risk, are among the hardest hit.
Making PPE in Britain is ‘highly desirable’
First established after the swine flu outbreak, Britain’s PPE stockpile was allowed to dwindle in the years prior to the pandemic. After £500m was spent on procuring equipment in 2009, by January of last year the stockpile had 10 per cent fewer respirators, 19 per cent fewer surgical masks and 28 per cent fewer needles and syringes.
Much of the remaining stock was out of date and visibly degraded, while gowns, visitors and body bags – vital equipment that Exercise Cygnus identified as a top priority to buy in 2016 – were simply unavailable.
Once Covid-19 hit, a frantic scramble to secure PPE followed, led by the “smoking ruin” that was the Department of Health and Social Care, as Dominic Cummings put it last week.
NHS insiders say that the global rush for masks and gloves led to confusion, miscommunication and panic within the DHSC’s rapidly assembled PPE channel, with civil servants – many of whom had no experience in procurement – racing to obtain whatever supplies they could, regardless of where they came from.
“Stockpiling is a sensible insurance policy, but gowns and masks do have a limited shelf-life, and so the UK needs to have a ready source of such materials in an emergency,” says Jimmy Whitworth, a professor of international public health.
Therefore, he says, “having domestic manufacturing capability is highly desirable” – something the government has committed to. Last September, it outlined its intention for 70 per cent of all PPE, excluding gloves, to be made within the UK by the end of 2020. It remains unclear if this target has been met.
But one NHS procurement source says: “They’ve already bought so much new PPE from abroad that, for now, only a small amount of future supplies will need to be manufactured by British companies. That’s how they get away with saying 70 per cent of PPE is made here by a certain date. The vast majority of stuff we’ve got in stock is from other countries.”
He points out while gloves make up the bulk of PPE circulated within Britain, there are no manufacturing capabilities within the country, with the majority of supplies provided from overseas. Once these items are taken into account, UK-based PPE makes up just over a quarter of the total supply.
Unless this changes, the UK may well find itself short of life-saving PPE in the eventuality of another major outbreak.
The vaccine rollout has been the greatest feature of the UK’s response. But such success should come as no surprise: the foundations were already in place via Britain’s annual flu programme, which is smoothly delivered every winter by GPs and nurses.
The real challenges have been in synthesising the vaccines, testing them and ramping up manufacturing capabilities. There was an assumption that such hurdles could not be overcome in the space of 10 months, yet all expectations have been firmly exceeded.
Such innovation has “really shown what we’re able to do well and do rapidly”, says Prof Gilbert. It’s vital, she argues, that this moment is capitalised on, that the processes and frameworks which fuelled the creation of her jab are maintained.
The technology behind her vaccine – 10 years in the making – is here to stay. Similar in design to the mRNA vaccines from Pfizer/Biontech and Moderna, the Oxford jab uses a modified adenovirus vector to transport genetic instructions into the body’s muscle cells, generating an immune response.
But this technology can be used to deliver all sorts of genetic coding which, in theory, could provide protection against a range of viruses and bacteria.
“Think of it as a plug-and-play vaccine,” says Professor Peter Horby, chair of the government’s New and Emerging Respiratory Virus Threats Advisory Group (Nervag). “We have clear proof of safety and immunogenicity of the backbone; you then plug in the pathogen that comes along.”
This formula, it’s hoped, will allow the UK and the rest of the world to produce the vaccines needed to rapidly respond to many of the infectious threats lurking out in the natural world. But Prof Gilbert and others are adamant that there is “definitely more work that needs to be done”.
Within Britain, the soon-to-open Vaccines Manufacturing Innovation Centre (VMIC) will help to increase and streamline the production of supplies. Had this facility been available last year, it would have cut two months off the time taken to inoculate participants in the final testing stage for the Oxford vaccine, Prof Gilbert believes. When it comes to the next global pandemic, she adds, every second will count.
However, even with the increased manufacturing capacity provided by VMIC, there is concern this still might not be enough. “We’re almost nowhere on manufacturing in the UK,” says Professor Adrian Hill, director of Oxford University’s Jenner Institute. “Have we got the capacity? No, probably by a factor of 10.
“We could lose hundreds of millions of people [in this situation],” Prof Hill says. “It’s like in the movies. That’s not fantasy. That could happen. How much do we spend on military defence? We need to spend money on biodefence and we can do this.”
Recovery trial and collaboration
On the therapeutics front, the success of the UK’s Recovery trial, which has been testing existing drugs for Covid-19, has demonstrated the value in integrating large, randomised clinical studies with the NHS.
Throughout the pandemic, thousands of hospitalised patients have been recruited into the trial, co-led by Prof Horby, allowing medics to seek out treatments for those severely infected with coronavirus. At one point, one in every six Covid-19 patients within UK hospitals was enrolled in the trial.
It showed both Tocilizumab and dexamethasone – two types of anti-inflammatory drugs – to be effective in reducing the risk of death among hospitalised patients. Other medicines, such as hydroxychloroquine, have been taken out of the equation. These findings have then been channelled immediately into NHS policy to further instruct and guide treatment strategies.
“What Recovery has done is enable drugs to be tested quickly and effectively almost as part as clinical care,” says Sir Mark. “I think that has been quite important, and hopefully it will set a template. There has been a degree of collaboration that doesn’t happen in peace time. Hopefully we can learn the lessons of that.”
Prof Horby hopes this “frictionless” approach and “easy” linkage of data can be carried forward and applied not just in the context of a future outbreak, but on a permanent basis for other chronic diseases. “It could be a real unique selling point for the UK,” he says.
However, UK Research and Innovation, the government’s funding body, has warned of a £120m hole in its budget – a shortfall that threatens to undermine overseas projects seeking to understand “how we can better mitigate against zoonotic diseases like Covid-19,” says Professor Melissa Leach, director at the Institute of Development Studies. “Successful responses to major global challenges are only possible through international collaboration.”
‘Humble in the face of nature’
Predicting what the next pathogen will look like is near-impossible. There is wide consensus that the influenza viruses hold the greatest pandemic potential, yet coronavirus has highlighted the dangers in fixating too much on the flu.
This was a mistake the UK made last February. Former health secretary Jeremy Hunt has admitted that the government had been “part of a groupthink that said that the primary way that you respond to a pandemic is [through] the flu pandemic playbook”, rather than immediately adopting the measures needed for Sars and Mers, as much of Asia did.
“Learning from past pandemic responses is an important part of preparing for the next pandemic,” says Dr Claas Kirchhelle, a medicines expert at University College Dublin. “But focusing too narrowly on familiar pathogens, like influenza, risks reducing speed and flexibility when dealing with a novel pathogen.”
For Prof Horby, a “broad perspective” to all threats is needed. “And you need to be prepared for what you don’t know too,” he adds.
Zika virus, carried by the Aedes aegypti mosquito, is the perfect example of a pathogen that few experts predicted. It spread to South America in 2015, later threatening the Rio Olympics, and was detected as far north as Florida. When passed from an infected mother to her foetus, the virus can cause birth defects and neurological disorders in children, as has been widely recorded in Brazil.
“Nobody expected Zika virus and for it to go global in the way it did, as fast as it did,” says Prof Dye, who was involved in the WHO’s response. “The implication of this episode is we need to be very broad minded about what might happen.”
As global temperatures warm, the distribution of the mosquito could shift northward as parts of the world become more tropical in climate. There had been discussion of Zika reaching southern Europe during the 2015-16 epidemic, and although this never materialised, the picture could change if conditions allow for it. The same goes for Malaria, another mosquito-borne disease.
Ultimately, the best approach to both predicting and responding to future outbreaks, says Sir Mark, is to “remain humble in the face of nature”.
“The forces of nature are substantial and always do win,” he adds. “In principle will we have learnt a lot of lessons from the past year and taken great scientific steps forward … but we mustn’t be triumphalist. This isn’t us conquering infection. We will never do that completely.”