Fight COVID-19 while saving the global economy
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As the weeks of social distancing isolation accumulate, it may feel like we've been suffering through and fighting COVID-19 forever. But in actuality, just how far through this pandemic are we? Reported cases in Spain - a country with one of the highest current infection attack rates – are now around 0.5%. To reach herd immunity, either by infection or vaccination, we would need to get to a level of cumulative infection of around 65% or more. Clearly, reported cases reflect a lower than accurate figure - many mild cases have gone unreported, and we have no indication of how many asymptomatic infections have occurred. However, we seem far away from reaching herd immunity.
Lockdowns and social distancing have been the only two measures used widely by most governments. They vary in intensity from country to country but have been somewhat effective as weapons in humanity's arsenal against the virus. They've been enforced not just by law enforcement but also social pressure. Whilst their true levels of effectiveness have been the subject of scientific debate, they have often become popularly accepted as the core measure to slow the spread. However, social distancing lockdowns have severe economic consequences. What has resulted is a false choice: save lives or save the economy.
However, there are alternatives.
In fact, several measures currently being overlooked are more targeted in their focus and execution, and less disruptive economically and socially.
Social distancing and lockdowns are blunt instruments that require high levels of compliance by a large proportion of people to work. This compliance needs to be sustained for long enough to first slow the curve, then flatten it, and finally bend it down, leading to a decrease in the numbers of new cases. For many people, this has not only disrupted their lives but has also ruined their livelihoods. Charities like foodbanks are seeing unprecedented demand as unemployment rises. In addition, lockdowns and social distancing are likely to have negative psychological and even physical effects: Domestic abuse calls to police have increased, whilst mental health helplines have reported a surge in traffic. In addition, we are faced with cancellation of routine medical procedures, face-to-face GP appointments and hesitation to act when other medical needs arise.
If these measures were the only options at our disposal, and the alternative was a massive wave of deaths, with all the grief and suffering that would cause, then we may have to accept the consequences. However, there are targeted measures which are more focussed on individuals who are infectious, or we have reason to be believe are at high risk of being infectious.
First the epidemiological perspective: An average person needs to just infect more than one other person for there to be exponential growth in a communicable disease. Success in fighting spread is reliant on blocking enough onward infections so that the number of people with the disease is reduced and eventually the contagion is suppressed or even eradicated.
With that in mind, what are these targeted, effective measures? How can we slow spread without ruining the economy?
Identifying Infection Early
The first of these is testing, which many countries are scaling up to deal with the challenge. But testing on its own is not enough – it’s what testing helps to achieve that really matters.
Testing should be the immediate recourse for people that think they may be infected. Currently the guidance in most countries is to not to contact medical services unless you are becoming more seriously ill. Instead, if you think you are infected, you and others in your household are told to stay home and self-isolate for a certain number of days. That has to change.
If an individual develops symptoms like fever or a persistent dry cough, they should take action immediately. An effective public campaign should encourage people to self-identify and self-report, and we have the technology already available to enable this: the symptom tracker developed by Guys and St Thomas's Hospital in London is one example. Developed at the end of March, it was accessed overnight by almost 1.5 million people.
Immediately after self-identifying, individuals should contact health services, and ideally, also be offered a test as soon as possible. Many studies have now shown that households are a key location for spread of the virus – more so than schools, workplaces or other locations in the community. Merely leaving people at home, unsure of their infection status, and expecting them to take appropriate measures to protect others in their households is unrealistic. Not only are most people unsure of exactly what to do to prevent the spread of infection, but in particular, those who are uncertain will likely not follow stringent infection control practices.
In the scenario that tests are in short supply in the near future, a reasonable alternative is utilising clinical protocols for diagnosis, such as were used in China. These can be used to make determinations where disease status is clearly indicated one way or the other. Importantly, tests in China were reserved for individuals where there was less certainty. Clearly, above all, a responsive, well informed health system that can advise and take action is vital.
Home Quarantine: A misguided policy
So what currently happens if a person tests positive? In most countries, infected individuals are sent right back into their households with complicated rules about how to isolate from fellow householders and the general public. As mentioned earlier, households are one of the environments most suited to onward infection. It is estimated by the Office of National Statistics that in the UK only 15% of the population live in single person households, meaning a significant majority of the population would be self- isolating with someone else in proximity. Most people won't be completely sure what to do, even with some medical guidance, and human nature dictates that they will become less careful as time passes. The end result will be that in many households further infections will occur that might have been averted. One or two more householders infected make it much more likely that the virus will eventually spread beyond that household.
Quarantining infected people away from home should be the objective in as many cases as possible, but crucially, this policy should also be voluntary - compulsion to isolate separately from home may have the undesirable effect of discouraging testing. So far, people have proven, on the whole, quite willing to comply with some disruptive interventions for the sake of the greater good. Currently, hotels all over Europe are largely empty, and could be repurposed to house people quarantining away from home.
Contact tracing – an attempt to find individuals potentially infected before they notice symptoms and self-isolate – is also crucial in disrupting additional chains of onward infection. This coronavirus is well suited for contact tracing and it could be highly efficient, given that a person is at their most infectious probably from a day or two before symptoms emerge to a day or two after. Many contacts would be found before they have even reached a stage where they've become infectious. In China this was quite regularly the case. This requires a dedicated teams of contact tracers, but setting up this infrastructure is not an overly costly or difficult thing to achieve, especially as we currently have access to the right technology to make this relatively effective and efficient.
Using these targeted measures could substantially make a difference in quelling the spread of the virus. These actions would disrupt and terminate countless chains of infection, preventing its exponential growth. These measures need initial resources and effort, but the returns would be in multiples through healthcare needs and costs avoided, and the level of grief, loss and suffering averted. Add to that the reduced economic and social disruption, and it seems obvious to implement these measures. We are not facing a trade-off which tells us we can either save lives or save the economy, but never both. We can and we should save both.