Coronavirus pandemic: How will Britain and the NHS cope
It looks increasingly likely that the coronavirus outbreak which started in China in December will become a global pandemic.
The disease is now spreading rapidly in South Korea, Italy and Iran and is likely to be present but as yet undetected in other populous countries across Asia and the Pacific.
In several countries, including Italy, there is no obvious direct link back to China, which makes containing the spread of virus all the more difficult.
Critics will say the lockdown imposed by the authorities on Wuhan and much of central China has not worked and that the World Health Organization's (WHO) strategy of containment has failed.
But there is little doubt China's crackdown has delayed the spread of the virus and bought the rest of the world considerable additional time to prepare.
The key question now, as the virus gains territory, is whether the NHS and other health authorities around the world have used that time wisely.
Here are some of the key things to expect if Covid-19 does now do a lap of the world.
If containment does not work, what’s the plan?
Mitigation follows containment in the public health response to major new outbreaks. While containment strategies aim to stop or hold back a disease, the goal of mitigation is to reduce its impact on society.
“The ultimate goal of [mitigation] measures is to reduce the intensity of an outbreak, flattening out the epidemic curve and therefore reducing strain on the health system, and on social economic well-being,” says Dr Josh Michaud, an associate director for global health policy at the Kaiser Family Foundation.
In simple terms planners will try to prevent sharp spikes in case numbers so the NHS and other services do not become overwhelmed.
What does that mean for the UK?
Mitigation efforts in the UK will be driven by the UK Influenza Pandemic Preparedness Strategy 2011 and fall into four main areas:
Encouraging individual behaviour change - hand washing, staying at home if unwell, looking out for neighbours and relatives.
Social distancing - encouragement of home working, discouraging public gatherings, possible school closures, international travel restrictions, online medical consultation and testing
Environmental hygiene - cleaning and spraying public surfaces, stepping up checks on restaurants and takeaways, ensuring good funeral practices
Building medical capacity - stockpiling of protective equipment and drugs, limiting non-essential hospital visits and operations, developing effective treatments and vaccines
What about quarantines?
Quarantines are about containment but expect to see such strategies run alongside mitigation measures if health authorities think they will buy more time.
Italy, for instance, has followed China’s example and placed more than 50,000 people under quarantine in a series of villages in the north of the country.
The recently updated Public Health (Control of Disease) Act 1984 affords the government similar powers here but whether they will be used is a moot point and is likely to hinge on the exact circumstances.
The Prime Minister's official spokesman knocked the ball into the Department of Health’s court on Monday saying: "We will be led by the advice from public health and medical experts and will take steps which they feel are required to best protect the British public."
Public health officials would have to balance the impact of quarantines on people’s freedom with the wider impact on public health. They must also get approval from a local justice of the peace.
While it is conceivable that quarantines could be placed on containable UK communities should an outbreak occur, large-scale quarantines or curfews seem unlikely unless the virus becomes more severe. Any action would have to be judged proportionate.
So how severe is the virus?
This remains the million dollar question. In Wuhan - the epicentre of the Covid-19 outbreak - the current death rate is between two and four per cent but is around 0.7 per cent in the rest of China and the world, says WHO. If it falls as low as the 0.026 per cent death rate for swine flu in 2009, it should be manageable even if it spreads throughout the UK.
But even with the extra time China’s shutdown has bought, experts are still far from sure about the clinical severity of the disease or how to treat it. The virus is more likely to affect the elderly and those with underlying health conditions. However, a not insignificant number of healthy young people have died too - and this is worrying doctors around the world.
Writing in the Journal of the American Medical Association doctors in Singapore, where there have been 89 cases of the disease to date, say the coronavirus presents in a similar way to severe acute respiratory syndrome (Sars), although is much less lethal.
The virus attacks the lungs with the disease progressing in distinct phases. CT scans of the lungs scans show “ground-glass” opacity and then “crazy paving” patterns, as they fill with mucus making it harder to breathe.
“An interesting pattern is emerging in reports from China”, says Azra Ghani, professor of infectious disease epidemiology at Imperial College, London. “After the first week of infection there is a tipping point - where some patients go downhill but others remain more stable and then recover.”
What kills many patients is their own immune system going into overdrive, triggering septic shock. This is the body’s inflammatory response to microbial infection and it can lead to organ failure and death. Older people and those with underlying conditions are more vulnerable but the young are not immune.
“What’s different with this disease is that it’s a new virus and therefore the whole population is potentially susceptible. Everyone is immunologically naive and no one has been exposed to it before,” says Prof Ghani.
How many people might need hospital treatment?
It is not just the overall death rates that doctors and public health planners are worried about.
In China a study of the first 44,000 cases published last week by the country’s health authority found that nearly 14 per cent were “severe”, requiring hospital treatment. A further five per cent were “critical” - that is, they had respiratory failure, septic shock and/or multiple organ failure and required intensive care.
Another issue is the duration of the disease. According to one study in China of hospitalised patients who recovered, their pneumonia took a full 10 days to peak. This suggests demand on hospital beds will be high - hence the rapid construction of new hospitals in China.
The average hospital stay in China for Covid-19 patients is between 11 and 26 days. But the recovery period can be long - up to six weeks for some of the most severe cases.
And while it is too early to say what the long-term prognosis is for those who recover from the disease, some of the patients who survived Sars did suffer long-term health effects such as lung damage.
Could the NHS cope if the virus gets a grip here?
This is another big question. If an outbreak in the UK can be delayed until the spring it would avoid the worst of the winter pressures - although many commentators say the NHS is now running at or close to capacity all year round.
The latest data from the NHS show that in the week ending February 16 average bed occupancy in the 132 NHS trusts in England was 94 per cent, with several hospitals reporting that they were at 100 per cent occupancy - that is, they had no free beds.
The ideal, say planners, is for hospitals to run at about 85 per cent occupancy to ensure there is enough slack in the system in case of a sudden surge in demand.
If a China-style outbreak were to occur the NHS would struggle to cope, says Jonathan Ball, professor of molecular virology at the University of Nottingham.
“As a population we have never seen this virus before and therefore none of us are immune to it. The attack rate will be quite high,” he said. “We know what happens with seasonal flu – the NHS cannot cope very well. So this could put further pressure on services”.
However, the government is more optimistic.
"We are well prepared for UK cases, we are using tried and tested procedures to prevent further spread and the NHS is extremely well prepared and used to managing infections,” said a Number 10 spokesman.
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