How Britain lost track of the coronavirus PART TWO
By Stephen Grey, Andrew MacAskill, Ryan McNeill, Steve Stecklow and Tommy Wilkes
Sophie Grenville and her husband, Mark, who manage a country estate in the county of Hampshire, took matters into their own hands.
It was early March when the couple tested positive for the coronavirus. She described her experiences later in a journal she shared with Reuters called "A Diary of a Super Spreader." Her case illustrates the complexity and the slow pace of the early UK version of contact tracing.
The couple was tested for the virus after returning from a trip to Indonesia on Feb. 23. They developed what grew into a very distinctive, dry cough – like a fox or a deer barking – and reported it to the NHS helpline.
They waited three days for a test. All the while, she wrote in the diary, she and her husband were thinking of the hundreds of people they recently had come into contact with at social and business events, from "High Court judges to football chiefs."
Nurses in protective clothing visited their home on March 6 and took samples. The next day, they received the call with the positive test result, and later another call from an epidemiologist from Public Health England. Grenville said she was told the agency was only interested in people the couple had been in touch with when Grenville or her husband had recognizable symptoms.
At this point, Public Health England had been running a contact-tracing service for several weeks. When someone tested positive, they would get in touch and seek out potential contacts.
In response to questions from Reuters, Public Health England said it couldn't comment on individual cases, but, "We followed the contact-tracing guidance that was in place at the time. This guidance stated that contacts should be traced from the point of notification of symptoms. This has changed as the knowledge of the virus has grown." Public Health England and the World Health Organization now recommend tracing contacts from two days before the onset of symptoms.
Even by March, Public Health England's operation was under-resourced. Teams that usually dealt with food poisoning, measles or tuberculosis outbreaks had been drafted in.
According to two senior doctors who were directly involved, the Public Health England teams were asked to cover huge regions. They didn't have the manpower to conduct serious contact tracing for measles, let alone Covid-19.
Minutes of a February 18 meeting of the government's top scientific advisory committee, the Scientific Advisory Group for Emergencies (SAGE), revealed that nationally Public Health England could then handle only five new cases per week. A spokesman for Public Health England told Reuters that reflected the complex international nature of early cases.
Sophie Grenville said that in her case contact tracers reached out to just two people – two sons the couple had taken out for dinner the night they had developed slight coughs. She and her husband decided to do their own contact tracing, alerting many other people they had recently encountered.
"We were more upfront than we were advised we needed to be," Grenville said.
She recounted the chaotic scene in her diary: "All of Sunday we are making calls and discovering that all sorts of people we have seen have symptoms, some worse than others, and plenty we have seen are also completely fine.
Everyone in our circle is having to tell their workplaces about their exposure and they are all shutting down."
About 15 people the Grenvilles knew arranged to be tested, after reporting that they either had been in close contact with the couple or were exhibiting symptoms. Their farm manager tested positive, as well as a lady they had dropped in to see during the weekend, and two sons who had displayed no symptoms. Luckily, she said, none required hospitalization.
Meanwhile, the actual source of the outbreak remained a mystery, including to Public Health England, Sophie Grenville recalled. She and her husband originally had been able to get tested because on their return from Indonesia they had changed planes in Malaysia, which was considered an early hot spot. But their symptoms hadn't developed for more than a week.
That raised the possibility that they hadn't caught coronavirus in Southeast Asia, but in Britain. Scientists believe it takes up to 14 days to develop Covid-19 symptoms, but the average is four to five days.
Indeed, on March 5, the government was told by SAGE that transmission in the community was underway. Five days later, the committee heard the UK "likely has thousands of cases – as many as 5,000 to 10,000 – which are geographically spread nationally." That confirmed what many experts had suspected. Jason Strelitz, the director of public health in the east London borough of Newham, said from the end of February he began telling colleagues "time and time again" to be under no illusion: official figures for Covid-19 were "a massive underestimate."
Based on analysis of the wave of deaths in the weeks that followed, and applying standard methods developed by research epidemiologists, Reuters calculates that Britain only detected about 3% of all Covid-19 infections so far, including those with no symptoms.
This method may underestimate the rate of detection, however, when the epidemic spread into nursing homes and fatality rates were likely higher than average. Research by the London School of Hygiene and Tropical Medicine estimated the UK detected 18% of Covid-19 cases with clinical symptoms, compared to 43% in Germany.
But instead of ramping up testing and contact tracing across the country, the government brought the programme to a halt. On March 12, chief medical adviser Whitty announced from now on, "all of the testing capacity" would be pivoted to testing people in hospital with symptoms.
Anyone else who fell sick with suspected Covid-19 would have to cope – and advised not even to contact the health service unless their condition grew serious. And contact tracing was over in all but special cases, such as outbreaks in prisons or immigration centres.
For some who had spent their lives fighting disease, the decision to scale back contact tracing in the community came as a shock.
Among them was David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, one of the world's leading experts on infection control and a former chairman of Public Health England. He learned how to contact trace in 1976 when tracking the spread of smallpox in the slums of Kolkata, India.
He believes "modellers" — who use data and assumptions to predict a disease's spread — carried too much weight in decisions. And they appeared to have conditioned policymakers, he felt, to believe the virus could not be stopped. "I don't think any field epidemiologist would recommend to stop contact tracing in an outbreak."
Whitty, the government's most senior medical adviser, didn't comment.
Papers published by SAGE appear to support Heymann's suspicion that modelling scientists influenced the decision to stop routine contact tracing. SAGE's modelling committee said as early as February 3 that contact tracing "is not practical once there are large numbers of cases."
A further detailed study by three modellers from the University of Cambridge, Manchester University and Public Health England, submitted to SAGE on Feb. 12, argued that beyond a certain point in the outbreak, testing would be pointless. SAGE endorsed this paper on Feb. 18, according to published minutes, concluding that contact tracing would "no longer be useful" in the case of "sustained transmission" of the virus.
Some countries took a different approach. Just as Britain was shutting down its community tracing, Germany recruited an army of locally based contact tracers. In the southern city of Heidelberg and surrounding district of 800,000 people, local health director Rainer Schwertz told Reuters how by the second week of March, he had tripled the size of his department, recruiting 200 medical students to work on intensive tracing. By early June, just 38 people had died from Covid-19.
A Public Health England spokesman said that contact tracing "was never abandoned." But once there was clear evidence of widespread, sustained community transmission of Covid-19, it was clear that contact tracing "was unlikely to control the outbreak alone and so was targeted where it could be most effective during this phase." The agency did not respond to a request for data showing what tracing continued.
Public health directors, nursing home managers and NHS staff interviewed by Reuters said they were not aware of any further tracing by Public Health England until the programme was relaunched in June.
GOING IT ALONE
Tom Lewis, a consultant microbiologist at the Barnstaple hospital in north Devon, had spare capacity in his laboratory. He and his hospital team had tried in early April to offer testing for nursing home residents in the local community "because nobody else was doing anything." But senior NHS executives ordered his team "to back off. They said, this is not your job. This is a PHE job. So we said, 'fine.'"
The NHS didn't comment about the incident.
Local teams from Public Health England had done stellar tracing work in the early days of the outbreak, said Lewis. But then the "contract tracing stopped without really any warning and PHE then went very distant. I've had almost no contact with PHE since then."
He said the agency was "massively over-stretched" and it was unclear who was in charge.
This dysfunction was felt by some on the frontline. Roxanne Jenner-Ash, the manager of a Barnstaple nursing home, described a feeling of isolation at the height of the outbreak. "There was a point when no one wanted to support us," she said. Everyone – general practitioners, nurses and paramedics – all had different guidance and "everyone had different roles and opinions." At the same time, their residents were suffering: "You've got people who can't feel heat, they can't make sense of what's going on, they can't communicate that they're in pain."
After dealing with an outbreak in which nine residents died, Jenner-Ash was only sent swab kits to test her residents on May 9, when the infection had stopped spreading at the nursing home, at least for the time being.
But for Lewis the key thing was the absence of contact tracing – a real attempt to follow the spread of the virus, for example by interviewing and testing care workers who had been in contact with a Covid-positive patient, even if they had no symptoms.
Starting in early May, Lewis and his NHS colleagues decided to launch their own wider tracing scheme. They followed contacts who tested positive at the Barnstaple hospital with the help of a sexual health adviser employed by the trust, Joanne Hamilton. Hamilton's work on sexually transmitted diseases had made her an experienced contact tracer.
When another resident of her Pilton House nursing home tested positive in late May, this time, said Jenner-Ash, "I was no longer alone." Within a day of the test result, Lewis and Hamilton had arranged for the entire staff of Pilton House to be tested – an exercise that uncovered a staff member who was positive and could then isolate, possibly saving the lives of others. Since then, Pilton House has remained Covid free.
Reuters learned there were small, similar experiments repeated across the country, in the highlands of Scotland, in the Lake District, in Wales, and in Sheffield, in northern England.
Bing Jones, a retired doctor who specialised in haematology, was one of a group of six retired medics who set up the Sheffield project. He said the national decision to stop contact tracing was a "catastrophic decision" that has allowed the virus to travel largely unchecked across the United Kingdom and resulted in unnecessary deaths.
"It is complete ineptitude. It was such a basic mistake. It is one of the basic planks of managing an epidemic," he said. "There was no reason why you couldn't have kept it going on a small scale or doing whatever you could."
Working with local general practitioners from mid-April, the group found 13 people with coronavirus symptoms, who generated 58 contacts.
They concluded that health and care workers may have been unwittingly passing on the virus. Judy Stewart, one of the volunteers on the Sheffield programme, said she contacted five nurses, including some who worked at a nearby hospital, to advise them to self-isolate after they were named as being in close contact with someone who had recently tested positive for Covid-19. Stewart said the nurses told her they discussed the request with their managers, but they were advised to ignore the request and keep working.
"The resistance shocked me because of where it came from," she said. "I got lots of texts back saying: 'sorry I can't be involved, but good luck and it was nice talking to you.'"
Behind that resistance, some involved feared, was a concern among senior health service managers that too much testing and too much tracing of the contacts of healthcare workers would have – at a time of acute crisis – resulted in too many key staff taking time off work to isolate for at least the seven days mandated by the government.
Chris Morley, the chief nurse overseeing Sheffield's main hospitals, responded that the volunteer scheme was "not part of the Public Health England official Test and Trace System and our staff would therefore not necessarily have been aware of what it was or the legitimacy of the person asking them to self-isolate."
In London, the Francis Crick Institute, which runs a lab that has provided Covid-19 tests for hospitals, offered on April 15 to launch a programme to search for health workers who might be infected, even while showing no symptoms.
University College London Hospitals conducted a month-long study of 200 healthcare workers from the end of March; 42 tested positive with the virus, but only eight had symptoms that met the official case definition. By the time of its offer, Crick had spare capacity to run at least 1,000 more tests a day.
But despite Crick's intensive lobbying to government ministers, NHS leaders and Selbie, the Public Health England chief, the testing programme was blocked, two sources with direct knowledge told Reuters.
Public Health England and the NHS referred questions about Crick's offer to the health ministry, the Department of Health, which told Reuters: "There was no guidance or instruction to NHS trusts to limit their testing programmes to hospital admissions." Increased capacity meant testing could now be extended to asymptomatic staff, a spokesperson said.
Over the past two months, Britain finally ramped up community testing for the coronavirus and launched in late May what the prime minister called a "world-beating" contact-tracing system staffed by thousands. But the new British smartphone app - heralded as a lynchpin of the contract-tracing system that was supposed to roll out last month - has been delayed. The government conceded the NHS Covid-19 App may not be ready until autumn at the earliest.