by Timothy Moots
As we are all acutely aware, on 24 March 2020 the Prime Minister announced restricted movement on the UK population to prevent the spread of the coronavirus. As students of war, we have much to learn from observing how governments respond to the pandemic. Like on the battlefield, public health officials today are grappling with how they defeat this potent adversary. Last week I was fortunate enough to get insights into the processes that helped develop UK strategy leading to the situation we are in today in an interview with a world expert on pandemics who is leading research into the battle against the coronavirus.
The expert I sat down with is Professor Calum Semple, Professor of Child Health and Outbreak Medicine at the University of Liverpool, and a member of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) to discuss his role in outbreak medicine, the coronavirus outbreak, and UK Government strategy.
TJM: What is your role in dealing with the coronavirus?
CS: I am the Chief Investigator on a study called Pandemic Influenza Community Assessment Tools, which is the process of getting data to validate triage tools in the community. I am also the Chief Investigator on the Clinical Characterisation Protocol, which is a much larger research project. It is a very different type of research as it feeds information into various government departments and agencies. It is not research conducted for a paper in six month’s time, rather Urgent Public Health Research is delivered now to inform policy decisions tomorrow.
This involves working out your data collection tools in advance and so when the outbreak happens the nurses and medics can collect information when it comes to the hospital, pass it back to the research team, update to data entry systems, and have an analysis which in an automatic fashion presents it to a dashboard for policymakers. This data can include anything from the length of stay of a patient in hospital to the proportion of patients under the age of 18. Upon uploaded by a nurse say in Devon, policymakers can get this data within 30 minutes allowing quick decisions made in real-time. This has never been done before. I am also a member of NERVTAG, an advisory group set up to advise the government on new and emerging respiratory viruses.
TJM: How did you come to specialise in outbreak medicine?
CS: The very first outbreak I was involved with was the HIV epidemic in the 1980s. This was during my PhD which was researching HIV. The outbreak evolved while I was working on the thesis, and this was my first experience of research taking a U-turn, which resulted in diverting resources and activity to focus on the pressing question at the current moment. This question was the need to identify a surrogate marker of drug efficacy and a surrogate marker of progression of the disease. This led to my PhD focusing on the development of quantitative viral load, which we patented and were the first people to publish on this. Today quantitative PCR for viral load is the most commonly used way of measuring disease progression and drug efficacy of HIV in the world.
The next outbreak was the Respiratory Syncytial Virus (RSV), which is a very regular and predictable outbreak every winter. However, I moved into influenza, where there was greater scope for public policy and public impact. Working as a government advisor on influenza and running multiple research projects, I learnt a lot about working in outbreak situations. It is no surprise that a lot of those involved had worked alongside or in the military. It provided better discipline in focusing not so much on the interesting science, but in an outbreak scenario what is the question that needs to be answered over the next two-three weeks which will change decisions about how we manage patients and implement policy decisions.
This brings me to the 2009 H1N1 outbreak, which caused a lot of frustration in that we could not get our studies running as fast as we wanted. So, a group of us set up the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC). Our mantra was to prepare for the next outbreak. This was done by producing the counter-studies you would want to run in an outbreak situation, which turns out to be quite a shortlist. Here you may want to run a clinical characterisation study (the who; what; where; when; and why), a drug trial, a vaccine study, a study on triage. We designed protocols for studies that didn’t name a particular pathogen, as it didn’t matter what the pathogen was, but it did contain sampling schedules, data schedules, and from this we developed the protocols. From here we took it to the World Health Organisation (WHO), which was subsequently taken on by them, as it would enable rapid research for a fast-developing outbreak.
This meant that when the Ebola outbreak came, we were able to conduct the research in West Africa in a matter of weeks and this totally changed the paradigm. The same group was more than ready to set up the research during the coronavirus outbreak. As soon as we got wind that cases were likely to come to Britain, research protocols were activated to gather data and process the first admissions in the UK.
TJM: You previously worked on the Ebola epidemic. What made the Ebola so unique in its transmissibility?
CS: Regarding transmission, what happened in West Africa was part of a burial ritual called “laying out”. Once you would die, your friends and relatives would wash you down, dress you up, put you in a coffin and have a ceremony. It actually was still going on in Britain as recent as 30-40 years ago, and it is still a tradition in isolated parts of Europe where there are not enough undertakers to deal with the dead. In West Africa they take this very seriously.
But what complicated this in West Africa is the “secret society culture”. This is much more than the Masons in the UK. These societies are very important in where you go to school to getting your job and promotions at work. Often you will find that departments in organisations have a large number of members that are part of one secret society, whereas hospitals may have large numbers of members from other secret societies. Members of a secret society, who are typically your peers, will be involved in laying your body out. They will wash you down very carefully, with great care, love, and attention, and it is a very important part of the grieving process.
However, the exposure to the human body fluids meant that everyone who was involved in laying out the body was exposed to catching Ebola. What complicated things is if you were very important you might have over 200-300 people attend outside your house wanting to be involved in the process. The body fluids that had been washed down would be taken outside and distributed amongst the people – some people would dip their fingers in it, others would have it sprayed in faces – and this was a part of associating themselves with the deceased and their spirits. One example is we have one healer who died and at their funeral around 360 people contracted the virus from direct exposure to the body fluids. It was not limited to burial rituals, however. Other examples include in the hospital where you can catch it from a woman giving birth or someone vomiting. The virus spread very quickly and hit very hard.
TJM: What is the difference between the coronavirus and Ebola?
CS: Well Ebola is what we call a viral haemorrhagic fever. This is because the virus gives you a fever and it can make you bleed. But bleeding isn’t the most common symptom, it is actually vomiting and diarrhoea. Ebola can spread from blood, sweat, tears, diarrhoea, and lots of different body fluids. It does not have a clear respiratory spread and people don’t tend to cough and sneeze the virus up. For Ebola its actually profuse production of body fluids where the virus is and where it is coming from. Ebola is actually relatively easy to contain. Once you have identified someone who has been sick you can isolate and prevent contact.
Whereas with the coronavirus you cough, sneeze, and splutter. You do this for possibly 5-7 days before you take yourself out of society because you are feeling unwell or because you are recovering. People infected with coronavirus can walk around for 7 days incubating the virus and then have another 5 days where they have what is called a prodrome (an early symptom indicating the onset of a disease) and during that time remain active in the community spreading the virus, but not so sick that they take themselves to bed or get admitted to hospital. This makes the virus far more transmissible in a community. The virus survives on surfaces, in the house, outside. In dry air it survives for around fifteen minutes. Then people touch the surfaces, then touch their mouths, pick their noses, scratch their eyes. We all do this about twenty times an hour. This brings the virus to the respiratory tract where again it is perfectly suited to taking hold. It’s a very different virus to Ebola. And the transmissibility of corona is far greater than that of Ebola.
TJM: What have we learnt from military command and control structure that can be applied to Corona?
CS: A lot was learned from how the British Army and Relief Agencies interacted with society in Sierra Leone. The sort of planning instigated by the military created a very clear line of what needs to be delivered and what needs to be changed within the community, and it was absolutely critical to delivering rapid research and achieving rapid outcomes. It’s a very different method of patient management. You’re not just thinking about the individual patient – the individual patient is very important – what you’re thinking about is the message you are sending out in managing these patients. Do your messages encourage people in the community to come forward and seek appropriate healthcare, or will it encourage people to avoid the appropriate healthcare and seek traditional healers and ministries?
This is very much the same way in how you engage with the British public and pressing upon them the importance now of not going to the pub and staying at home. Because the reality is staying at home will saves lives. An issue is people thinking that the coronavirus does not affect them, and don’t immediately understand that going out and socialising will mean the virus will spread and people will die. This is because there will be fewer people around to care for people with other diseases. Car crashes, heart attacks, difficult pregnancies still happen. The reality is an overwhelming impact on health resources and general population health means that the doctors and nurses don’t have the scope to care for everyone they want to. This is just part of the medical aspect. If the approach was not taken you may end up with societal effects that have far greater secondary impact then we could have predicted and could have far more reaching impact than the health impact.
TJM: Is the UK really taking a different approach to other countries? If so why?
CS: The UK certainly did take a different approach in the lead up to the shutdown. I am quite pleased that we did not go for a kneejerk shutdown in the 3-4 weeks before we did. That period allowed a degree of calmness and preparation to go on at a very important stage. Where otherwise we could have had a huge, essentially, “phony war”. There was a phony war during the 2009 outbreak, where we saw a spike in GP attendances and health-seeking behaviour that arrived 3-4 weeks before the real flu arrived. This overwhelmed GPs who were prevented from doing their regular work and providing standard healthcare for those who needed it. The way the government policy managed information and society this time was far more sophisticated and prevented a phony war.
The careful considered management by the Chief Medical Officer (CMO) Professor Chris and Chief Scientific Officer (CSO) Sir Patrick Vallance in the month leading up to the lockdown prevented the excessive health-seeking behaviour that could have caused an earlier overwhelming of GPs and A&E practitioners.
TJM: Do you think the government has done a good job so far?
CS: I think the government has done a good job in cautiously and systematically raising fear in a controlled manner, and this can be seen from the very careful messaging from the CMO and CSO. You can work this out from the press conferences and news clips, which were deliberately telling people about the severity of the crisis. It was realistic and conducted sensibly.
This approach got people to start stocking up – and yes some people were panic buying – but most people stocked up. Over the last 3 weeks of stocking up to the situation we are in now, it has made the lockdown a lot more manageable. Most people have filled their larders, and no one can say they weren’t warned about it. Supermarkets have been warned in advance and are able to cope with the disruptions in demand.
Think about how you manage and keep an army in readiness. There is a level of preparation, training, regular exercises to keep the army in readiness. Equipment, which is not used is checked, serviced to ensure it actually works. And this is the same for us. We have a stockpile of medication and a stockpile of masks, the equivalent to the beans and bullets in the depots.
TJM: Is “herd immunity” Government policy?
CS: It was never policy. It was an assumption by lots of speculators from the side-lines. I never saw a concept that we are going for herd immunity – this is not the case. The terminology used by Prime Minister Boris Johnson was “flattening the sombrero”. It sounds rather crude, but it is not a bad way of explaining how you flatten an epidemic curve. It is unavoidable that we will get exposure. But what is going to cause greater societal disruption is a sharp spike in epidemic activity that will overwhelm services. And this is not just about health services but also national services. [The minutes of NERVTAG are publicly available.]
TJM: Were we really unprepared by not investing in ventilators?
CS: At what point in the last 100 years would you have predicted the global healthcare systems would have needed an extra X amount of ventilators? Even if you wanted to buy an extra hundred, rather than the 10,000 quoted in the press, it would have been impossible to predict this. Ventilators are not household items like microwaves, they are not made in mass in a factory, and nor are we able to go out and shop for them on the market. They are complicated sets of equipment that are bought on a well-resourced planned renewal project. At the same time, there is no way that any advisor to a government would say let us keep X amount of excessive numbers of ventilators in a warehouse, requiring them to be switched on every several months to check they work, service them, and replace parts. It is far beyond any policymaker’s capability to do that.
However, the irony to that is, that it would have been in our interests to do it with the economic effect on businesses over the next few months. If I was a politician, I would not have had warehouses with ventilators. But what we do have, are warehouses stocked with PPE, anti-biotics, anti-virals, which are essential and can be maintained.
TJM: What about PPE?
CS: Local supply issues. There are different types of PPE. Now the PPE you have for the higher risk procedure is different to the PPE for standard procedures. Human nature is to grab the one considered to give the highest level of protection regardless of whether you need that or not. Infections do not work that way. If you are not treating a patient needing to have their lungs washed out, or a tube put down their throat with your face twenty cm away from their mouth while doing it, then you do not need the protection offered by an FFP3 respirator with face shield. If you are doing simple straight forward care you will be fine with a face shield and standard mask.
But that’s not what people do they tend to grab respirator because they perceive it for greater protection. You don’t need a bulletproof vest to go down to the shops, you only need the bulletproof vest if bullets are flying. You only need the FFP3 masks for aerosol-generating procedures, where one gets up close and personal to the aerosols. But people pick these masks thinking it gives them greater protection. But it’s not, it is simply preventing someone who needs that mask from having it. We have kept a huge number of FFP3 masks in reserve for years, but at the current rate, they are being consumed too quickly as people are using them inappropriately. And this is a difficult message to get across.
There may be local supply cases, but the idea we are somehow negligent is very different. Junior doctors have been very good at communicating these shortfalls using the various social media tools to share this. At most places, we do have the equipment but it needs to be used appropriately. The right level of PPE needs to be used for the right circumstances.
TJM: In your experience, what kinds of communications are most effective when engaging populations and getting them to do things – rational or emotive?
CS: Are all people the same? Some people are young, some people are old, some work on emotion prompts, some people work on facts. The biggest mistake is that one communication strategy will work. Instead, what you need is a blend – everything from the Twitterati to the Radio 4 audience. Some people don’t listen to the radio, they rely on social media like Facebook and other sources. I think that clever messaging is blended. A lot of people like the CMO Professor Whitty, as he is seen as the nation’s doctor. But at the same time, he is not going to be everyone’s cup of tea. He may be seen as a “pale male”. Is he going to engage a young ethnic minority male in a deprived inner-city London? Will he reach out to a single mother in Birkenhead?
The way you reach out to these parts of the population is through using a mix of social influences, various magazines, and social media apps like Instagram. This is a very different messaging style to what the Radio 4 generation is used to. The government needs to learn more sophisticated communication strategies that are involving social influencers to make sure its message is being read by all corners of the population. In my personal opinion there is a big scope for improvement. Public health messaging has to change, especially to adapt to this.
TJM: Finally, how can governments prepare themselves for pandemics?
CS: Set up advisory groups like the New and Emerging Respiratory Virus Threats Advisory Group. The reason it is called that is that it does exactly what is say on the tin, advises on new and emerging respiratory virus threats. The group is tasked with questions such as what is coming, and if it is coming what it might look like, and how can we prepare. And it is exactly what we did.
Professor Calum Semple, Professor of Child Health and Outbreak Medicine at the University of Liverpool, and a member of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG)
Timothy Moots is a Senior Editor at Strife and a PhD Candidate at the Department of War Studies, King’s College London.