Coronavirus: the decade-old warnings about unpreparedness and mass testing left unheeded

HPS, the organisation that co-ordinates health protection in Scotland, warned ministers that among the improvements needed was "planning mass testing and treatment facilities", including access to swabbing.

It said systems in the swine flu crisis were required to be developed or modified "very quickly with limited time for testing and investigation", and this resulted in them being established at the same time as they were required to report.

In the early stages the intense focus was on the severely unwell and it was "not possible to provide the public with an accurate population risk". This was partly because of an "inevitable delay" initially in the creation of a test.

It warned that "resilience was a concern" and added: "Containing a more severe, long-lasting pandemic would be difficult. Greater resilience needs to be built in to arrangements for future pandemics.

"Planning should take account of more severe pandemic scenarios..."

It comes as David McCoy, co-chair of the Centre for Health and the Public Interest has said he believes a lack of virus testing was a deliberate strategy, believing the "herd immunity" theory for dealing with the virus was "still part of the government's thinking" despite the imposition of lockdown measures on March 23.  

On Saturday, the UK's daily death rate rose above that of than Italy, which has recorded the most deaths worldwide. On the 30th day from the point of the first reported death in Italy there were 651 fatalities from coronavirus. On day 30 for the UK there were 708 deaths. 

Health secretary Matt Hancock denied "herd immunity" was part of its strategy in the midst of criticism that it would put people unnecessarily at risk and Boris Johnson said earlier in the week that testing was "key" in unlocking the coronavirus puzzle.

But Mr McCoy, Professor of Global Public Health at the Centre for Primary Care and Public Health at Queen Mary University London said in an analysis that the government had not been prioritising testing, individual case detection or contact tracing as a control measure, when it should have been part of their strategy.  

He said there were "no indications" that the NHS was adequately prepared and that the "key issue" of insufficient intensive care unit capacity was only fully grasped in March.

"The current plans to suppress community transmission have gaps, which suggests a willingness to accept some continued transmission, albeit at a lower rate," he said.

He said it was "hard to understand" the reasons for "such belated planning given the various reports and studies about pandemic preparedness that followed the swine flu and Ebola epidemics".

He added: "But undoubtedly, structural weaknesses within the health system – produced by austerity, marketisation and constant restructuring – have diminished the capacity for rapid and effective planning and mobilisation...

"Covid-19 is not a black swan event. It was waiting to happen. The failure to prepare the NHS for Covid-19 signals how it has not been led, financed or organised as a public service to work in the public interest to fulfil its national health protection function adequately."

He told the Herald that the lack of testing for the virus was "a combination of incompetence in terms of planning supply chains and some people in government arguing against its usefulness".

Both the UK and Scottish government have been coming under fire for a failure in mass testing for the current coronavirus pandemic which has claimed the lives of thousands, with 218 in Scotland (Weds figure).
South Korea's success has been put down to early testing and surveillance.

Testing in South Korea.

They were among the first to travel to the epicentre in China to learn more about a virus which has now engulfed the world and went on to shape what has become the world's most ambitious virus testing programme.

When the first cases were confirmed in South Korea it began to roll out its trace, test and treat approach - which has led to almost half a million people being tested for Covid-19.

German laboratories were conducting more than 50,000 coronavirus tests a day, according to data revealed on Wednesday while in the UK, daily testing reached less than a fifth of that at 9783 in a 24 hour period from 9am on Tuesday with the government stating it hoped that would rise to 25,000 a day in the coming weeks.

South Korea's first case was reported on January 20, while Germany's was on January 27, while it was January 31 for Britain and Italy - but the disease's trajectory could not be more different.

South Korea, with a 51.5m population has seen just 183 deaths, while the UK, with a 64.4m population has 4313 deaths, nearly 24 times as many.  Germany has 1444 deaths.

Italy, with a population that is just 9m greater than South Korea's has the most deaths globally now at 15,362.

HPS, which warned that "greater resilience" was required to deal with future pandemics, said that at one point in the swine flu crisis,  as numbers cases started to rise substantially, this caused a "considerable burden" on a number of staff involved in this aspect of the response.

The number of cases just seeking treatment in Glasgow for a few days exceeded the health service's capacity for the taking of swabs for testing. This led to a suspension of the gathering of surveillance data.

"Organising swabbing and testing became very burdensome," HPS said. "Within NHS Greater Glasgow & Clyde, the evolving situation became untenable because of the pressure on primary care services and surveillance had to be temporarily suspended."

It added: "The large of number of people requiring testing led to the virology laboratories having difficulties processing samples."

The HPS said the primary objective of virology and bacteriology laboratory services was not just to confirm clinical diagnoses of swine flu, but also to identify secondary infections.

During the inital stages of the swine flu pandemic, a priority was given to early detection of cases of infection and their close contacts and "putting in place measures to reduced the probability of transmission from them to other in the community".

It also needed to provide testing to support surveillance including "monitoring the extent of pandemic infection".

It said that while the rapid development and roll out of molecular based tests in Scotland "went well" improvements were needed to improve "surge capacity of virological laboratories" due increasing demands.

HPS said the Scottish Government should ensure access to molecular testing facilties was distributed " more widely" across NHS boards and called on ministers to review the need for a specialists lead laboratory for respiratory viruses in Scotland.

NHS boards were asked to review their ability to deal with a surge of demand on virological services.

The HPS said that the  West of Scotland Specialist Virology Centre which has an established link with the UK National Influenza Laboratory in studying viruses not seen before, was "particularly stressed" in June, 2009, due to high demand for influenza testing arising from cases in the south of Glasgow and for several weeks was sending samples for testing at the Health Protection Agency virology laboratory in Manchester.

In the move from containment to treatment the public health investigation of cases and their contacts was discontinued, and the role of the  Scottish Flu Response Centre (SFREC)  evolved to that of providing clinical management and advice to those with illness.

HPS said much of the early evidence on the impact of the swine flu virus came from rapidly designed and implemented surveillance systems and that it took time to ensure they were consistently employed across the country.

It also revealed that efforts in Scotland to carry out an accurate risk assessment by carrying out investigations about the presence of antibodies in at-risk groups were unsuccessful partly due to a "lack of planned capacity to undertake these but also due to concerns about ethical approval".  

HPS said the framework for pandemic surveillance and investigation should be revised.

The imposition of 'lockdown' measures on March 23, which brought the UK in line with the approach of other countries was seen by some as a change in strategy or a belated response.

The Imperial College modelling report produced in mid-March for the Scientific Advisory Group for Emergencies (SAGE) stated that 'suppression is the only viable strategy' due to the realisation that mitigation would be insufficient to prevent the health system from being overwhelmed.

Mr McCoy said: "While there is no longer explicit mention of ‘herd immunity’, there are reasons to think that this is still part of the government’s thinking."

"Ongoing concerns about a second-wave epidemic and emphasis on expanding antibody tests (not viral or antigenic tests) also suggest an interest in building up herd immunity."

Mr McCoy also pointed out that in giving evidence to parliament’s Science and Technology Committee last week, the UK government's chief scientific adviser Sir Patrick Vallance indicated no significant change in government strategy.

He said a "comprehensive and bold social and economic strategy" is now important, and needs to address multiple and complex challenges.

"Mass quarantine, travel restrictions, school and university closures, unemployment, and economic recession can also cost lives," he warned. "How do we weigh this up against the harms caused by the virus, and make choices between competing calls on limited resources?"

A year after the HPS analysis, the UK influenza pandemic preparedness strategy, which was believed to  provide a solid template for the management of coronavirus containment and treatment, stresses the need for "detection, diagnoses and reporting of early cases through testing and contact tracing".

It stressed there should be changes of approach to explore measures such as serology - the examination of blood to test for antibodies or immunity to a virus - "to measures the severity of a pandemic in its early stages".

It said that "accurate and detailed surveillance data"  including numbers affected and hospital and critical care admission were to be "gathered as an early priority".

"Early comprehensive assessment of the epidemiological and clinical characteristics of a novel influenza virus is essential to enable the implementation of a proportionate response to a new pandemic," it said.

"The primary aim of surveillance is to ensure that accurate, timely, and reliable information is available to understand the nature of the disease and to inform decision making about the response to the pandemic. Surveillance data also informs the ongoing operational response to an influenza pandemic, the public and professions."

Public Health England in response to the strategy, three years later said it was recognised that it had a key role, for example, in the "capability to develop a diagnostic test to detect the new virus and the rapid collection and analysis of data on cases in order to assess the impact of the new illness".

On Sunday former Labour health secretary Alan Johnson asked about why the country has not been better prepared in the wake of the swine flu pandemic said: "That is the big question.

"I am absolutely amazed at how badly prepared the government is for this."

Mr Johnson, who was health secretary for two years from June, 2007 added: "When I first became health secretary I walked straight into a dress rehearsal on how we would deal with a pandemic.  

"Pandemics, whether they are respiratory, or flu-based, the basic things you need at the start is protective equipment, that doesn't change.  The first thing you [also] need is the arrangements for testing, that doesn't change, to see if people have got it or not. 

"You can prepare those things."

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