After seven weeks of lockdown and more than 30,000 deaths, the first phase of the UK’s coronavirus outbreak is slowly drawing to a close. On Sunday April 10, prime minister Boris Johnson is expected to announce a slight relaxing of distancing rules that should see exercise limits relaxed, but is likely to be a long way off the kind of national unshackling splashed across tabloid front pages on April 7.
Easing the UK’s lockdown will depend on us managing to prevent another spike in coronavirus cases like the one which pushed the NHS to its very limits in late March. The government is hoping that the NHS contact tracing app, currently being trialled on the Isle of Wight, will allow it to stay on top of new Covid-19 cases and stop them before they spiral into localised outbreaks.
The contact tracing app – already dogged by concerns over privacy and its effectiveness – is only the technological heart of the UK’s contact tracing plan. The government is also hiring 18,000 contact tracers to do the leg work of identifying people with Covid-19, finding out who they might have spread the disease to and following up with those contacts to ensure they don’t continue the chain of transmission.
But there are signs that the UK’s contact tracing plans are already on shaky foundations. After largely dropping contact testing on March 12, the UK’s scheme will be taking off from a standing start. Wide-scale testing, which forms the central part of any contact tracing scheme, is already faltering as the government has hit its self-imposed 100,000-a-day testing target just twice since it was announced. And scientists are dubious that, with local authority health departments eviscerated by years of cuts, contact tracing teams will have the detailed local knowledge required to carry out effective contact tracing.
Lessons from other countries that have implemented effective contact tracing regimes show the scale of the challenge now facing the UK. In Singapore, which is currently seeing a spike in cases after keeping them low for many weeks, all suspected coronavirus cases were isolated in hospitals while any close contacts of confirmed cases were placed under mandatory quarantine for 14 days. Although the country was one of the first to release an automated contact tracing app, it has relied on a network of police officers and army staff to trace thousands of contacts each day.
“If you ask me whether any Bluetooth contact tracing system deployed or under development, anywhere in the world, is ready to replace manual contact tracing, I will say without qualification that the answer is, No,” wrote Jason Bay, the product lead for TraceTogether, Singapore’s contact-tracing app, in a blog post.
Simply tracing contacts isn’t enough. In South Korea, moderately sick Covid-19 patients are sent to isolation dorms at converted workplaces, while asymptotic contacts of recent cases must follow strict self-quarantine at home and use separate bathrooms and cooking equipment from cohabitants. Dedicated contact tracers follow-up with contacts twice daily to see if they have developed symptoms. In China, mild cases were also sent to isolation wards to recover.
It looks unlikely that the UK contact tracing regime will require out-of-home isolation, but this could be helpful for particularly vulnerable people says Gabriel Scally, a professor of public health at the University of Bristol and a former regional director for public health. People who share crowded homes could be putting their household at risk if they isolate at home, he says. “There would be a good case in my view for helping the person spend their period of isolation somewhere they wouldn’t have such direct contact with others.”
Doing so would require local expertise and spare accommodation capacity. “There is a need for local knowledge, particularly around the close contact issue,” Scally says. Local contact tracers would be more familiar with likely contact hot-spots in communities and also better set-up to contact people who are more vulnerable or likely to be completely isolated.
This isn’t the approach that the UK is taking. Of the 18,00 contact tracers being recruited by the government’s mid-May deadline, 3,000 of them will be doctors and nurses recruited from the pool of volunteer retired NHS employees and the remaining 15,000 will staff call centres reportedly outsourced to private operators. According to a letter sent by Public Health England to directors of public health, local council resources will go towards managing the most complex outbreaks, such as those in care homes.
It is no surprise that local authorities aren’t being asked to deliver the bulk of contact tracing. Even if they wanted to, a decade of cuts to council budgets mean that local public health departments simply don’t have the staffing to run widespread contact tracing, Jim McManus, director of public health for Hertfordshire County Council says that he is operating with a third less staff than he had in 2005. “We have expertise and experience; we don’t have capacity in and of ourselves to deliver this national system.”
Even done effectively, contact tracing is no silver bullet against this pandemic. A study from Shenzhen in China found that contact tracing reduced the time for someone with Covid-19 to be isolated from an average of 4.6 days after the first sign of infection down to 2.7 days. But this still leaves a window where people are possibly spreading the infection without knowing it. As an editorial in The New England Journal of Medicine notes, transmission from people who aren’t showing symptoms yet (or never show symptoms) is one of the major challenges we’re facing in combating the disease. Narrowing the window of asymptomatic transmission will mean tracking contacts extremely closely and making sure they have rapid access to tests.
And contact tracing itself is only one part of the puzzle. The government is reportedly already preparing to cut wage subsidies while an additional 600,000 young people are facing unemployment in the next year. Without a financial safety net, people in precarious employment may be unable to comply with strict self-isolation requirements.
By the time the government’s mid-May hiring deadline comes around, it will have been two months since the UK last widely pursued contact tracing. The country will be well past its initial peak by then but the challenge it will face will be of a more drawn-out, intractable nature. Without a vaccine, social distancing may have to be in place for a year or more, with the threat of a new outbreak putting a constant pressure on individuals and the economy.
Despite its initial limitations, the UK’s contact tracing regime must get started sooner rather than later, says McManus. “I don’t think we have a choice. We have to go with what we can deliver and improve it as we go along.”
Matt Reynolds is WIRED's science editor. He tweets from @mattsreynolds1
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This article was originally published by WIRED UK
