Balancing the risks: Dr Nathalie MacDermott on lockdown easing and the UK perspective

Dr Nathalie MacDermott is a clinical lecturer at King’s College London, sub-specialising in paediatric infectious diseases in the NHS. She also has significant experience in medical response to disaster and epidemic situations in Africa and Asia

Some countries in Europe, including the UK, have begun easing their lockdown restrictions. In what ways can lockdowns be relaxed without triggering a resurgence in infections?

Nathalie MacDermott ESMH scientistI think that is a really difficult question to answer, because we don’t have a frame of reference for it and there is not a lot of evidence for what works and what does not, and what should open first and what should not.

I think the best answer is to do things in a gradual way, constantly monitoring if there is a resurgence in infections so that we can quickly step back again if we need to, rather than relax everything all in one go and suddenly find ourselves in a full-blown second wave. It just has to be done gradually, with constant monitoring of the R-naught, the reproduction number, and the infection rate in each country.

What factors should be considered in this easing, are there certain professions or industries that can safely reopen first?

There are many things that we consider when we talk about safely reopening things and children going back to school, and it is not just if we’ll see a resurgence of the epidemic. Are these essential professions to the running of the UK or whichever nation we are talking about? I think it is essentially a balance of the risks. It just comes down to what the government’s priorities are, what they feel is essential to bolster the economy and where they feel it is safe within those professions that they can maintain social distancing to a degree as well.

Is it safe for children to return to school?

In terms of children, we have to look at it from two angles. Children, as far as we know, are less likely to be severely affected by this virus. So actually it probably is safe for children to go back to school and we won’t necessarily see lots of severe illness in children.

What we might see is a resurgence in the epidemic because we don’t yet know how well children are able to transmit the virus. Yes, they may be less likely to become infected based on some of the recently available data and we know that they are less likely to have severe illness if they do become infected. But we don’t know how well they transmit the virus when they are infected, so it could result in a resurgence of the pandemic in the UK by children returning to school.

The other component to look at is what is happening to some of our children who are remaining at home for long periods. In the UK we have a relatively high rate of children who live in poverty and deprived circumstances, who may be vulnerable and at risk by staying at home. So we are going to start seeing a significant or even greater discrepancy between our lower and higher socio-economic classes when it comes to education, which obviously has a long-term impact in the future. So it is trying to find the balance of can we contain the pandemic by enabling children to return to school.

Children seem to be less vulnerable to the virus, but there have been reports of children with a severe inflammatory syndrome related to Covid-19.

We are still learning what is going on in this context. Speaking to some of our colleagues, there have been a large number of young adult and adult patients who have also had what is a kind of a severe inflammatory process going on in their bodies, or a cytokine storm, so it is possible that what we are seeing now in children is very similar. It is only a relatively small proportion of cases, some children who have or have been previously infected with Covid-19, so maybe they have no recollection of the infection or do not test positive, but they have antibodies to the virus, they are developing this multi-system inflammatory syndrome, which in some cases is very severe and requires intensive care admission.

So yes, we certainly can’t dismiss that, and this is something that has only really become apparent in the last few weeks, so it is very difficult for us to say how widespread it is. Something that is particularly apparent in these children is what we have seen in the adult population, that black and minority ethnic populations are much more badly affected by this virus than other populations.

Covid-19 is a global disease, yet the way countries report on the related statistics vary. What does this mean for our understanding and interpretation of these data? Are comparisons between countries useful?

I think that comparisons can be useful provided that they are done appropriately and each country is comparing similar data. There needs to be some degree of consistency in how the data is collected and reported. Without widescale testing in every single country and similar parameters for reporting of data, it can be very difficult to do what would be a fair and reasonable analysis between countries.

For instance, you might see a vastly higher proportion of deaths in a country that is only testing people who are showing symptoms and are coming to the hospital with the virus, and missing a whole group of people in the community who have mild or no symptoms, and therefore the proportion of deaths looks a lot higher. It is useful when you talk about deaths, to compare them to per million of the population, and also to compare the number of cases per million of the population.

When we interpret data in terms of deaths and severity of disease, we need to interpret it in the context of the health facilities available in that county, the socio-economic status, and the ethnicity demographic. If we determine definitively that the black and ethnic minority population have worse outcomes with this virus, it is likely that a country that has a higher proportion of the population that is black or from a minority ethnic group will have a higher rate of severe disease and death. It is important that everything is taken into consideration.

I don’t think that at the moment it is necessarily useful to compare countries, because I don’t think we have all the data. Once this pandemic is over and all of the data can be appropriately collected and interpreted, I think then there will be value in it.

In this time of public health crisis, the need for clear communication between experts, policy-makers and the public is greater than ever. What do you believe are the best practices for this?

I come from the background that is not political, where I believe that the best way to engage the public in a situation like this, even when it is frightening for them, is for them to have information that is accessible and they can understand, and where there is openness and transparency in communicating that.

I believe we should be clear when there is uncertainty about things, that it is perfectly appropriate to say “we are still learning and that we still need to understand how the situation might change”, rather than to come out with clear cut statements that perhaps are questionable in terms of the evidence – where the public are also very sensible and bright, they can look at that and say, that’s just a political message.

I think that it is really important that we convey messages that are at a level that people can understand, are short, to the point and clear, but also take into consideration the background that people are coming from and their needs, as well as try to understand from a behavioural and psychology perspective what is actually causing people to be anxious. Is it the risk of infection? Is it the risk of infection to their elderly relatives? Or is it actually the economic impact on their family? If we can understand their fears and where their concerns lie, then we can approach them in a way that answers or at least helps moderate those. If we don’t, we see what is starting in Spain and other countries like the US, where there have been demonstrations against the lockdown. It might only be a very small subset of the population, but these movements, especially with social media, can gain significant momentum.

I worked a lot in West Africa during the Ebola epidemic and it was very clear that people often rioted or responded with aggression because they were fearful. The most important thing from my perspective is that we engage people very early on in a situation that could become a problem, that could be associated with high levels of fear, and where we might have to introduce behavioural modifications that we need the public to be on board with.

The UK has reported the highest death toll in Europe: what factors do you think contributed to this?

I think it is a little bit difficult at the moment to properly compare, in part because the UK is reporting suspected cases where it is documented on the death certificate that Covid-19 may have played a role, but the patient did not necessarily have a positive test result. I think this is a reasonable decision to take, but I know that not everywhere is doing that, so we have to look at the data proportionately. We also have here in the UK taken it upon ourselves to test a lot of people in our nursing homes. In other countries they may simply be reported as having died of heart failure or another comorbidity, where Covid-19 may have played a role but it hasn’t been included in their death tolls.

I think we need to be careful in interpreting the data, but I think that we do perhaps have a higher rate, in part because I think we have had a significant outbreak in our care homes. We need to reflect on that later after the pandemic, about how we can avoid that in the future. I think ultimately, we had patients who probably had Covid-19 who were discharged from hospital back to their nursing home and subsequently spread the virus, in a setting where people are elderly and frail.

We did not provide those nursing homes with adequate personal protective equipment for their care workers and we were not testing people going into work with what is a highly vulnerable population. We also didn’t really provide much guidance that I am aware of to the nursing homes in terms of which patients should be kept in their bedrooms when they might be unwell. So I think we have a lot to learn – I don’t know if it is all related to what was happening in care homes, but I think we will have to do a thorough analysis once everything has settled to try and understand what factors really did contribute.

In what ways could the UK and other countries be better prepared for future epidemics?

I’m sure that following this pandemic, countries will be prepared for a number of years. The problem is that the memories of what happened grow faint and it no longer remains on the political agenda, there is a changeover of political parties, and things get put to one side because they no longer see it as a priority. I think we really need to hammer home for our political institutions that pandemics remain and always will be a threat to our society. In the increasingly inter-connected world in which we live, an epidemic in one country can very quickly become a pandemic. Sometimes a virus like this, it doesn’t really matter what we do, it is going to manage to create a pandemic anyway, but we can certainly minimise its spread and the level of casualties.

I think from a UK perspective, we probably didn’t have the level of laboratory facility required to test and that we perhaps made some mistakes in the sense that we didn’t have the level that was required in the public sector – but we can more than make up for that in the private sector and in using university laboratories as well.

So I think that including the private sector, ensuring there is an adequate stock of personal protective equipment, and ensuring we have sufficient plans in place for different types of epidemic. And perhaps plans that we all agree on internationally rather than all doing our own thing, which might be quite diverse from one country to another.

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