Update 22nd September, 2020
Until 9th September, NHS Test and Trace report reaching 83% of cases, of which 83% provided at least one contact, but much less than expected with an average of only 3 in non-complex settings. They spoke to only 74% of contacts overall (64% for non-complex cases and 99% for complex cases managed by PHE health protection teams), equivalent to only about 50%. The greatest jump in outbreaks has been seen in care homes as a result of regular screening, although most transmission is still occurring within households. As schools struggle to access tests for symptomatic children, some are startinghaving to isolate entire bubbles based on suspicion alone as a protective measure.
The existing system remains the same in that cases are asked to input their contacts onto an online system, and those contacts are subsequently telephoned by any of the 10,000 newly recruited (level 3) contact tracers, employed to two main commercial companies, Serco and Sitel. On the 22nd September, the secretary of state announced that these contact tracers would also start to check that cases were actually isolating. The police have also been given responsibility to follow up with compliance but it is unclear how they will do this as they are not part of the test, trace isolate system. Cases who do not upload their contacts receive a telephone call from newly redeployed (level 2) NHS workers (including pharmacists, retired GP’s, environmental health officers and sexual health workers) who interview the case and perform a risk assessment. Where a case has attended a complex setting where transmission risk is deemed to be high, (such as a care home, school, restaurant or workplace) these cases are referred to the Public Health England (PHE) regional health protection teams, employed by Public Health England who investigate whether there is an outbreak or not and manage the subsequent public health actions where this is confirmed. The definition of an outbreak does change slightly between settings but essentially involves the presence of two (usually) confirmed cases, linked in time and space. Although recruitment has been focussed on level 3 (15,000 lay workers recruited to telephone contacts), health protection teams have also been asked to recruit more staff, though this has been complicated by the lack of trained health protection nurses and the political climate with the future of PHE uncertain. Many staff who were redeployed within the NHS to level 2 from sexual health teams are now slowly having to return to their original jobs. Local authorities are also now starting to receive data on cases and their contacts so that they can start to follow them up. Different areas are pursuing this in different ways. Some will initiate door knocking, though this is unusual and time consuming. Others are verifying telephone numbers for uncontactable cases and their contacts and calling them from local, rather than national call centre numbers, which has increased engagement somewhat. Many contacts who are not reached are also those who live within the same household and it is believed that some may not respond because they are already aware.
Pubs, households, and organised sports now seem to be the main settings for spread in some places in England, marking a transition from predominantly household transmission and mixing in communities. Yet despite a requirement to keep records, ONS data report just 31% of adults visiting public indoor places always being asked to provide details for contact tracing, with 11% rarely providing their details. The delays in test turnaround times add to the challenge of contact tracing. After a previous failure, England and Wales are now introducing a contact-tracing app on September 24th, but this will require a high uptake (estimates from 56% to 95%), while there are widespread public concerns about privacy and equity. There is still no guidance about how the app will be integrated into the test trace and isolate system or how this will work in complex healthcare settings. It also appears at present that it will not link directly into any kind of testing access (https://www.bbc.co.uk/news/technology-54250736).
Conversely, the app has been more successfully rolled out in Scotland, where it has been downloaded more than 600,000 times in the second week of September. Similarly, Northern Ireland released an app on 30th July (the first UK nation to do so), which was downloaded an estimated 50,000 times in the first 24 hours. The app is based on Bluetooth technology, uses exposure APIs developed by
Google and Apple and is interoperable with the app used in the Republic of Ireland.
Self-reported ability to self-isolate is three times lower in those who earn less than £20,000 per year or have less than £100 saved. The UK has one of the lowest proportions of pay covered by statutory sick pay in Europe (29% compared to 100% in Germany and 93% in Belgium), and millions do not qualify. SAGE and Independent SAGE agree that individuals need to be supported properly for them to isolate, advising a daily text or phone call, with provision of food supplies, essential goods and employment protection, stressing solidarity and togetherness. From 28th September, 4 million people on low incomes will be offered £500 to support them to self-isolate, authorities and contact tracers will check up on people to see if they are self-isolating, and £1,000 fines will be issued to those found to have broken self-isolation rules, rising to £10,000 for those who refuse to adhere (see: https://www.medrxiv.org/content/10.1101/2020.04.01.20050039v1
Update 1st September, 2020
Switzerland, Czech Republic, Jamaica, Austria, Croatia, Trinidad, Tobago, France, the Netherlands, Monaco, Malta, Turks and Caicos Islands, Aruba, Brunei, Malaysia, Andorra, The Bahamas, Belgium, Luxembourg, Estonia, Latvia, Slovakia, Slovenia, St Vincent and the Grenadines have all been removed from the travel corridor.
Workers on low incomes in parts of England where there are high rates of coronavirus will be able to claim up to £182 if they have to self-isolate. Some have argued that this is still not sufficient for workers to live on and should be applied to all areas of the country to prevent high rates of transmission but this still represents notable progress for individuals on universal credit who are not eligible for statutory sick pay.
Update 4th August, 2020
The duration of isolation for positive cases has been increased from 7 to 10 days
Update 28th July, 2020
Spain was removed from the list of travel corridor countries on July 26th, while Estonia, Latvia, Slovakia, Slovenia and St Vincent and the Grenadines added to the exempt list on 28th July. There has been some dispute over the rationale for quarantining returning travellers from areas of countries with very low incidence of COVID-19, such as the Balearic Islands and this remains under discussion between the Spanish and UK governments.
Update 3rd July 2020
The UK government has released a list of 50 ‘travel corridor’ countries that people can travel from and into England from 10th July without needing to quarantine for 14 days on arrival (https://www.gov.uk/guidance/coronavirus-covid-19-countries-and-territories-exempt-from-advice-against-all-but-essential-international-travel). Arrivals will not need to quarantine if they are returning directly from one of these countries and have also not been in a country not on the corridor list in the previous 14 days. Scotland, Northern Ireland and Wales have not yet agreed to these exemptions (https://www.bbc.co.uk/news/uk-scotland-scotland-politics-53277092). Update 12th June 2020
The government has announced that now that testing is population-wide for anyone who either has symptoms or is a contact of a case, support will be offered to those who say that they cannot isolate. This support is intended to be provided by Local Authorities and NHS volunteers, but it is unclear what support will actually be available and funding has only recently been made available to Local Authorities to support the initiative.
Although the government had promised that a contact-tracing app would be made available in early June, this is still being piloted in the Isle of Wight, where it believed that it has faced a number of challenges relating to low uptake and data security. The results of the pilot are still awaited but manual contact tracing has meanwhile started between May 28th and June 3rd, and contact tracers have been referred more than 8,000 cases, of whom 70% have been reached. Over 30,000 contacts have so far been identified, of which 85% have been contacted, leaving more than 5,000 cases who have not yet been contacted (https://www.gov.uk/government/statistics/nhs-test-and-trace-statistics-england-28-may-to-3-june-2020).
Update 7th June 2020
On 22nd May the Home Secretary announced that people arriving in the UK through ports (including airports and ferry ports) and international rail terminals on or after 8th June 2020 must self-isolate (at home or another address provided) for 14 days following arrival (https://www.gov.uk/government/publications/coronavirus-covid-19-how-to-self-isolate-when-you-travel-to-the-uk/coronavirus-covid-19-how-to-self-isolate-when-you-travel-to-the-uk). Non-British citizens that do not provide contact details may be refused permission to enter the UK, while refusal to provide contact details may be subject to a £100 fine in England and £60 in Northern Ireland. Individuals that fail to self-isolate can be fined £1,000, while those that do not update contact details in the event of moving from one place to another to self-isolate may be fined £3,200. These measures do not apply to people travelling within the Common Travel Area (covering Ireland, UK, Channel Islands, Isle of Man), unless they have been outside the Common Travel Area within the 14 days prior to arriving in the UK. Exemptions also apply to those escaping harm or to access victim services.
These plans have been heavily criticised by representatives from the travel and tourism industry, who say they will cause significant economic damage to an industry already suffering due to the pandemic (https://www.theguardian.com/world/2020/jun/01/critics-round-on-no-10-over-ridiculous-rules-for-14-day-quarantine-coronavirus). The three leading airlines in the UK (British Airways’ owner IAG, EasyJet and Ryanair) have launched legal proceedings to get the decision overturned. Criticisms have also been forthcoming from MPs from Conservative party and opposition MPs, who have said the policy will bring few public health benefits and should be revised to target countries with high COVID-19 infection rates and to introduce “air-bridges” between countries with low infection rates to facilitate quarantine-free travel.
Update 15th May 2020
Test, trace, isolate:
As stated in section 1.4, there is a move to recruit 18,000 people to support the contact tracing effort going forwards, including 3,000 from the NHS and a further 15,000 lay workers. It is not known how much progress has been made in doing this, but it is understood that test, trace isolate will work at 3 levels: centrally, regionally and locally.
The programme is under the leadership of NHS Executive Baroness Dido Harding and she is also joined by Tom Riordan, the CEO of Leeds City Council and Sarah-Jane March from Birmingham Women and Children’s hospital. Senior leadership from Public Health is also coming from Richard Gleave although there is still very little public information on how this will be rolled out (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881231/Letter_to_DsPH_on_contact_tracing.pdf).
The government is piloting the use of an NHS COVID-19 bluetooth based App on the Isle of Wight, which is believed will feed into a test, trace, isolate system in which 15,000 call handlers, employed by Serco will call all the contacts determined by the app when cases are confirmed on testing. These callers will escalate to a second tier of 3,000 health workers, including sexual health specialists and environmental health officers who have experience in contact tracing. Local councils have also been asked if they can second staff to support this effort, as have a number of NHS trusts, but this is also a challenge given workforce capacity constraints. The second tier will work with and be trained the existing Health Protection Teams, in local PHE offices to facilitate contact tracing. Complex cases and complex settings (such as care homes and prisons) will still be managed by experienced contact tracing teams in local PHE centres and regions. Local authorities will also be used at present to help to support local vulnerable populations who either cannot isolate or are at risk if they do, including those who are shielding.
The government does claim that ‘NHSX has involved experts from the National Cyber Security Centre to advise on best practice through the app’s development. Data will only ever be used for NHS care, management, evaluation and research and the NHS will comply fully with the law around its use, including the Data Protection Act.’, but there are widespread concerns still about privacy and data security with the new app and speculation about how many people actual Isle of Wight residents have downloaded it.
At the start of the epidemic, home isolation was limited to confirmed and suspected cases and their close contacts according to advice on the .gov website. The case criteria for suspected cases has changed throughout the epidemic. From January to late February the definition included asymptomatic travellers returning from lockdown zones in Hubei and Northern Italy as well symptomatic travellers from other high risk areas and contacts of confirmed cases. All suspected cases underwent testing and were advised to self-isolate until confirmation of a negative test result. This has now changed and since Friday 13th March 2020, all individuals with either a fever or a new persistent cough are advised to isolate themselves at home for 7 days from symptom onset without any testing unless they are hospitalised. From Monday 16th March 2020, their household contacts were also advised to isolate themselves for 14 days.
Mandatory quarantine measures were introduced early on for people returning from places with a very high infection rates, including Wuhan, China and people who had been on cruises with confirmed outbreaks. Asymptomatic persons were quarantined on repatriation and this was mandatory.
On 21st March 2020, people particularly susceptible to infections, including those who are immunosuppressed and recipients of organ transplantations were advised to shield themselves at home under all circumstances.
Prisons, immigration centres and young offenders’ institutions have also been advised to place suspected cases in protective isolation, but capacity does not always allow this. Symptomatic staff are also requested to isolate at home. At the end of March, the Home Office released 300 detainees at 'high risk' of contracting severe COVID-19 from detention centres, owing to the increased risk of transmission in these centres and the inability for these populations to self-isolate. Other detainees were not released but a commitment was made to stop new admissions (https://www.theguardian.com/uk-news/2020/mar/21/home-office-releases-300-from-detention-centres-amid-covid-19-pandemic). Prisons are also planning to release some low-risk prisoners early, given the increased risk of outbreaks in crowded and confined spaces (https://www.ft.com/content/4cffcc98-898e-4a78-bed9-584ee754b456). Officials have committed to undertaking risk assessments to ensure safe release.
People with symptoms and those classified as vulnerable have been dissuaded from visiting health facilities for consultations, and instead were asked to dial the urgent care advice service (111). However, there has been no comprehensive increase in the availability of video / remote consultations for health services. Reports so far suggest that healthcare utilisation has fallen dramatically and emergency departments attendance has also fallen by 25% (https://www.bmj.com/content/369/bmj.m1401).
Social care providers have been advised to implement isolation strategies of cohorting policies to manage those with a positive covid test, those displaying symptoms, or those awaiting the results of a test on discharge from hospital (i.e. individuals are still expected to be admitted to a care home from hospital even if symptomatic, while awaiting results of a test, or after having tested positive). For those entering the care home from hospital who are asymptomatic, even with a negative test, a 14 day isolation period is advised. For those entering a care home from the community, the guidance says homes “may wish” to isolate the new resident for a 14 days period.
If an outbreak within a care home is suspected, providers are to follow usual control plans for all infectious disease, including contacting local Health Protection Teams who will agree an action plan, which will include isolating cases, reinforcing infection control and reviewing escalation plans. Decisions about whether to move vulnerable individuals to different locations will be made where “clinically and socially required”. Some in the care home industry have expressed concern about the practicalities of isolating vulnerable older people (many with dementia) and the associated increased need for staff and PPE to make this effective (https://www.alzheimers.org.uk/news/2020-04-09/coronavirus-care-home-safety-letter-government). The ability of a care home to implement effective isolation procedures will vary according to a number of factors, including size. Care homes range in size from 5 beds to over 45 but the average care home has 29.2 beds (https://futurecarecapital.org.uk/research/data-that-cares/).
Where care homes are not able to implement adequate isolation or cohort policies, it is the responsibility of the local authority to secure alternative accommodation for the isolation period, drawing on the £1.3 billion discharge funding (https://www.gov.uk/government/news/2-9-billion-funding-to-strengthen-care-for-the-vulnerable).
For those being taken on by a home care provider or supported living provider, the individual should be cared for as covid-positive for an initial 14 day period, adhering to guidance around PPE. The home or domiciliary care sector is of particular concern as care workers may visit twenty different private homes per day presenting significant risk of spreading the virus without correct use of PPE.
Guidance issued by the government on 2 April said care homes should advise family and friends not to visit except in exceptional circumstances (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/880274/Admission_and_Care_of_Residents_during_COVID-19_Incident_in_a_Care_Home.pdf) but it was documented in the media that some homes had voluntarily taken action much earlier to stop or reduce visits (https://www.theguardian.com/world/2020/mar/13/care-homes-uk-ban-family-visits-stem-spread-coronavirus).