1.4 Monitoring and surveillance
Update 22nd September 2020
Despite increased testing, since late September, hospital admissions and deaths are increasing. Between 22nd August and 7th September the estimated doubling time of viral prevalence accelerated to approximately 8 days and on September 11th, the Scientific Advisory Group for Emergencies (SAGE) confirmed that the reproductive number (Rt) was at least 1 in most regions in England. Test positivity in the community has risen above 4% overall, with the greatest increases of 8-11% in the over 85s.
Antibody testing has now been initiated in care homes who did not participate in the initial study, which targeted a large group of care homes. Ongoing weekly surveillance reports continue to be published on a Friday including a range of measures including sentinel surveillance in GP flu clinics (https://www.gov.uk/government/publications/national-covid-19-surveillance-reports).
Update 4th August, 2020
Individual data on cases and contacts has now been made available to each local authority. PHE now include a watchlist of local authorities based on incident cases, test positivity rates, the nature of spread and other factors. These areas are offered enhanced support and some have started to implement local test and trace programmes to chase those contacts who have been uncontactable.
Update 4th July, 2020
As the NHS test and trace system has been rolled out, using predominantly Pillar 2 testing, there have been many criticisms that the data about local outbreaks and local exceedance of expected rates of infection have not been shared frequently enough with local authorities or in granular enough detail. Despite ongoing surveillance, cases in Leicester increased rapidly in the end of June, leading to a local lockdown and raising many questions for how data can and must be shared at a local level to equip local authorities to support local organisations to manage outbreaks early. Data sharing has now increased at a postcode level and closer inspection of the data from Leicester suggests that many of the emerging cases were in younger people working in food and factory outlets, as has been seen in other countries such as Germany (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/897128/COVID-19_activity_Leicester_Final-report_010720_v3.pdf).
Update 19th June 2020
Following a recommendation from the Joint Biosecurity Centre and a review of evidence, the four Chief Medical Officers of England, Northern Ireland, Scotland and Wales have agreed that the COVID-19 alert level should be downgraded from level 4 (the second highest alert level - a COVID-19 epidemic is in general circulation; transmission is high or rising exponentially) to level 3 (a COVID-19 epidemic is in general circulation). It was emphasised that while a steady decrease in cases in all nations had been recorded, localised outbreaks were still likely (https://www.gov.uk/government/news/update-from-the-uk-chief-medical-officers-on-the-uk-alert-level).
Update 12th June 2020
By the 10th June, 1,126,944 people had been tested under Pillar 1 of which 225,554 have been confirmed positive for COVID-19 in England. Surveillance reports do show that cases are falling, although it remains unclear what proportion of people who are infected have actually been tested, irrespective of symptoms (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/891721/Weekly_COVID19_Surveillance_Report_-_week_24.pdf).
Update 7th May 2020
Public Health services have been chronically underfunded in the United Kingdom, with the funding available to Public Health England approximately equivalent to the value of only half a District Hospital. This has many consequences for the ability to scale up contact tracing in order to release lockdown. Plans to scale-up contact tracing will depend in part on the use of a Bluetooth based mobile phone app, designed by Google and Apple and implemented by the NHS. Individuals in the community with symptoms will receive testing (described in section 1.5), and the app will perform automated contact tracing for individuals who test positive, identifying others who have been in prolonged close contact (less than 2 metres) using Bluetooth. Allied with the use of the app is the planned recruitment of 18,000 call handlers who will be trained to provide advice to contacts of confirmed cases determined through the app. These handlers will be supported by health protection practitioners in Public Health England who will also be responsible for providing telephone advice to cases. Recruitment has begun and this is expected to be implemented at some point in or after the middle of May. There is no intention at present to visit cases at home or to enforce their isolation.
In light of the new measures, the government has announced that it will publish the weekly reproduction number here: https://www.gov.uk/government/organisations/government-office-for-science. The reproduction number at present is 0.7, which reflects the period for 2 weeks prior to May 15th.
Both the number of new hospitalised cases and the number of deaths in the UK are reported daily in press briefings and are recorded by local area here: https://coronavirus.data.gov.uk/.
Monitoring of the epidemiology of COVID-19 cases and their contacts was initially undertaken by Health Protection Teams in Public Health England (PHE) and data is collated by the PHE field epidemiology service, who analysed data collected from the ‘First Few 100 cases’ (by PHE) as well as data collected daily from hospitals and the Office for National Statistics. All laboratory confirmed cases of COVID-19 are now notifiable by law to Public Health England.
Since 12th March 2020, mandatory reporting of aggregate data by NHS Trusts has been daily rather than weekly in view of the escalating COVID-19 situation and change in testing policy. PHE has established a COVID-19 Hospitalisation in England Surveillance System (CHESS), adapted from the UK Severe Influenza Surveillance System (USISS) (https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/phe-letter-to-trusts-re-daily-covid-19-hospital-surveillance-11-march-2020.pdf). CHESS collects epidemiological data (demographics, risk factors, clinical information on severity, and outcome) on COVID-19 infection in persons requiring hospitalisation and admittance to intensive care or high dependency unit (ICU/HDU). The intensive care national audit and research centre also publishes data on COVID-19 admissions to intensive care.
Surveillance testing is underway to test 800 people in the population to determine what proportion of the population have had the virus - this is expected to increase to 5,000 samples per week by the end of April (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878121/coronavirus-covid-19-testing-strategy.pdf). 16,000-20,000 people per week are expected to be recruited into a study using at-home immunity tests every 4 weeks to determine what proportion of the population are immune and how long immunity lasts.
The NHS have launched a coronavirus status checker to establish what proportion of people in the community have symptoms (https://www.nhs.uk/coronavirus-status-checker/). This is a collaboration between NHS England, NHSX, NHS Digital and Public Health England at the request of the Health and Social Care Secretary. Information collected by the NHS Coronavirus Status Checker will form part of a core national COVID-19 dataset held by NHS England.
On 27 April 2020 new figures released by the Office for National Statistics (ONS) showed that deaths in England and Wales hit a 20 year high in the week up to April 10, with about 11,854 more deaths than the five-year average. In London, this represents more than half of deaths during this period and overall more than 3 quarters of deaths are believed to have occurred in hospital. Of these, 39% (8,758) mentioned COVID-19 on the death certificate but this may omit some people who died of COVID-19 but were not tested. The greatest number of deaths from COVID-19 have occurred in those aged 85 or older (3,413), whilst the highest proportion of COVID-19 deaths was observed in those aged 65-74 (43%). However, it is expected that the proportion of deaths registered outside of hospital will increase as the weeks progress and the deaths in care homes catch up, and the latest and most up to date figures from Public Health England on the 29th April indicate that a total of 26,097 people have died from COVID-19 in the UK (https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweeklyinenglandandwalesprovisional/latest).
Until 30 April, deaths in care homes were not routinely reported in the government’s daily deaths figures, which only included hospital deaths. This was largely because care homes are not part of a single infrastructure with established reporting mechanisms as in the NHS. Throughout, deaths in care homes have been captured in ONS statistics but there is around a ten day time lag between death and publication in ONS data. From 30 April, deaths outside hospital (including in care homes) were included in daily deaths figures.
The focus of the majority of official government communications and updates was firmly on the NHS and references to long-term care (known as social care in the UK) were largely absent until early April 2020 in England (as social care is a devolved matter, the response in the other UK countries was slightly different – updates related to social care in this report refer to England only). This prompted many groups that represent social care bodies (https://www.local.gov.uk/letter-secretary-state-matt-hancock-lga-and-adass) to express concern about the lack of attention being paid to social care, with calls for a sector strategy. During the week of 13th April, social care began to have greater visibility in government daily briefings, among growing concerns in the media and among interest groups about deaths in care homes and the overall stability of the sector (https://www.independent.co.uk/news/health/coronavirus-social-care-nhs-homes-nurses-a9444886.html), and an action plan for social care was published on 15 April (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf). Although welcomed, many concerns and questions remain about the stability of the sector and the practicality of some of the guidance. While care homes are, at the time of writing, a key issue within national debate, the home care sector remains much less visible.