Four things the government should really do about Covid-19

The world has been watching the UK's response to Covid-19, and commentators see the response as confused, ineffective and arbitrary. How should the government proceed to rescue this situation?


Poverty is an issue

The increased risk of transmission in deprived areas and among people in low-paid jobs suggest that poverty and household crowding need to be addressed with interventions that go beyond guidance on social distancing, hand hygiene, and mask use. Previous research from the 2009 H1N1 swine flu pandemic suggests that although social distancing was effective in reducing infections, it was most effective in households with greater socioeconomic advantage.

Similar findings are emerging for COVID-19, with the ability to practice social distancing strongly differentiated by county and household income. The disproportionate impact of COVID-19 on households living in poverty, emphasize the need to urgently address these inequities that directly impact health outcomes. This could include social and income protection and support to ensure low paid, non-salaried and zero-hours contract workers can afford to follow isolation and quarantine recommendations, provision of protective equipment for workplaces and community settings, appropriate return-to-work guidelines, and widespread and effective testing and opportunities for isolation outside of the home to protect those still at work.


75% not self isolating

Second, clearly knowing and communicating which contacts and settings confer the highest risk for transmission can help direct effective contact tracing and testing efforts to increase the efficiency of mitigation strategies. We know that the early viral load peak in the course of the infection is crucial; in order to prevent onward transmission immediate self-isolation with symptom onset is essential. In addition, prompt, easily available testing and results with a 24-48 hours turnaround time, and a robust contact tracing system are a prerequisite for success.

In many countries, people with symptoms access testing late in the disease course, by which time they may have had multiple contacts while in the most infectious period. While self-isolation with symptoms is crucial, 75% of those with symptoms and their contacts in the UK reported not fully self-isolating. While presymptomatic transmission likely contributes to a fraction of onward transmission, over half of transmission is caused by those with symptoms, especially in the first few days after symptom onset. These findings suggest that messages should prioritise isolation practice, and policies should include supported isolation and quarantine.


Which activities are higher risk?

Third, policy makers and health experts can help the public differentiate between lower-risk and higher-risk activities and environments and public health messages could convey a spectrum of risk to the public to support engagement in alternatives for safer interaction, such as in outdoor settings.

Without clear public health communication about risk, individuals may misidentify unlikely sources of transmission —outdoor activities — while underestimating the dangers of higher-risk settings, such as family and friend gatherings, and indoor settings. Enhancing community awareness about risk can also encourage symptomatic persons and contacts of ill persons to isolate or self-quarantine to prevent ongoing transmission.


Crowded indoor spaces

Finally, because crowded, indoor spaces and gatherings likely will continue to be the driver of transmission, public health strategies will be needed to mitigate transmission in these settings. Examples are nursing homes, prisons, shelters, and meat-packing plants. Strategies such as personal protective equipment and routine regular testing to identify infected individuals early in the disease course should be implemented.

As part of the pandemic response we may need to consider fundamentally redesigning these settings, including improved ventilation, just as improved sanitation was a response to cholera. Such strategies should be adopted in settings where large outbreaks and superspreading events have been identified by contact tracing studies.

Further understanding of transmission dynamics is also critical to developing policy recommendations for the safe and effective reopening of businesses, primary and secondary schools, and universities.