Better Health For All

Writing a blog about Coronavirus, I confess to feeling slightly odd that I am not reporting from the frontline of the NHS. As a medically trained Public Health consultant, my name is down on the reserve list to get back in to scrubs if more resources are required. However, I am also incredibly aware that the job I am doing in my shed cum office at the bottom of the garden, is providing Public Health support in a way that I could only hope might be possible when I was an over enthusiastic Public Health registrar. 

I work for a company who are pioneers in providing health and insurance services to millions of people living in emerging markets. People who have previously been excluded from traditional health insurance models and who lack access to decent healthcare. The company has developed simple, affordable mobile delivered health insurance for people in developing countries, where there is often little or no public health system. And the reason that I work in my garden shed for them is because they also provide a mobile Health service (mHealth) – teledoctors and digital public health programmes – to millions of people across the Globe. My role is to design and write tailored and relevant health programmes, and to work with the technical brains of the company to get them out to as many people as possible, across as many digital channels as people are able to access.  

As I write, Coronavirus cases are increasing in many of the countries where we work, with particular cause for concern in Bangladesh and Pakistan. From a teledoctor perspective, we have increased capacity and are braced for high demand for these services, not least because people are unable or unwilling to utilise their local clinic for non-coronavirus health issues. In Pakistan, we are partnering directly with the Government to bolster their health service offer. For our health programmes, we are running as fast as we can to get information out on prevention, local guidelines, dealing with symptoms, mental and physical wellbeing, with some myth busting thrown in for good measure. I have to write an easily understandable, actionable message in 160 characters or less to fit the parameters of our SMS allowance (never have words seemed so valuable or so long!). Cultural context must be accounted for and the fact that my English version will be translated by our local teams in to languages such as Bengali, Urdu and Twi, before being sent out to millions of people who do not have an NHS equivalent, and who have limited reliable sources of information beyond this SMS delivered to their mobile phone.  

Coronavirus has also been the catalyst for putting out our health messages to people who do not have insurance in the countries where we work. Through websites, apps, Facebook, Instagram, and WhatsApp, these evidence based health messages are translated into visual images that allow people with smartphones the opportunity to gather reliable knowledge as to how we can all effectively fight this pandemic. 

In the UK, I think that we are still wary of digital health. We have heard about virtual doctor surgeries and the concerns that they are not as effective as in person consultations. I think that as we become more comfortable with technology, these concerns will diminish. This global pandemic is in a way aiding this adoption process. In the Countries where this mHealth service is working, we are already filling a gap where the number of doctors per head of population is simply not compatible with offering everyone who needs it an in-person consultation, particularly in the face of a global pandemic. Furthermore, providing accurate, personalised, health information to millions of people through their mobile phones has the potential to revolutionise our approach to ensuring population health. For coronavirus, these messages are designed to encourage people to keep safe and well by following the best guidelines, based on the best evidence that we have.  

If I am called back to the NHS frontline, of course I will go. But whilst I am in my shed, if our work is able to alleviate even a small amount of the stress on overstretched health systems around the world in the coming months, I am very grateful and proud to have had the opportunity to contribute to such an essential endeavour. 

Written by Rebecca Cooper

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The recent guidance published by the UK Government on mental health and wellbeing during Covid-19 was a welcome addition to the various guidance and resources provided to support us to manage the pandemic.

There is no public health without public mental health, and communicable disease control is no exception.

Direct impacts of the virus through illness, loss of loved ones, and anxiety around contagion are mixed with the effects of control measures – self-isolation, social distancing, and changes in social and material circumstances can all have a detrimental effect on mental health and wellbeing and also have the potential to widen existing inequalities in mental health.

As public health professionals, our role is to manage the acute response to the virus and mitigate its short-term effects, and also to ensure that wider systems are in place to protect against collateral damage and support the ‘recovery and repair’ phase and beyond. From a public mental health perspective, this means providing advice and guidance on how to maintain wellbeing during the pandemic, ensuring access to further support when required (including maintaining access to services for those currently receiving care), and using the opportunity created by the pandemic to embed resilience and wellbeing at a population level over the longer term.

As well as limiting the harm directly caused by Covid-19, we need to be vigilant for where control measures may exacerbate existing adversity or place people at additional risk. Where someone’s home is not a place of safety, or when they do not have ready access to essentials such as food and medicine, social distancing and self-isolation may place them at greater risk of harm. In addition, now is a good time to consider information about the impact of stress and social isolation on harmful health behaviours (e.g. smoking, alcohol and substance use), mental health and even the immune response.  It may also be appropriate to examine the links between external stressors and the incidence of domestic violence and child abuse.

While much of the current focus is understandably on mitigating the harmful impacts of the virus, a number of unexpected positive impacts have emerged as a result of social distancing measures. Communities have mobilised to support those who are alone and vulnerable. Increases in remote working have led to improved air quality and better work-life balance. Innovative use of technology has widened access to events and the arts. Exercise has been reframed as an opportunity rather than a chore, with people keen to enjoy being outdoors. Sustaining improvements in social capital once the pandemic is over and harnessing these benefits in a way that includes everyone, particularly the most marginalised, is key to promoting cohesion and wellbeing in communities.

Because we are part of the populations we serve, and have the same challenges, worries and limitations this also means being a role model. Looking after our own wellbeing is something we often neglect particularly in times of crisis, but now it is especially important. While much of the world slows down, workload has increased for many working in public health, whether at home or in the office and whilst we may secretly want to be, we are not superheroes. We are parents, carers, spouses, friends. Some of us may be vulnerable or even extremely vulnerable to the effects of Covid-19, or have loved ones that are. And just like anyone else, we can be scared, anxious, exhausted and overwhelmed.

Our own health and wellbeing is vital to being able to give the best service we can, and so taking our own advice becomes as much a matter of good public health practice as one of individual necessity. Those of us with management responsibility also have a duty of care to our teams, and to ensure that we model good practice as well as support them to stay well and healthy at work.

The Public Mental Health SIG is collating information and resources on maintaining and enhancing mental wellbeing and on mental health more generally, in times of Covid-19, which can be found here.

This addresses the wealth of evidence and good practice currently available to support and improve population mental wellbeing, which can be drawn on in relation to both the acute response and the legacy impact of Covid-19.

While the ‘normal’ we go back to may look quite different to the one we left behind, we know what works – the challenge will be in how we apply that knowledge to take care of ourselves and others.

Written by Lina Martino, Chair of FPH’s Public Mental Health SIG

With thanks to Professor Sarah Stewart-Brown (Professor of Public Health, Warwick University) and Dr Vaishnavee Madden (Consultant in Public Health, Ealing Council)

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Summary
Each day that public health in England fails to adhere to basic public health control methods the cost to the country grows. Public health’s reactions to the epidemic have been hesitant, limited, centralised and unconventional. It is as though the senior staff still think this is an influenza epidemic. Now is the time for an ambitious public health response. The government say they are following scientific advice. Our public health leaders should listen to colleagues in the far east and to Public Health Directors in our own local authorities.

Public health in England is quite capable of seizing the opportunity and rapidly

• Reorienting its purpose from mitigation to control and elimination
• Setting up a robust case finding and contact tracing function at local authority level
• Devolving disease controls to local authorities to allow divergent and locally appropriate responses to future outbreaks
• Requiring the control of travel where necessary
• Explaining that control must precede easing of physical distancing measures and this will be achieved quicker in some parts of the country than others
• Explaining the key role each member of the public has if they become unwell.

Introduction
According to the Office of Budget Responsibility (OBR), the GDP in the UK will shrink by 35% in the second Quarter 2 of the fiscal year on account of the COVID-19 lockdown. The cost during the period of ‘full lockdown’ from 23rd March to 7th May will be about £92 billion. This is equivalent to £2 billion a day (1). Is there anyway the public health measures in the UK could have reduced the lockdown period and saved some of this cost? What strategy will minimise costs in the future?

Different countries have used alternative approaches. The successful ones so far have gone for elimination not mitigation. Elimination requires rapid isolation of all known cases and contacts, which in turn requires prompt identification of cases and contacts within hours not days. Successful control means universal physical distancing is not necessary because targeted isolation of cases and contacts is sufficient to curtail the epidemic. This level of control has been achieved in countries using this approach (2–6). How successful has public health in England been in each phase of the epidemic?

Phases
The COVID-19 epidemic can be considered to have three phases – (i) the containment phase which seeks to eliminate the virus infection from the population, followed if this fails by (ii) the mitigation phase, which in many countries including the UK has matured into a suppression phase, which seeks to minimise the effects of the epidemic by suppressing transmission, followed when successful by (iii) the control phase which seeks to re-establish containment.

Containment phase
WHO declared the outbreak was a Public Health Emergency of International Concern on 31st January and in the UK the containment phase was abandoned seven weeks later on 23rd March. The first case was identified on 1st January and by 23rd March 5,683 cases had been identified including 335 hospital deaths. Public Health England (PHE) has not published details of what exactly it did during this phase, but one can assume it was case finding, contact tracing and isolation of travellers from infected countries. Apparently, this activity stopped when the containment phase was abandoned. The failure to contain the epidemic at this stage has cost the country a massive sum both in terms of health and socio-economic wellbeing.

Mitigation phase
The lockdown began on 23rd March. It has succeeded in supressing transmission to the extent that the NHS has not been overwhelmed. Five weeks into the mitigation phase while the rate of new deaths is falling there is no control of the epidemic. Control requires an understanding of the state of the epidemic from surveillance, complete case finding and contact tracing. What could have been done to gain control of the epidemic during this phase?

Surveillance
For the first time since the start of the epidemic on 23rd April PHE published a COVID-19 surveillance report describing details of the available surveillance data (7). The report, updated weekly, contains no analysis and minimal commentary. It contains no mention of:

• An estimate of the number of actual rather than known cases by age and sex
• The number of contacts traced per case by risk category, average time since case identification, test result and trace failure
• The specificity and sensitivity of the tests in use
• An estimate of the number of asymptomatic cases
• The current reproduction number for each region
• The number, size and location of outbreaks.

These figures are required to gain an understanding of the epidemic and its control. Some countries provide these estimates on a daily, weekly or fortnightly basis.

Case finding and contact tracing
No system of notification and control

Case finding and contact tracing were abandoned at the start of the mitigation phase for no publicised reason. Perhaps public health wanted to reserve tests for NHS cases. Testing never has been an essential component of case finding in public health and a shortage of tests is not a valid excuse to stop contact tracing. The European Centre for Disease Control (ECDC) has updated guidance on contact tracing with or without testing (8). PHE still has not provided similar information needed to build up the system here:

• A case definition and recommended follow up actions
• Contact definitions and recommended follow up action
• A streamlined notification system including a database system such as the WHO’s Go.data tool to assist staff at local level and staff centrally
• Instructions for 111 call centres, GPs, hospitals and care homes to use the database.

Too little, too late
On 24th April the Government announced the recommencement of case finding and contact tracing in England. A meagre 18,000 people will be involved initially. Much reliance seems to be placed on a new and untested smart phone application. The number to be recruited seems symptomatic of the inability to appreciate the need to control the epidemic and how to do this expeditiously and at scale.

The number of people required to successfully identify, test and contact trace varies from local authority to local authority (9). The number of staff required will fall as the number of new cases falls, which in China in provinces other than Hubei was 5.5% a day after the peak of cases (5). A recent report taking into account changes in case definition suggests a decay rate of 18% a day (10). In two weeks’ time by 6th May the numbers will be 1.6/1000 population or five times the number proposed by the Government (Table 1). Staff numbers required will be less if the decay rate is nearer 18% so the numbers for the 6th May in Table 1 are conservative. If our lockdown measures are less effective than in China then the staff numbers required will need to be somewhat higher.

Table 1 – Personnel required to test and trace contacts by English region

Not going local
If contact tracing had been built up from the start, it is clear from the regional figures in Table 1 that the East of England, the North West, the South East and the South West with half the number of deaths for their size as compared to the other regions would have been able to handle the number of cases by now. The economies of these regions which represent two thirds of the nation’s population could have been gradually resumed between 22nd April and 28th April.

The remaining high incidence regions should have been able to take control soon after 6th May. There would not have been the need to maintain economic shutdown after that date if the contact tracing system had been built up and working.

The socio-economic cost of the public health strategy so far
The cost of the lockdown from 23rd March to 7th May will be about £92 billion. The lockdown could have been eased 14 days earlier in the low incident regions if they had taken control of the epidemic then. This would have saved £15 billion of the lockdown cost (Table 2). Each day the lockdown continues past 7th May will cost an additional £1.7 billion.

Table 2 – Estimate of cost of delayed control of epidemic in England

Getting back on track – the potential gains
The control phase
Each day the control phase is delayed will cost the country £2 billion. But the control phase can only safely be initiated when the mitigation phase has reduced new cases to a level which can be handled by case finding and contact tracing.

This phase will be difficult and will need to last until herd immunity stops transmission. It requires rapid 100% case finding and contact tracing, an ability to enforce quarantine and travel restrictions and local knowledge and resources to investigate and deal with outbreaks.

Case finding and contact tracing
For case finding and contact tracing to be effective:

• Every new case must be found and isolated within 24 hours and the source of the infection identified if possible
• All close contacts need to be identified within two days and isolated for 14 days or until a negative test result
• Isolation needs to be monitored daily to ensure compliance.

The following points need to be emphasised: –

• Testing is helpful but not necessary to identify cases, which can be done on a symptoms only basis. The workload will be higher as two thirds of suspected cases will not actually have the virus but manageable (9). Clinical judgement is required as the test is not 100% sensitive with a proportion of false negative results inevitably emerging.
• Unlike influenza the longer incubation period of Covid-19 allows contact isolation to be the key to successful control. Basically there are three days to find and quarantine the high-risk contacts (11).
• Contact tracing apps would help but are not essential; the higher the uptake the easier will be the listing of contacts. Again the number of volunteers required to undertake the work is manageable. Table 1 does not assume an app will be available.
• Management of case identification and tracing contacts can only be done at local authority level as the amount of detail of the local population, geography, community, health staff and laboratory is only available locally.
• Travel restrictions between regions will be needed if the source of more than a handful of new infections comes from outside the region.

Outbreak investigation and control
Until a vaccine provides herd immunity the control phase will be punctuated by local outbreaks with the potential for one or more very large outbreaks. As already appreciated in New Zealand which has just entered the control phase these outbreaks will need to be anticipated and dealt with expeditiously (12). Local teams will help each other when necessary.

What preparations have been made to set up these control measures?
It appears that the system is trying to keep controls at central and regional levels, presumably because they have no staff of their own at local level (13). It is difficult to see how control is possible unless:

• local authorities who have the local experts available including directors of public health, health visitors and environmental health officers are given responsibility for case finding, contact tracing, enforcement of quarantine and travel restrictions
• surveillance is available at regional level.

Lifting the lockdown and cutting costs
Every day control is delayed will cost £2 billion. Control will be achieved in different regions at different times. Lockdown can be lifted as soon as the epidemic is under control in each region. The local economy can then emerge. To wait for the last region to achieve control will frustrate the rest of the country. Decentralised decisions about universal physical distancing measures will reduce costs.

Conclusion
Here is an identifiable public health strategy, other than the one the Government seems to be adopting, which would save a lot of money, allow restrictions to be eased in different parts of the country depending on the state of infections, and allow us to remain generally on top of the pandemic until a vaccine becomes available. Our public health leaders should listen to colleagues in the far east and Lewis, the Dauphin “Strong reasons make strong actions. If you say, ay, the king will not say no.” (Shakespeare; King John, Act III, Scene IV).

Written Dr Cam Bowie, retired director of public health, Somerset and professor of community health, Malawi. cam.bowie1@gmail.com. Axminster, EX13 5BL

References
1. OBR. Coronavirus reference scenarios [Internet]. Office for Budget Responsibility. [cited 2020 Apr 29]. Available from: https://obr.uk/coronavirus-reference-scenario/

2. Ng Y. Evaluation of the Effectiveness of Surveillance and Containment Measures for the First 100 Patients with COVID-19 in Singapore — January 2–February 29, 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2020 Apr 7];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6911e1.htm

3. Song J-Y, Yun J-G, Noh J-Y, Cheong H-J, Kim W-J. Covid-19 in South Korea — Challenges of Subclinical Manifestations. N Engl J Med. 2020 Apr 6;0(0):null.

4. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. 2020 Apr 14;323(14):1341–2.

5. Leung K, Wu JT, Liu D, Leung GM. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Lancet Lond Engl. 2020 25;395(10233):1382–93.

6. Cowling BJ, Ali ST, Ng TWY, Tsang TK, Li JCM, Fong MW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health. 2020 Apr 17;

7. PHE. Weekly COVID-19 surveillance report published [Internet]. GOV.UK. [cited 2020 Apr 25]. Available from: https://www.gov.uk/government/news/weekly-covid-19-surveillance-report-published

8. ECDC. Contact tracing: Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union – second update [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020 Apr 28]. Available from: https://www.ecdc.europa.eu/en/covid-19-contact-tracing-public-health-management

9. Bowie C, Hill A. Re: Is it possible to implement the proposals in the Editorial ‘Covid-19: why is the UK government ignoring WHO’s advice? (1)’. 2020 Apr 29 [cited 2020 Apr 29]; Available from: https://www.bmj.com/content/368/bmj.m1284/rr-9

10. Tsang TK, Wu P, Lin Y, Lau EHY, Leung GM, Cowling BJ. Effect of changing case definitions for COVID-19 on the epidemic curve and transmission parameters in mainland China: a modelling study. Lancet Public Health. 2020 Apr 21;

11. Baker M, Kvalsvig A, Verrall AJ, Telfar-Barnard L, Wilson N. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J. 2020 03;133(1512):10–4.

12. Rapid Audit of Contact Tracing for COVID-19 in New Zealand [Internet]. Ministry of Health NZ. [cited 2020 Apr 30]. Available from: https://www.health.govt.nz/publication/rapid-audit-contact-tracing-covid-19-new-zealand

13. Pollock AM, Roderick P, Cheng KK, Pankhania B. Covid-19: why is the UK government ignoring WHO’s advice? BMJ. 2020 30;368:m1284.

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The Project

Barnet Public Health Team, RCN, and Middlesex University worked together to develop a local authority hosted public health placement specifically for pre-registration nursing.

Nursing Context

It is increasingly important for nurses to understand and recognise their role and contribution to public health. Nurses make up a significant body of professionals working in public health, supporting communities with disease prevention, assessment, education, and evaluation of population health. This move from nursing an individual or small group to the wider community is an opportunity to influence change at a strategic level.

To prepare pre-registration learners for the future workforce a variety of learning experiences in practice including public health is essential. While this has always been implicit within curricula there is a need for more emphasis and direct learning opportunities. The NMC (2018) Standards framework for nursing and midwifery education require all registrants to have an understanding and knowledge of public health agendas and associated health promotion strategies . It is in this context that the pilot project was devised.

First placements

Two child health field student nurses have both completed five weeks placements. With more planned for other field students. The placements were positively evaluated by the students and the public health team.

The students reported

“When out in placement we need to use evidence-based practice to give rationale to the care we are giving to our patients. When the opportunity to spend five weeks of our placement in Public Health we jumped at the chance…

Public Health is all about our community. The decisions made for healthy eating in schools, prevention of diseases through immunisation programmes, flu vaccinations, community centres and support for families, social prescribing, smoking cessation to name just a few…

Listening to the impact that the healthy schools project has had on school children was inspiring. Growing their own vegetables at school AND being able to eat the produce! Healthy lives start with healthy children. Educating from young the importance of a nutritious diet will have positive outcomes for future generations”.

The Learning

The students reported the whole system learning was key to understanding the needs of local families and provided an opportunity to consider more expansive learning regarding the young people who will be in their care:

• Attending foodbanks
• Understanding infection control on a local population level
• Focussing on the health promotion and illness prevention occurring in Barnet
• National initiatives related to the wider social determinants of health.

The Public Health perspective

Having students on placement in public health is a learning opportunity for staff as well as the students. The students bring their recent theoretical learning and the staff can find this interesting and learn too for example discussions about the projects they undertook meant that staff could update themselves on breastfeeding support or staff retention practices in the NHS.

The University perspective

The evident success of this placement as a learning environment for the 2 students so far is exciting. Both considered the transferable skills gained, including enhanced communication, developing a more social model of health and being aware of the public health team roles. This includes the knowledge that public health may be a career choice in the future.

Widening the learning opportunities for the learners is a key objective for the university. With the main campus located in Barnet, the collaborative working with our local authority supports a key university aim to be actively involved in the community.

Benefits for Nurses in Public Health

It can be a challenge for nurses working in public health to meet the NMC revalidation requirements and thus retain registration.

Facilitating student nurse placements is one way of demonstrating how they meet The Code’s requirement to support learners.

This full placement was only possible as there was an NMC registered nurse to undertake the Practice Assessor role within the public health team.

Conclusion

The local authority and HEI were committed to the project and demonstrated the benefits of this collaboration.

This pilot was a success. All involved were able to see the value and reciprocal learning for everyone.

Next steps

• To continue to offer this experience to more nursing students in Barnet.
• To present this experience to public health teams and HEIs in the hope to inspire others to consider this student placement opportunity.
• To develop a toolkit for other localities to support the introduction of this type of placement

Written by Pam Hodge, Middlesex University

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