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COVID-19 a year on: Why was the UK hit so hard?

Summary:
The initial COVID-19 epidemic in the UK was due to allowing vast numbers of people into the UK from abroad during late February and March 2020.  The UK receives millions of air passengers per month and estimates of 20,000 or more cases entered the country between January and March 23rd 2020 lockdown.  These initial cases were unhindered from infecting very large numbers of people.The failure of the UK to control its borders in the month after "political" Brexit is not surprising because it was following EU norms during the transition period and the EU did not authorise countries to take independent action until late March.  This does not exonerate the UK from inaction because several EU countries broke ranks with EU policy and the UK should have been expected to do so.  Whatever the

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The initial COVID-19 epidemic in the UK was due to allowing vast numbers of people into the UK from abroad during late February and March 2020.  The UK receives millions of air passengers per month and estimates of 20,000 or more cases entered the country between January and March 23rd 2020 lockdown.  These initial cases were unhindered from infecting very large numbers of people.

The failure of the UK to control its borders in the month after "political" Brexit is not surprising because it was following EU norms during the transition period and the EU did not authorise countries to take independent action until late March.  This does not exonerate the UK from inaction because several EU countries broke ranks with EU policy and the UK should have been expected to do so.  Whatever the politics it is the case that the UK had at least 100,000 people wandering around with COVID before lockdown in March 2020 and so could expect a very severe start to the epidemic.

The way that COVID spreads in the community has been poorly investigated.  Restaurants were thought to be fairly safe until the government tested this idea with the "Eat out to help out scheme" which increased COVID cases by between 8 and 17% (Fetzer 2020).  So how does COVID spread?

Hospitals are a major source of COVID-19 infections (up to 23% of cases). The rest of infections are acquired in the community and then spread in the home or between friends.  A study of household infection showed that about half of previously non-infected household members will be infected if COVID is brought home (Grijalva et al 2020). If the average household size is 2.4 in the UK then each infected person will infect on average about 0.7 people in the home. So 40% of COVID cases are probably due to household transmission.  However, other studies from China have put the household transmission rate at half of this figure so it is possible that the type of housing and lifestyle at home affect the figures.   There was a 6% chance of getting COVID from friends (MRC Data).  A study of Care Homes showed that once COVID had entered the home the residents had a similar chance of getting infected to people in other homes (Magni et al 2020).

It is astonishing that there is so little data on the spread of COVID-19 in the UK.  The meta-analysis by Thompson et al 2020 contained this table, largely based on studies from China:

COVID-19 a year on:  Why was the UK hit so hard?
The SAR is the "secondary attack rate" which is the percentage of people who were exposed who got COVID. The "Pooled Robs" is the number of people that each COVID case infects.  The numbers for Robs were too small and unreliable for Travel, healthcare and casual contacts.

Thomson et al found that the length of time family were exposed to an infected family member increased the SAR from 15% at less than 5 days exposure to 28% at more than 5 days.  There is little doubt that being indoors with family or friends is the truly high risk activity when someone in the group is infected.

Studies of the spread of COVID are scattered and incomplete but this graph shows the relative risk of commercial businesses:

COVID-19 a year on:  Why was the UK hit so hard?
Source: Chang et al 2020
Schools had a similar rate of COVID infection to the working community aged 25-49.

All of this means that once the epidemic had become established the ease with which it would be controlled would depend upon how well people controlled their socialising.  Some countries such as Italy put troops with guns on the streets to stop transmission but in the UK the population was largely trusted to control itself.  The population had been told very clearly that COVID was highly dangerous but in some countries this had less effect than we might expect.  

The very high case numbers in the UK were a result of the very high number of tests.  "Seek and ye shall find"!

COVID-19 a year on:  Why was the UK hit so hard?
Source: Our world in data
However, if we look at the axes they are logarithmic. The UK actually performed 50% more tests than Russia.  The typical number of tests in large European countries is about 50% of the UK number and so would have spotted about half the number of cases.

COVID-19 a year on:  Why was the UK hit so hard?

This means that the real case rate for France should have been almost twice as high as shown on the graph above.  The fact that the UK spots many more cases than other countries should make the death rate in the UK even more worrying.  The graph below shows that the UK is an outlier for deaths:

COVID-19 a year on:  Why was the UK hit so hard?



There is no doubt that hypertension, diabetes, obesity etc. are associated with an increased death rate from COVID but the massive excess of deaths in the UK cannot be due to obesity, hypertension etc.  because the USA and other Western countries also have these problems.  Hospital admissions in the UK are proportionate to the death rate so the high level of deaths cannot be bad practice in hospitals.  

The UK has one of the highest levels of life expectancy in the world.  True, the population is fat and physically unfit but so are the populations of many countries.

COVID-19 a year on:  Why was the UK hit so hard?
So why has the UK been hit so hard?  Why does the UK have almost twice as many deaths per million of population as similarly infected countries?  Superficially it looked like we had more cases but this is an artefact of performing twice as many tests or more than most countries.  The general health of the UK population is as good as that of most developed countries. So why are the British dying?

The answer to this question probably lies in the data showing that the severity of COVID depends upon the "viral load"  - the amount of virus entering the body during the process of being infected (See Fajnzylber et al 2020).  British people live in small, unventilated rooms in the cold, wet winter and it is this that is probably helping COVID kill us.  This would also explain the class and ethnicity (BAME) differences in death rates because overcrowding is related to class.

28/1/2021

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