If the current lockdown easing does not create a second wave of infections over the next two months, it is somewhere between probable and very likely that we will get a second wave of COVID-19 this winter.
Recent analysis of the global 1918 flu pandemic by National Geographic Magazine has given us some clues as to what might happen. The 1918 flu pandemic played out differently in different US cities. Those cities like Philadelphia that did not lock down early had a sharp rise and fall of deaths in the first wave and the most overall deaths. Those that did lock down early and maintained strong social distancing had fewer deaths - but some like San Francisco and St Louis, had stronger second waves and in St Louis’ case, the second wave killed more than the first.
So what should we be doing now to make sure that further avoidable COVID-19 deaths are prevented this winter?
We can broadly think about individual and population COVID-19 mortality as determined by three factors; the risk of being infected in the first place; the risk of being hospitalised if infected; and the risk of death if ill enough to require medical treatment or hospitalisation.
The overall risk of death is cumulative across these three domains and is not evenly distributed across all populations. It depends on both individual and community vulnerability at each point and it is that vulnerability which we now urgently need to identify, prevent, mitigate and manage if we are to save lives.
Studies on who dies and who lives if infected show that age, front line working (exposure to more people), non-white ethnicity, low income and long term conditions each generate additional vulnerability.
Analysis of the first 16,749 patients hospitalised with COVID 19 showed that average age at death was 72, and that chronic cardiac disease, diabetes, non-asthmatic chronic pulmonary disease; and asthma were all associated with higher mortality risk.
Much of the COVID-19 vulnerability from these diseases is predictable, preventable and modifiable- and higher in BAME and low income groups. We can now also identify the communities with high vulnerability to a COVID second wave by area. Ben Barr and colleagues have created a Small Area Vulnerability index (SAVI) using ONS Middle Super-output area data (about 7,200 population seize).
They have explored the association between mortality from COVID-19 in each area and the proportion of the population from Black, Asian and Minority Ethnic (BAME) backgrounds, those income deprived, over 80 years old, or living in care homes, or living in overcrowded housing and those having been admitted to hospital in the past five years for a chronic health condition. Taken together these factors can give a vulnerability score for each area highlighting exactly where second wave vulnerability may be highest.
Many of the Middle Super-output Areas in my own local authority of Blackburn with Darwen are above average vulnerability risk on this index. If I had a £2m ‘COVID-19 Wave 2 Ready Community fund’ to invest between now and December, I would be immediately commissioning joint programmes in each our four primary care neighbourhoods, with GPs and primary care networks working closely with the voluntary and community sector and our own council and leisure and wellbeing services. They would deliver an accelerated community engagement programme for the diagnoses, prevention and improved management of obesity/ type 2 diabetes, asthma, COPD and a programme to ensure maximum uptake of winter flu vaccinations. The programme would also closely involve social media and our local paper. It is possible of course to do some of this through re-direction of existing mainstream funding and services. But in reality, primary care is underfunded and is likely to be overwhelmed in the coming months dealing with ‘supressed demand’, council services are now under substantial financial pressure due to loss of income during COVID-19 and the voluntary and community sector have already seen very significant disinvestment over the past five years.
We have about five months to get all of us, but particularly the most vulnerable communities, ready for a second wave. The epidemiology and spread of the second wave will probably be very different to wave 1, which spread up from the south and out from metropolitan areas. If the first wave could be described as a ‘pluvial inundation’ travelling sequentially from place to place-the second wave will be more like rising groundwater. Low income and BAME communities, who will have higher reservoirs of infection and more long term conditions are likely to be hit first, hard and universally in any second wave.
We urgently need a national fund to 'manage down' this vulnerability in these target communities, if we are to reduce further avoidable mortality.
If the second wave does come in December we can’t say we were surprised, we can’t say we did not know what to do, we can’t say the additional deaths were all unavoidable.
If a second COVID-19 wave does not come, the worst that will happen is that we will have improved health and reduced health inequalities faster than we have ever managed it before.
Either way a ‘COVID-19 Second Wave Ready Community Fund’ allocated now, will reduce future avoidable hospital admissions, prolong life, reduce NHS costs and promote equal life chances for all.
Dominic Harrison is director of public health and wellbeing at Blackburn with Darwen Council