Jodie Simpson: Highlights of the SAGE minutesSat 10:25 am +01:00, 6 Jun 2020
This is an article by Jodie Simpson (not her real name), who has gone through the minutes of the meetings held by the UK’s Scientific Advisory Group of Emergencies (SAGE).
I’ve read through the SAGE minutes, from March to the present date. Below are selected quotes, with very little input from me. This is just my take on it – someone else might find other elements more noteworthy, so a selection bias should be taken into account. My italics throughout.
My personal impression from reading the minutes is that:
1. There is a noticeable shift in approach after the Imperial team release their modelling.
2. New data are mentioned – but the advice seems to continue to be based on the modelling rather than on these data, even when they appear to conflict.
3. The claim that the government is ‘following the science’ was initially true. However, post-Lockdown, the minutes seem to show that SAGE is now fully on board with the government’s extremely cautious approach; tunnel vision is the order of the day.
“Social distancing” for over 65s is mentioned, but not as a distance rule – instead it means staying out of circulation as much as possible.
“SAGE noted the importance of assessing the wider health implications of these interventions, e.g. the effect of self-isolation on mental health.”
“There is currently no evidence that cancelling large events would be effective.”
“There are currently no scientific grounds to move away from containment efforts in the UK.”
“Individual home isolation” of symptomatic individuals is recommended – SAGE’s modelling assumes 50% compliance.
“No evidence that banning very large gatherings would reduce transmission”; “preventing all social interaction in public spaces would have an effect… but would be very difficult to implement”.
Summary mentions social distancing, again as a general practice regarding vulnerable groups and no one else. SAGE notes that “a balance needs to be struck between interventions that theoretically have significant impacts and interventions that the public can feasibly and safely adopt in sufficient numbers over long periods”.
The three measures agreed upon for dealing with the epidemic at this point are:
1. Home isolation of symptomatic cases;
2. Whole household isolation; [HD: ie. if a household member develops symptoms]
3. Social distancing for over 70s and vulnerable groups.
“SAGE is considering further social distancing interventions… to reduce demand below NHS capacity to respond.”
“The behavioural science suggests openly explaining to the public where the greatest risks lie and what individuals can do to release their own risk and risk to others… Greater transparency will help people understand personal risk and enable personal agency, send useful signals about risk in general and build public trust. Citizens should be treated as rational actors, capable of taking decisions for themselves and managing personal risk.”
“There is no strong evidence for public compliance rates changing during a major emergency. There is however, a link between public anxiety and protective behavioural change.”
‘There are no strong scientific grounds to hasten or delay implementation of either household isolation or social distancing of the elderly or the vulnerable in order to manage the epidemiological curve compared to previous advice. However, there will be some minor gains from going early and potentially useful reinforcement of the importance of taking personal action if symptomatic. Household isolation is modelled to have the biggest effect of the three interventions currently planned, but with some risks.”
“ACTION: DHSC Moral and Ethical Advisory Group (MEAG) to be invited to consider the ethical ramifications of household quarantine, given the increased risk to other residents where one resident is symptomatic.”
“SAGE was unanimous that measures seeking to completely suppress spread of Covid 19 will cause a second peak.”
“The risk of one person within a household passing the infection to others within the household is estimated to increase during household isolation, from 50% to 70%.”
“The objective is to avoid critical cases exceeding NHS intensive care and other respiratory support bed capacity… It is vital to understand numbers of cases regionally relative to NHS capacity, to know where local more stringent interventions might need to be introduced. The science suggests additional social distancing measures should be introduced as soon as possible.”
“Compliance with the measures by the public is key. It is expected to take two to three weeks before the impacts of measures are observed (this needs to be monitored carefully and the appropriate metrics need to be in place).”
“While SAGE’s view remains that school closures constitutes one of the less effective single measures to reduce the epidemic peak, it may nevertheless become necessary to introduce school closures in order to push demand for critical care below NHS capacity. However, school closures could increase the risks of transmission at smaller gatherings and for more vulnerable groups as well as impacting on key workers including NHS staff. As such it was agreed that further analysis and modelling of potential school closures was required (demand/supply, and effects on spread). SAGE agreed that its advice on interventions should be based on what the NHS needs and what modelling of those interventions suggests, not on the (limited) evidence on whether the public will comply with the interventions in sufficient numbers and over time.”
17th March – Neil Fergusons’s Imperial team release their modelling, which predicts a potential 500,000 deaths in the UK.
“SAGE advises that available evidence now supports implementing school closures on a national level as soon as practicable to prevent NHS intensive care capacity being exceeded.”
“Modelling suggests that, without mitigation, London could reach Covid 19 intensive care capacity by early April.”
“SAGE considered the modelling now supports school closures on a national level and that the effect would be greatest if instituted early… SAGE discussed behavioural science considerations on school closures. With limited evidence, SAGE considered the importance of clear public messaging and of drawing on the views of teachers on keeping schools open for key workers or vulnerable groups. There is a risk that even if schools remain open for the above groups, children may not attend.”
On London: “Measures with the strongest support, in terms of effect, were closure of a) schools, b) places of leisure (restaurants, bars, entertainment and indoor public spaces) and c) indoor workplaces. Modelling is unlikely to be able to analyse the impact of these interventions with great precision. Transport measures such as restricting public transport, taxis and private hire facilities would have minimal impact on reducing transmission.”
There are no minuted meetings for four days.
23rd March – LOCKDOWN
“Estimated Covid 19 fatalities are anticipated to overlap with those who are likely to be within the final year of their lives. It is important to get an accurate excess deaths estimate, including potential deaths due to the measures taken… Given the clear links between poverty and long-term ill health, health impacts associated with the economic consequences of interventions also need to be investigated.”
“SAGE noted that social distancing behaviours have been adopted by many but there is uncertainty whether they are being observed at the level required to bring the epidemic within NHS capacity. Key areas for further improvement include reducing contact with friends and family outside the household, and contact in shops and other areas… Compliance levels vary throughout the country; higher levels of compliance are being observed in London.”
“Number of cases arriving from other countries are estimated to be insignificant in comparison with domestic cases, comprising approximately 0.5%.”
“SAGE will consider how to minimise potential harms from the interventions, including from those arising from postponement of normal services, mental ill health and reduced ability to exercise. It needs to consider in particular health impacts on poorer people.”
“Spare bed capacity is at roughly 20%, including in London. Surge capacity planning for London is underway.”
“SAGE advises that there are currently conflicting data concerning potential treatments, such as chloroquine. No drug is completely safe, and it is vital not to make hasty decisions regarding treatments based on poor data. All cases should be used in some form of clinical trial.”
“SPI-M are reviewing 2 scenarios today using a consensus model from the Imperial group: the reasonable worst case and a more optimistic scenario… SAGE advises that, of these two scenarios, the reasonable worst case is the less likely.”
“Vast majority of admissions to ICU and high dependency are aged between mid-40s and 70. There are fewer admissions among the over 70s. ICU care may not reflect the full burden of the disease, as now many patients are being cared for in other settings. NHS reported that critical care bed occupancy is not yet reaching saturation levels, London included.”
“Reasonable worst case and optimistic scenario: SAGE endorsed the document under review… further work is required to understand how best to release measures and the scale of the second epidemic peak.”
“SAGE noted that the trends in ICU admissions and deaths appeared consistent with a straight line increase rather than an exponential increase.”
“NHS reported that critical care bed occupancy has not yet reached saturation levels, with around 1,000 beds in London, but that surge capacity was being used…”
“R is estimated to be around 0.6 with an upper bound of 0.9.”
“SAGE agreed that it is unlikely before week 13th April it can start to advise whether the interventions in place are having enough of an effect. SAGE does not currently recommend that changes be made at that point. There is a danger that lifting measures too early could cause a second wave of exponential epidemic growth – requiring measures to be re-imposed.”
“CO-CIN data is signalling nosocomial infection more strongly than previously.”
“SAGE agreed that the reasonable worst case scenario remains valid.”
“There is no current evidence that transmission is accelerating; it may be slowing. ICU admission doubling times are lengthening, particularly in London, and are now at 8.8. days in London and 6.5 days elsewhere. There remains NHS capacity in London and elsewhere, with the Nightingale hospitals available in addition to this.”
“ICU numbers appear to be flattening and new admissions to hospitals stabilising. Doubling times in hospitals continue to lengthen. Calls to NHS 111 and 999 appear to have peaked and be on the decline. The epidemic may be reaching its peak, but could remain at a plateau for some time.”
“WHO has concluded that there is currently no conclusive evidence that facemasks are beneficial for community use.”
“The number of deaths is plateauing, with transmission in the community highly likely to be declining. Nosocomial transmission accounts for an increasing proportion of cases.”
“Relatively small changes to social distancing measures could push R back above 1 in the community. It is therefore too early to recommend releasing any measures.”
“Risk of outdoor transmission is significantly lower than indoors.”
“Data indicate that hospital death numbers are still high… with a possible decline in London.”
“There is a decline in hospital admissions newly confirmed with Covid 1”
“Transmission in the community has slowed and it is highly likely that R in the community is less than 1… There is significant transmission in hospitals. This may have been masking the decline in cases in the community.”
“Overall, the evidence that masks could prevent spread is weak, but probably marginally in favour of a small effect. If there are benefits, these are only likely in specific circumstances.”
16th April – Lockdown extended for ‘at least’ another three weeks.
“There is some regional variation in compliance with distancing measures – with London having the highest compliance and the South West of England and Wales the lowest. There appears to be a relationship between compliance levels and epidemic growth. It was noted that the epidemic entered the South West of England last.”
“NHS remains well within bed capacity…”
“There is no indication that R is greater than 1 across any region, but there could still be more localised outbreaks.”
“Public Order: SAGE noted the importance of continually considering and testing the legitimacy and equity of lockdown measures, as well as thinking about approaches to addressing this. SAGE also noted the importance of developing evaluation strategies before measures are lifted.”
“The ‘2 metre rule’ remains appropriate, though closer contacts of a short duration are likely to pose a very low risk.”
“Hospital admissions are declining consistently across the country.”
“SAGE noted that evidence concerning the role of children in transmission and their susceptibility to infection remains inconclusive.”
“SAGE advised that, in addition to the importance of developing a vaccine for Covid 19, a clear UK plan is required for the seasonal flu vaccine for winter 2020-2021, including consideration of whether to vaccinate the entire UK population.”
“The consequences of changes in behaviour or contacts outside of schools as a result of schools reopening (such as changes to adherence to measures and to working patterns) are likely to have a larger effect on R than the effect of the schools themselves. These consequences are complex and highly uncertain. Even a short period of reopening may result in some of these occurring, which may persist even after schools close again for holidays.”
“SAGE discussed the test and trace system in development. It agreed that at least 80% of contacts of an index case would need to be contacted for a system to be effective.”
“There is currently insufficient evidence to determine whether the testing of index case contacts would significantly impact the epidemic compared with isolation alone (nor is it clear when to test to avoid false negatives).”
“It is considered essential that this testing capability is reached before the autumn/winter flu season when a large number of those reporting symptoms may not have Covid 19.”
“There is also a lack of information on modes of transmission in the UK… both in hospitals in the community. A case control study is urgently needed.”
“R is in the range 0.5-0.9. If health and social care settings are excluded, it is likely to be at the lower end of this range… SAGE advises that, based on current data, focus should be maintained on reducing transmission in health and care settings.”
“The overall epidemic can be considered as three separate, but interacting, epidemics…”
“Better data are needed from care homes… Data suggest that urgent action should be taken in settings where it is not already underway… such as avoiding movements of patients or staff between establishments, separating people as far as is practical, and testing extensively.”
“Preliminary swabbing results indicate that a significant proportion of infections are associated with healthcare workers… in both COVID and non-COVID areas.”
“The idea of ‘bubbles’ has many merits and should be explored further. There are both positive and negative behavioural aspects to be considered.”
“SAGE noted the important contribution made by Neil Ferguson over the course of the response and agreed the importance of continuing to draw upon the work of the Imperial College London team.”
“A safe approach to bubbles would need to include isolation of all members of a bubble in the case of one member showing symptoms. This would lead to increased frequency of isolation for people, particularly in the winter months.”
Concerns are expressed over the resilience of SAGE participants as they “continue to work under intense pressure for many more months… The need for pastoral support to be available to participants was noted.”
Update: Submissions still wanted. This is especially the time to submit if you are a sciencey type who would never dream of submitting an article to a non-technical journal. Live a little, hey? But also please submit if you have a totally non-Covid piece, eg. monetary symbolism in the poetry of Ewan McTeagle. Also: Please donate! Keep me from having to eat my children. I need expensive supplements to stop the cravings.