The Government has created the National Institute for Health Protection, which combines the roles of Public Health England (PHE) and NHS Test and Trace, in addition to harnessing the analytical capability of the new Joint Biosecurity Centre (JBC). The first priority of this single organisation will be to tackle the ongoing COVID-19 pandemic and protect the nation's health. This pending new governmental organisation's primary focus will be public health protection and rationalising the capability of the country to combat infectious diseases now and in the future.
Although the new body exists to minimise disruption to the vital work of dealing with the second wave of COVID-19, the organisation will be formalised and fully operating from spring 2021. In learning the lessons from the past 9 months since the initial outbreak of COVID-19, the institute aspires to focus on a rigorous science-led approach to public health protection with a goal of boosting the country's resilience in dealing with, and recovering from, the pandemic, in addition to meeting the health challenges of the coming winter.
Background
Perhaps fearing the worst, the Government announced the creation of the institute last August, when many people were hoping the worst of COVID-19 was over and were enjoying the lifting of lockdown, which coincided with the reopening of the hospitality sector and the arrival of a glorious summer. Desperate to escape the emotional trauma of lockdown, many families took advantage of the reopening of international travel to enjoy favourite beach holidays in countries such as Spain and Greece.
However, almost as soon as the lockdown restrictions were eased, worrying signs began to emerge of the return of the virus. At first there were optimistic voices proclaiming that the virus was becoming more incapacitated and, with a corresponding decrease in infectivity the optimists hoped that it might not withstand the heat of the 2020 British summer. Alas, as the summer wore on, it became obvious that the virus was not simply going to disappear as had happened with SARS (severe acute respiratory syndrome) in 2003, which affected many counties; like SARS-CoV-2, it had also emerged first in China. The SARS pandemic was short lived, but it is important to stress that it was also caused by a coronavirus and, as with SARS-CoV-2, bats have been implicated in the transmission of the virus, the first directly and the second indirectly (Dutton, 2020).
Unlike SARS, this coronavirus may be with us for years to come and, in the absence of an effective vaccine, could kill many more people; the worldwide death toll currently stands at more than 1 million (Johns Hopkins University, 2020).
Although, with the benefit of hindsight, it is easy to be critical of the way the Government handled the first wave of the pandemic, certain aspects could have been anticipated. The issue of the availability of personal protective equipment (PPE), for example, could have been avoided if the Government had acted sooner on its own analysis of PPE provision, carried out in 2016. Exercise Cygnus was an Emergency Preparedness, Resilience and Response exercise on the ability of the NHS as a whole to handle a potential pandemic on a scale similar to the current situation. In context, the NHS failed this assessment of its preparedness, and after the exercise ministers were informed that it was likely that the country would be quickly overwhelmed during a severe pandemic with a shortage of critical care beds, morgue capacity and, crucially, PPE. Despite these findings, it appears that little was learnt.
Regardless of public optimism, there has been a new surge in SARS-CoV-2 infections. In the UK, more than 620 NHS staff and social care worker deaths have been linked to the virus, and many frontline carers will be worried about the current resurgence of COVID-19 (Lintern, 2020).
The launch of the new Institute for Health Protection is timely because there is growing recognition worldwide that COVID-19 is not the last pandemic of this century. So why are societies now more concerned about pandemic infections, given the successes of modern medicine compared to that of previous centuries? Many scientists consider that continued human encroachment on the natural world is accelerating the transmission of zoonotic disease, that is infectious diseases spread from different species of animal to humans, resulting in these new pandemics. Humans are now coming into close contact with wild animal disease vectors, for example certain species of bats, ant eaters and birds, which previously would have been rare. This is probably exacerbated when humans eat these animals after buying them live from so-called wet markets (Fine Maron, 2020).
The past two decades have seen a number of significant pandemic threats, none of which fortunately reached the magnitude of the current pandemic. These were SARS, MERS (Middle East SARS), Ebola, avian influenza and swine flu. Although humanity was able to dodge these biological bullets, unfortunately SARS-CoV-2 has hit the target. Furthermore, and perhaps waiting in the shadow of SARS-CoV-2, are reports of pig farmers in China being infected by a new, virulent strain of swine flu (Gill, 2020).
The role of the new institute
The new public health body for England will be modelled on Germany's Robert Koch Institute, named after the famous Victorian microbiologist. It is perhaps no surprise that the Government is using this model because Germany has shown several elements of success in dealing with this viral outbreak. The Robert Koch has four phases of a preparedness and response framework—prevent, detect, contain, and treat—which has proved successful in reducing mortality figures. This has been attributed to ensuring that there was sufficient testing capacity early on, high levels of actual testing (in the European Union, Germany is a leader in tests per confirmed case), and an effective containment strategy among vulnerable older people, which explains the much lower mortality rate among this group in Germany compared with other countries such as the UK (Wieler, 2020).
Although nominally independent, the Robert Koch Institute is owned and funded by the German Health Ministry, and research and prevention of infections is one of its main activities. Since January 2008, for example, it has been administrating a pan-German health monitoring system that uses health examination surveys and health interview surveys, with longitudinal components being alternatingly applied. These nationwide studies are also triangulated with data from annual cross-sectional interview surveys of the German population (Kurth et al, 2009). Such a framework of a continuous health monitoring is proving not only to be successful, but also worthy of emulation (Hallam, 2020).
As public concern grew over the way in which the first wave of the COVID-19 pandemic was handled, ministers became frustrated with how PHE was organising the testing of people suspected of being infected with SARS-CoV-2, the tracing of contacts of those shown to be infected and how it counted COVID-related deaths in both the hospital and social care sectors. It is hoped that the new organisation will enhance the science-led approach to public health protection and the country's ability to cope with the second wave of COVID-19.
The National Institute for Health Protection now has a single command structure to advance the country's response to the pandemic. It combines PHE and NHS Test and Trace, in addition to the analytical capability of the JBC, under a single leadership team primarily, at first, to protect the nation's health by concentrating on tackling COVID-19, the worst pandemic since the Spanish flu that erupted in the aftermath of the First World War. The organisation will support local directors of public health and local authorities on the frontline of the COVID-19 response.
The institute will also provide the emergency response and lead on preparedness to deal with the most severe incidents at national and local levels, such as that which has already occurred in the north of England and in South Wales. Its other roles will include supporting and resourcing local authorities to manage local outbreaks, in addition to enhancing the SARSCoV-2 testing programme and boosting contact tracing. The new body will provide specialist scientific advice on immunisation and other countermeasures that will be vital when the long-awaited vaccine trials are completed.
Joint Biosecurity Centre
A fundamental part of the National Institute for Health Protection is the JBC, created to bring together expertise and analysis to inform decisions on tackling COVID-19. It will add to the variety of bodies already providing expert advice to the Government on pandemics. The JBC is predicated on the successes of the current Joint Terrorism Analysis Centre, which analyses intelligence related to terrorism and sets threat levels, which in turn inform ministers' decisions on protecting the public, and operational deployments by the police and other agencies. Given the threat of nature's own biological terror in the form of pandemics this is perhaps an apt organisation to emulate.
Operating under the jurisdiction of the National Institute for Health Protection, the JBC will have two main functions. The first is to provide real-time analysis on infection outbreaks of SARS-CoV-2 as they arise, collecting and analysing data related to the prevalence of the disease and the infection rates nationwide. The second is to advise the Government on how to respond to spikes in infections, such as closing schools or workplaces in specified localities where infection levels have risen.
All arms of the new institute will report directly to the Secretary of State for Health and Social Care and support the clinical leadership of the UK's four chief medical officers. The institute's primary focus is to ensure that the country has optimum capability to control infectious diseases such as COVID-19, and respond to current and future pandemics or other health protection crises.
It is to be hoped that the institute will help put the country in a strong position to deal with the growing second wave of COVID-19 in meeting the health protection challenges over the winter months. There are many human tragedies behind the death toll wreaked by this pandemic and healthcare staff are at the forefront of both delivering care to those who need it while protecting their own lives, and those of colleagues and other service users.