In the air tonight…Or is it?

Across the country businesses have reopened giving a slight boost to the economy,¹ but the level of sales and visiting customers is only half of what it was pre lockdown.   The Government has provided business support guidance ² to help business manage risk safely.

As you would expect it is based on carrying out a risk assessment and managing the number of staff and customers that can safely enter the business whilst social distancing is being observed.   Every ‘do and don’t’ is underpinned by universally understood basic principles  that the WHO has succinctly summarised in their Q&A’s.³   The disease transmits from person to person in aerosol form when we cough or sneeze and disease particles travel for about a metre in the air before gravity forces them to land on others or on surfaces that are then touched by other persons, who then touch their eyes, mouth or nose.  If we can maintain a 2 metre distance where possible and wash hands or use gel and prevent crowding particularly where there is poor ventilation ^3,4 and above all stop touching our faces we can go about our business relatively safely.   Or can we?

 

Concerns have now been raised by 239 experts across 32 countries ⁵ that smaller sized droplets could hover in the air for longer and travel across greater distances posing a risk beyond 2 metres.  So, is it time to rip up all our do’s and don’ts and start again?  The current thinking is that droplets from coughs and sneezes, basically projectile virus that drop out of the air after about a metres travel are greater than 5 micrometres in size.  Smaller droplets than this can stay in the air for longer. ⁶   But is exposure to smaller sized droplets sufficient to infect a person?  And if so, is it a significant route of transmission?    A Chinese epidemiological study examined how several families in Guagzhou who dined in the same restaurant became infected by COVID-19 despite taking social distancing measures.⁷  They were apparently all sat in front of the air conditioning unit and this study, non-peer reviewed as it is, forms part of the evidence used to strengthen the argument.⁸

 

This raises another question does being exposed to a higher or lesser dose of COVID 19 determine the severity of infection?  For other infectious diseases such as HIV during close contact, the amount of viral load whether higher or lower makes all the difference as to whether or not a person can transmit the disease.⁹  But this does not seem to be the case with COVID-19.  Testing of patients in Guangzhou and symptomatic or asymptomatic health care workers in Lombardy, Italy, ^10,11 were not able to conclude that viral load plays any significant part in whether or not a patient has better or worse outcomes.   The WHO have updated their guidance ¹² acknowledging that aerosol transmission is a risk to health care workers during medical procedures but remain cautious about the risk it presents to the rest of us because exactly just how much exhaled droplets it would take to evaporate and generate aerosols sufficient to infect another person in this way remains unknown.

 

Returning to the risk of infection though air conditioning the study doesn’t tell us whether before reopening after lockdown whether or not the business owners took any of the expected precautions to flush their water systems to safeguard against Legionella, ¹³ typically found in stagnant water systems.  Legionella sufferers experience coughs, fever and shortness of breath, ¹⁴ sound familiar?

 

Whatever the truth of the matter it is clear that the most significant route of transmission is still from person to person so let’s keep doing what we are doing, if or until a statistically significant body of evidence suggests otherwise. Oh and go shopping and eat out, but perhaps ask for a table by the window.

 

Sources of Reference:

1. Romel, V. (2020) UK consumer spending down despite reopening of hospitality sector. Financial Times. 10 July 2020. [online.] Available from: https://www.ft.com/content/98db5d94-ce2b-4038-bd48-64838bf13be7 [Accessed 12 July 2020]
2. UK. (2020) Part of Coronavirus (COVID-19) Business support. Crown Copyright. [online.]  Available from: https://www.gov.uk/coronavirus/business-support [Accessed 12 July 2020]
3. WHO. (2020) Q&A: How is COVID-19 transmitted? World Health Organization. 9 July 2020. [online.] Available from: https://www.who.int/news-room/q-a-detail/q-a-how-is-covid-19-transmitted [Accessed 12 July 2020]
4. UK. (2020) 5 steps to working safely. Crown Copyright. [online.]  Available from:  https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19/5-steps-to-working-safely [Accessed 12 July 2020]
5. Dyer, O. (2020) Covid-19: Airborne transmission is being underestimated, warn experts. 7 July 2020. [online.] Available from: https://www.bmj.com/content/370/bmj.m2720  [Accessed 12 July 2020]
6. WHO. (2020) Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. World Health Organization. 29 March 2020. [online.] Available from: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations  [Accessed 12 July 2020]
7. Li Y, Qian H, Hang J et al, (2020.) Evidence for probable aerosol transmission of SARS-CoV-2 in a poorly ventilated restaurant.  medRxiv 2020.04.16.20067728; doi:https://doi.org/10.1101/2020.04.16.20067728
8. Cockburn, P. (2020) Coronavirus spreads through the air as aerosol, 230 scientists write in open letter to World Health Organization. ABC Health & Wellbeing. 6 July 2020.  [online.] Available from: https://www.abc.net.au/news/2020-07-06/aerosol-transmission-of-covid-19/12425852 [Accessed 12 July 2020]
9. Pebody R. (2020) Viral Load. Aidsmap [online.] Available from: https://www.aidsmap.com/about-hiv/viral-load [Accessed 12 July 2020]
10. He X, Lau EHY, Wu P, et al. (2020) nature medicine. 15 April 2020. [online.] Available from: https://www.nature.com/articles/s41591-020-0869-5 [Accessed 12 July 2020]
11. Cereda D, Tirani M, Rovida F et al. (2020) The early phase of the COVID-19 outbreak in Lombardy, Italy. org. [online.] Available from: https://arxiv.org/ftp/arxiv/papers/2003/2003.09320.pdf [Accessed 12 July 2020]
12. WHO. (2020) Transmission of SARS-CoV-2: implications for infection prevention precautions. World Health Organization. 9 July 2020. [online.] Available from: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations  [Accessed 12 July 2020]
13. CIEH. (2020) Legionnaires’ disease: lockdown risks and reopening safely. org. [online.] Available from: https://www.cieh.org/policy/coronavirus-covid-19/resources/  [Accessed 12 July 2020]
14. NHS. (2017) Legionnaires’ disease. uk.  22 September 2017.  [online.] Available from: https://www.nhs.uk/conditions/legionnaires-disease/ [Accessed 12 July 2020]

 

Managing the Private Rented Sector under COVID-19; or The Art of Investigation Without Inspection.

By Paul Oatt BSc (Hons) MSc CEnvH MCIEH

How do you check that a rented property is safe, without actually inspecting it?  This is the dilemma that Local Authorities now find themselves in during the Coronavirus lockdown.  The Government have made it clear that despite the challenges presented by COVID-19 Local Authorities still have a duty to enforce safety standards and Landlords still have a duty to ensure the safety of tenants. ₁   There is a recognition that it will be difficult for Landlords to comply whilst occupiers are self-isolating and quite tellingly   the new guidance is non-statutory advice to Local Authorities on how to administer their statutory duties, even going so far as to suggest they take a ‘pragmatic approach.’ ₁

Anyone involved in making local authority housing enforcement decisions using the prescribed risk-based assessment methodology of the Health and Housing Safety rating System (HHSRS) ₂ will tell you that it for all its faults, ₃ pragmatism has always been at the heart of arriving at an appropriate enforcement decision.   Irrespective of the UK Lockdown imposed on the 23^rd March this year, ₄ Local Authorities must clearly continue to take appropriate action when they find the most serious ‘category 1’ hazards _{(5., p.5.)}  They may take action for category 2 hazards _{(5., p.6,)} but these are likely to be  ‘deprioritised’ if lower risk ₁ and delayed until restrictions are eased.

Ordinarily the first response would be to arrange to carry out an inspection, _{(5., p.188.)}  But under the current conditions Local Authorities will have to decide case by case if the situation presents a serious hazard and an imminent risk to tenant’s health.  They will have to look at any relevant previous complaints or enforcement history to see if the hazard had previously been identified.  This desktop survey will have to be balanced with what is known about the occupiers, such as any previously recorded vulnerabilities, and whether or not the occupiers would be sufficiently aware of the extent of the hazard presented by disrepair or poor conditions.

To aid in these decisions the new Government guidance suggests seeking  provision of photographs, video or live streaming from the occupier, ₁   when responding to new cases.  For existing cases, any requirement to carry out works in relation to ongoing enforcement will have to be suspended and in cases of emergency remedial action the Local Authority may have to consider  serving a Prohibition Order _{(5., p.14)} to prevent access to parts of the property whilst the restrictions are in place,₁ until such time as they can be remedied.

In working to ensure hazards are addressed the Government urge Local Authorities to work closely with Landlords and tenants.₁   But usually if there is a close working relationship then it is not necessary for a Local Authority to commence enforcement action through the service of a notice or an order.   But when enforcement action is taken evidence has to be gathered along the way to the criminal standard of proof in anticipation of the possibility that the notice or order will be breached or not complied with, necessitating a prosecution.  When prosecuting the council must be certain beyond a reasonable doubt₆ that an offence has been committed and present this in evidence.  A Landlord has available to them a defence of reasonable excuse for allowing or permitting the premises to be used in contravention of either a notice or an order, _{(5., p.20-21)} evidence gathered must successfully demonstrate that the offence was committed without a reasonable excuse for which the burden of proof _{(7., p.61)} rests with the defendant to provide.

So, the Governments expectation is that Local Authorities and Landlords alike still observe their respective duties whilst Coronavirus restrictions apply.  The Government have stated that essential repairs and maintenance can still be carried out in rented properties during this time and have issued guidance for tradespeople working in people’s homes,₈ including handwashing and social distancing measures.  According to the Gas Safety Register, the current Health and Safety guidance for Landlords regarding gas safety,₉ also emphasises that there is still a need to comply during this time but if circumstances are such that compliance is not possible a Landlord must be able to show that they took all reasonable steps to comply with the law and be able to evidence communication with tenants and engineer’s to arrange access.   The Health and Safety Executive (HSE) announced that annual gas safety checks can now be carried out 2 months prior to the due date, and retain the existing expiry date.₁₀  Given the additional flexibility in the law it would be hard for a Landlord seeking to mount a reasonable excuse defence to explain why there had not been sufficient time for a safety check or a repair to be carried out.

But it remains to be seen if courts will be equally flexible towards Local Authorities by accepting submission of photographic or video evidence provided by an occupier as satisfactory evidence, in lieu of an inspector collecting it first-hand during this lockdown.

Ordinarily when assessing the vulnerability of an occupier, we look at the social determinants of health,₁₁ beginning with the relationship between maternal health and well-being and that of the child, the environment children grow up in and opportunities for early cognitive development and educational attainment, patterns of work or unemployment and adverse work conditions, all of which relate to income and health, the ability to work, to earn and to afford, and this dictates what kind of accommodation a person can afford to live in.  Poor housing conditions lead to poor health and often house the most vulnerable.

But under the Coronavirus lockdown vulnerability takes on a new dimension, the increased risk of severe illness and poor outcomes from exposure to COVID-19.₁₂    Persons with chronic neurological diseases or long-term chronic conditions that are pulmonary bronchial, kidney, liver or cardio-vascular related.  Persons with diabetes, weakened immunity through disease or aggressive treatments, being overweight with body mass index over 40, or being pregnant are all factors to consider when assessing vulnerability, and not all of them are solely applicable to the elderly vulnerable age group.

The stay at home guidance from Public Health England ₁₃ (PHE) is clear that persons living alone can self-isolate with COVID-19 symptoms for 7 days and for those who live with others it is 14 days.  If there are vulnerable household members the site advises that arrangements be made to move them out to stay with family or friends and if this is not possible to ‘stay away from them as much as possible.’₁₃  Anyone reading that can see that this is easier said than done, for a family in that situation the necessary cooperation and coordination required to maintain social distancing measures is relatively feasible.  But what happens in a House in Multiple Occupation (HMO)?

Having now inspected more private rented properties than I could ever possibly count, and met and interviewed numerous tenants either renting properties as a family or in HMO’s, ₁₄ to get a sense of the level of occupancy and whether or not the amenities are suitable for the number of occupiers, you have to ask an occupier how many people live in the property?  In single family dwellings the answer comes almost immediately, it’s their family the answer comes without hesitation.  But ask a person living in an HMO and it is not so straightforward, often there is a pause while they count and they don’t always know everybody’s name.  You may interview a number of different people from the same property and get a different answer from each one to the question of how many people are living in the house.  Many occupiers find it uncomfortable to live in HMO environments that feel crammed with occupiers from all walks of life, and problems often stem from too many people living in one house. ₁₅

The state of the kitchens and bathrooms in HMO’s tell you how socially cohesive the occupiers are.  Generally, in my experience those properties with the worse bathrooms and kitchens are the ones where the occupiers barely know each other, keep to themselves ₁₆ and have no overall responsibility for cleaning and maintaining the common parts they all share, and hardly any of them can correctly tell you the exact number of persons they live with let alone identify them all by name.  This is not a criticism, there is a large churn of occupiers in HMO’s especially in London, ₁₇ new occupiers get their room and keys and keep to themselves because that is what everyone else in the house is doing.

But now we are all in a situation where we have to manage and coordinate our movements in a way that we have never had to consider before.  In line with the Government guidance,₁ HMO Landlords have a duty of care towards their tenants and are best placed to give the occupiers advice on what to do if an occupier has Coronavirus symptoms.  The Local Authority should support Landlords in helping them to manage this.

If a person has symptoms and they live with other people, regardless of family or HMO set up, all household members must stay at home and not leave the house for 14 days starting from the day when the first person in the house became ill, ₁₃ to isolate and control the disease and prevent or reduce the risk of spreading it amongst the community, occupiers who are still unaffected after 14 days can end isolation as this is believed to be the incubation period and after this period persons are unlikely to be infectious.  But managing this in an environment where up until now everyone has just done their own thing is going to need occupiers to step up and they will need support from their Landlord and from the Local Authority.

In the best managed HMO’s often you see that the occupiers have organised a kitchen and bathroom cleaning rota, there are signs reminding persons to wash up and tidy up after themselves.  In an HMO where occupiers are self-isolating the use of the kitchen will have to be managed on a rota basis to ensure that everyone can observe social distancing.  Living room recreation areas will have to be avoided altogether, and absolutely everyone is going to have to thoroughly clean bathrooms and toilets after use on top of regular hand washing or use of hand gels and be aware of what to do in an emergency if an occupier’s health deteriorates. ₁₃

What if there is a vulnerable person living in an HMO susceptible to severe illness and likely poor outcomes arising from Coronavirus infection?  What if they have no other family here in the UK?  Most outbound flights have now been grounded, ₁₈ with nowhere to go that means a vulnerable person is faced with self-isolating in a room in a shared house, providing of course they are not sharing that room with another occupier.

The vulnerable person will need their own room to self-isolate in and options such as moving a roommate out to share with someone else or for them stay with family or friends if possible, or even by turning a living room into a temporary bedroom may need to be considered.  In London where rental space is at a premium the living room is probably already let as a bedroom; both of these options may be non-starters if the property is occupied to the maximum.  But this has to be managed appropriately and for the right reasons. Before the lockdown, it was reported that a well-known agency was allegedly telling self-isolating occupiers to get out of the house while they showed some prospective buyers around. ₁₉

If the Landlord is unable to arrange alternative accommodation, or the occupier is unable to temporarily move to a hotel, given that many of them are already closing and displacing temporarily housed homeless, ₂₀  it may fall to the Local Authority to arrange.  Any accommodation that a Local Authority might be able to provide on a temporary basis for a vulnerable person to self-isolate, is likely to be very scarce and this will have to be carefully managed through a screening process to ensure that the person fits the definition as set out by PHE, ₁₂ because any place wrongly allocated will be at the opportunity cost of allocating it to someone in genuine need.

There are no easy answers here, the Local Authority enforcement powers ₅ and HMO licensing conditions, ₅are in place to prevent poor management and overcrowding leading to unsafe conditions, but under lockdown conditions where everyone is encouraged to restrict movement, our ordinary procedures for intervention to prevent spread of disease in relation to overcrowding ₂₁ is either unworkable if there is nowhere to decant to, or will be suspended until Coronavirus restrictions are lifted.

At the time of writing this, Chancellor Rishi Sunak has announced a further £14bn in public services funding to tackle Coronavirus £1.6bn of which will go to Local Authorities. ₂₂  We may well need it as we reorganise the regulation of the Private Rented Sector, mastering the art of investigation without inspection.

Paul Oatt is the Author of Selective Licensing: The Basis for a Collaborative Approach to Addressing Health Inequalities, available now from Routledge, Taylor & Francis.

 

References

1) MHCLG. (2020) COVID-19 (Coronavirus) and the enforcement of standards in rented
properties. Ministry of Housing, Communities and Local Government. March 2020. [online.]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/876501/Local _authority_rented_property_COVID_enforcement_guidance_v2.2.pdf [Accessed 12 April 2020.]
2) ODPM. (2006) Housing Health and Safety Rating System Operating Guidance. Office of the Deputy Prime Minister [online.] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/15810/142631 .pdf [Accessed 12 April 2020]
3) MHCLG. (2020) Outcomes of report on Housing Health and Safety Rating System (HHSRS) scoping review. Ministry of Housing, Communities and Local Government. 11 July 2019. [online.]. Available from: https://www.gov.uk/government/publications/housing-health-and-safety-rating-system-outcomes-of-the- scoping-review/outcomes-of-report-on-housing-health-and-safety-rating-system-hhsrs-scoping-review [Accessed 12 April 2020.]

4) BBC.co.uk. (2020) Coronavirus: Strict new curbs on life in UK announced by PM. 24 March 2020. BBC News. [online.]. Available from: https://www.bbc.co.uk/news/uk-52012432 [Accessed 12 April 2020.]
5) legislation.gov.uk. Housing Act 2004. [online]. Available from: http://www.legislation.gov.uk/ukpga/2004/34/contents [Accessed 12 April 2020.]
6) Weinstein, J.B., Dewsbury, I. (2006) Comment on the meaning of ‘proof beyond a reasonable doubt.’ Law, Probability and Risk, Volume 5, Issue 2, June 2006, Pages 167–173. [online.] Available from: https://doi.org/10.1093/lpr/mgl016 [Accessed 12 April 2020.]
7) Legislation.gov.uk. Magistrates’ Courts Act 1980 [online]. Available from: http://www.legislation.gov.uk/ukpga/1980/43/section/101 [Accessed 12 April 2020.]

8) MHCLG. (2020) Social distancing in the workplace during coronavirus (COVID-19): sector
guidance. Ministry of Housing, Communities and Local Government. March 2020. [online.]. Available from: https://www.gov.uk/guidance/social-distancing-in-the-workplace-during-coronavirus-covid-19-sector- guidance#tradespeople-and-working-in-peoples-homes [Accessed 12 April 2020.]
9) Gas Safe Register. (2020) Coronavirus (COVID-19): Advice for Landlords. gassaferegister.co.uk [online.] Available from: https://www.gassaferegister.co.uk/help-and-advice/covid-19-advice-and- guidance/landlords/ [Accessed 12 April 2020.]
10) HSE. (2020) Gas Safety (Installation and Use) Regulations 1998 (GSIUR) as amended. Approved Code of Practice and guidance. Health and Safety Executive. [online.] Available from: https://www.hse.gov.uk/pubns/books/l56.htm [Accessed 12 April 2020.]
11) Marmot, M. (2010) Fair society, healthy lives: The Marmot Review: strategic review of health inequalities in England post 2010. [online.] Available from: http://www.instituteofhealthequity.org/resources- reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf [Accessed 12 April 2020.]
12) PHE. (2020) Guidance on social distancing for everyone in the UK. Public Health England. 30th March 2020. [online.] Available from: https://www.gov.uk/government/publications/covid-19-guidance-on-social- distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting- older-people-and-vulnerable-adults [Accessed 13 April 2020.]

13) PHE. (2020) Stay at home: guidance for households with possible coronavirus (COVID-19)
infection. Public Health England. 9th April 2020. [online.] Available
from: https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance- for-households-with-possible-coronavirus-covid-19-infection [Accessed 13 April 2020.]
14) Oatt, P. (2019) Selective Licensing: The Basis for a Collaborative Approach to Addressing Health Inequalities, 1st Edition. Routledge Publications. Abingdon, Oxon. ISBN 9780367429195

15) Murphy, I. (2018) What are people’s experiences of living in a shared home? BBC News (3rd October 2018) [online.] Available from: https://www.bbc.co.uk/news/uk-england-45717409 [Accessed 13 April 2020.]
16) Wall, T. (2020) Cramped living conditions may be accelerating UK spread of coronavirus. The Guardian 12th April 2020. [online.] Available from: https://www.theguardian.com/world/2020/apr/12/virus-hitting- hardest-modern-equivalent-victorian-slums [Accessed 13 April 2020.]

17) Mayhew L, Harper G, Waples S. The London Borough of Newham Population growth and change 2007 to 2011. (August 2011) [online.] Available from: https://www.newham.gov.uk/Documents/Misc/Research- Population2011.pdf [Accessed 13 April 2020]
18) Leadbetter, C. (2020) Which airlines are still flying from the UK, and where are they going? The Telegraph. 7th April 2020. [online.] Available from: https://www.telegraph.co.uk/travel/comment/flights-still- flying-coronavirus/ [Accessed 13 April 2020.]
19) Chapman, B. (2020) Coronavirus: Foxtons told self-isolating tenant with suspected Covid-19 to leave home so buyers could view it. Independent. 19 March 2020. [online.] Available
from: https://www.independent.co.uk/news/business/news/foxtons-coronavirus-covid-19-tenants-letting-self- isolate-a9412516.html [Accessed 12 April 2020.]
20) Butler, P., Gentleman, A., Booth, R. (2020) Government clashes with Travelodge after homeless told to leave. The Guardian. (25th March 2020) [online.] Available
from: https://www.theguardian.com/world/2020/mar/25/government-clashes-travelodge-after-homeless-told- leave [Accessed 13 April 2020.]
21) WHO Housing and Health Guidelines. (2018) Geneva: World Health Organization; 2 Household crowding. [online.] Available from: https://www.ncbi.nlm.nih.gov/books/NBK535289 [Accessed 13 April 2020.]
22) The Guardian. (2020). Coronavirus Outbreak Live. The Guardian. (13th April 2020 08:01am) [online.] Available from: https://www.theguardian.com/uk-news/live/2020/apr/13/coronavirus-uk-live-news-praise-nhs- nurses-prime-minister-boris-johnson-latest-updates?page=with:block-5e940d6c8f081a236f1924e5#block- 5e940d6c8f081a236f1924e5 [Accessed 13 April 2020.]

 

Don’t Stand so close to Me! COVID-19 The UK Situation – Paul Oatt

In response to the COVID-19 crisis in the UK, the Government has ushered in new restrictive legislation under The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020, ₁  providing local authorities with powers to enforce business closures and coordinate responses with the Police on enforcement of social distancing measures.  The powers allow Local Authority Environmental Health and Trading Standards teams to enforce closures of businesses that are selling food or drink for consumption on premises and take necessary steps, which can include the imposition of Prohibition Notices on premises, fines under fixed penalty notices or prosecution of persons whose actions are placing others at risk during this crisis.

At the same time the Government continues to encourage us all to stay at home as much as possible, ₂ amidst wider criticism of their overall approach,  particularly the herd immunity strategy, ₃ and the overwhelming demand placed upon health services along with the large loss of life that is likely to ensue.   But just how bad is COVID-19 in the UK?  And given that we are not yet testing in the community, ₄ how do we measure it?

Prior to the UK’s lockdown, one possible modelled trajectory simulation by Davies et al, ₅ (not yet peer reviewed,) was run across 186 counties using age specific probabilities of symptom onset, transmission rates, hospitalisation (ICU and non-ICU) and death rates.  The study found that a strategy without pharmaceutical intervention, reliant upon school closures, social distancing, protection of high risk and vulnerable groups and home isolation would have to be implemented and remain in place for many months at least, and if not followed could result in ‘16-30 million symptomatic COVID-19 cases and 250,000-470,000 deaths.’  With no measures in place this would lead to ICU bed capacity being overloaded, bringing NHS resources to breaking point.

The increased burden of disease on health services arising from COVID-19 cases prioritised for ICU treatment during this crisis, also means that there will be displacement of other patients with other types of chronic disease who ordinarily would use those same beds and facilities and be reliant upon the services of the same medical staff.  This displacement is the opportunity cost of prioritising resources to address burdens of mortality and morbidity associated with COVID-19.

In recognition of the burden that the disease is going to place upon the NHS the first emergency hospital was built at London’s ExCel centre last month, ₆ with a 4,000 bed capacity.  More are planned to be built across the country.   At the same time the Government is  also coordinating a series of temporary mortuaries nationwide, ₇ in response to the rising death toll.

Any measure or modelling of disease takes account of the reproduction number (R₀) this is a measure of exponential growth, representing the number of new infections caused by a person who is already infected, Kurchaski et al estimated that in Wuhan prior to travel restrictions each infected person transmitted the disease to an extra 1 to 4 people. ₈   The infographic commonly used to illustrate this point shows an R₀ of 2.5, ₉ and reducing this figure to below 1 through scaling back our contact with other persons by 75% should slow the infection rate sufficiently for the disease to die out.

At the beginning of April, preliminary estimates by Jarvis et al, ₁₀ found  that current Government measures might be driving the R₀ to below 1, estimating it to be approximately 0.62   95% CI (0.37, 0.89.) The study used an online survey of 1,300 persons disclosing the number of persons they had been in contact with the previous day, and compared this to a 2005-2006 study asking the same and found on average a 70% reduction in daily contacts which if sustained over coming months should reduce the burden on the NHS, forcing the epidemic into decline.   However, reports this weekend ₁₁suggest that a significant number of persons ignored the ban on social gatherings on Saturday 4^th April prompting further public warnings against congregating and a warning that should it continue the Government may ban outdoor exercise altogether.

The reported figures of new infections and deaths that we see daily in the media are taken from the Governments own website, ₁₂ but slight differences in reporting mean that deaths from outside hospitals are under reported because they are compiled from deaths recorded up to 5pm the previous day, but there are variations of up to a few days between the actual time of death and that death being reported.

A recent Guardian article argued that by undercounting the number of deaths in this way, ₁₃ the data on the curve that we are all desperately waiting to see flatten, will be skewed.  To illustrate the point the article uses the death rate reported on 30^th March, (originally 159 deaths up to 5pm 29^th March.)  This figure was subsequently revised up to 463 deaths for that day alone, and could be revised again as ‘more deaths come to light.’  In the article, Prof Sheila Bird, formerly of the Medical Research Council’s biostatistics unit at Cambridge University makes the point that underreporting will mean that we underestimate the steepness of the curve and may think we are doing better than we are, whilst the real deaths continue on an upward trajectory.  When the sombrero is finally squashed, we could be slow to recognise this too.  Might this also mean that we will be slow to recognise and react to a second wave when that comes?

COVID-19 is caused by an acute respiratory infection called SARS-Cov-2.  It is referred to as a novel pathogen because we still don’t know enough about it.  Despite this there is mounting pressure to assess not only current viral infection but also to test immunity in order to limit economic damage and see people return to work without further risk. ₁₄ This is particularly important for health care workers as staff shortages through illness place a further strain on services.  The test will also be essential for measuring the effectiveness of vaccines during clinical trials.  Lessons learned from the SARS-Cov outbreak of 2002 show that persons who developed immunity back then still have neutralising antibodies now.  But whether the same can be said for SARS-Cov-2 which has a 75% identity with SARS-Cov is not clear, and the upscaling of resources to develop an immunity test is stretching the resources of anti-body test developers.

The UK have ordered 17.5m “game changer” antibody home testing kits ₁₅ but doubts exist over the sensitivity and effectiveness of these kits which can produce a reliable result with 90% accuracy only when tested on hospital patients with severe symptoms and merely a 50-60% accuracy in detection amongst those with mild symptoms, but the latter are the intended target group.

There is of course a test to diagnose the disease, the polymerase chain reaction (PCR) nose throat test which detects viral particles, ₁₆ but the technology required to develop an antibody test is distinct because it requires a better understanding of  the proteins forming the viral coat or shell of the virus and how it can trigger recognition in the immune system to produce antibodies that flag or neutralise the virus,   Both of these tests are facing global challenges to meet supply. ₁₄

It feels as if we are holding pieces of the puzzle here in the UK and trying to complete the jigsaw without the missing pieces.  We have a lockdown of sorts and are preparing for the worst, but is this really going to be enough?  In China lessons were learned from the Sars-Cov outbreak of 2002. ₁₇   A key strategy in the Wuhan outbreak was the imposition of a cordon sanitaire to limit and contain the spread of the disease. ₁₈ However, Wuhan has major transport links to other areas and it was recognised that the disease had already seeded elsewhere.  Multi agency collaborations addressed the outbreak within Wuhan as well as the exported cases using isolation, treatment and social distancing to interrupt the chain of transmission, closure of wet markets and stricter safety measures on poultry markets, restriction of movement and introduction of temperature checks and quarantine measures.

Whilst genome sequencing of the virus was carried out protocols for diagnosis, treatment, epidemiological investigation, surveillance and PRC testing were established and continually revised.     New hospitals were built and certain places repurposed to ensure everyone could have access to treatment.  All primary cases were treated and their close contacts followed up as an R₀ and were isolated and put under medical observation.

Over time the focus shifted to reducing clusters of cases as the curve began to plateau, and there was differentiation across areas in the approach to reducing spread of disease depending on the identification of these clusters, and gradually restrictions were able to be relaxed.

The Local Government Association have consolidated the data on Covid-19 to report using the data provided by the government, ₁₉ in a range of graphs that provide a clearer picture of the spread of disease.

Graph 1.  Cumulative COVID-19 cases per 100,000 people for all English regions and England last seven available days.₁₉

Graph 1 shows that between March and April cases of COVID-19 were most prevalent in London and the West Midlands and the North West is catching up.  But interestingly areas with the highest rates of cases were generally found to have the lowest proportions of people aged over 65, which suggests that measures are working to protect the vulnerable age group but the report comes with the caveat that this could change.

On the 4^th April the daily confirmed cases stood at 2,910 which was a decrease of 666 case from the previous day, however on the 5^th April the daily recorded cases have shot up to 5,107 the largest increase we have seen. ₁₉  It does not appear that the plateau is yet within sight and the fluctuation demonstrates how unpredictable the disease is, and it is evident we still know very little, China admit there remain knowledge gaps on transmissibility, incubation, disease progression, risk of spread and even the effectiveness of prevention and control. ₁₈

Knowing more about all of this would make a huge difference, and just as they continue to evaluate their strategy in China I suspect we will be doing that here in the UK for some time to come.  Should we have enforced a lockdown earlier?  Are the measures we have in place sufficient?  Will people respect the Governments request to stay at home?  And might we have to do it for much longer than we think?

And what of those new powers for closure?  Early reports suggest that where non-compliance has been found most businesses have closed voluntarily and it has only been necessary to serve a handful of Prohibition Notices, ₂₀ but that like everything in this situation might change, let’s hope not.

 

Paul Oatt is the Author of Selective Licensing: The Basis for a Collaborative Approach to Addressing Health Inequalities, available now from Routledge, Taylor & Francis.

 

 

 

Sources of Reference:

 

1. gov.uk (2020) The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020 (26^th March 2020) UK statutory Instruments No. 350 [online.] Available from: http://www.legislation.gov.uk/uksi/2020/350/contents/made [Accessed 5 April 2020]
2. ITV.com. (2020) ‘Boris Johnson pleads with public to stay indoors ahead of weekend of warm weather.’ (3^rd April 2020) [online.] Available from: https://www.itv.com/news/2020-04-03/prime-minister-boris-johnson-coronavirus-covid-19/ [Accessed 5 April 2020]
3. Hanage, W. (2020) ‘I’m an epidemiologist. When I heard about Britain’s ‘herd immunity’ coronavirus plan, I thought it was satire.’ (15^th March 2020) The Guardian. [online.] Available from: https://www.theguardian.com/commentisfree/2020/mar/15/epidemiologist-britain-herd-immunity-coronavirus-covid-19 [Accessed 5 April 2020]
4. ITV.com. (2020) ‘Firms including Amazon and Boots to help UK reach target of 100,000 coronavirus tests per day.’ (2^nd April 2020) [online.] Available from: https://www.itv.com/news/2020-04-02/amazon-to-help-uk-reach-new-target-of-100-000-coronavirus-tests-per-day-by-end-of-april/ [Accessed 5 April 2020]
5. Davies, N.G., Kurchaski, A.J., Eggo, R.M., Gimma, A., CMMID COVID-19working group., Edmunds, W.J. (2020) The effect of non-pharmaceutical interventions on COVID-19 cases, deaths and demand for hospital services in the UK: a modelling study. London School of Hygiene & Tropical Medicine Centre for Mathematical Modelling of Infectious Diseases (CMMID) Repository. (1^st April 2020) [online.] Available from: https://cmmid.github.io/topics/covid19/control-measures/report/uk_scenario_modelling_preprint_2020_04_01.pdf  [Accessed 5 April 2020]
6. BBC News. (2020) ‘Coronavirus: Nightingale Hospital opens at London’s ExCel centre.’ BBC News (3^rd April 2020.) [online.] Available from: https://www.bbc.co.uk/news/uk-52150598 [Accessed 5 April 2020]
7. Booth, R. (2020) ‘Temporary morgues being set up across UK amid rising Covid-19 deaths.’ (19^th March 2020) The Guardian. [online.] Available from: https://www.theguardian.com/world/2020/mar/19/temporary-morgues-being-set-up-across-uk-amid-rising-covid-19-deaths [Accessed 5 April 2020]
8. Kurchaski, A.J., Russell, T.W., Diamond, C., Yiu, L., Edmunds, J., Funk, S., Eggo, R.M. (2020) Early dynamics of transmission and control of COVID-19: a mathematical modelling study.  The Lancet. [online.] https://doi.org/10.1016/S1473-3099(20)30144-4 Available from: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30144-4/fulltext 9 [Accessed 5 April 2020]
9. Yates, C. (2020) ‘Coronavirus is growing exponentially – here’s what that really means.’ The Conversation. [online.] Available from: https://theconversation.com/coronavirus-is-growing-exponentially-heres-what-that-really-means-134591?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20April%203%202020%20-%201583515177&utm_content=Latest%20from%20The%20Conversation%20for%20April%203%202020%20-%201583515177+CID_c54f13d96a49de2c81acb79bbcc8f416&utm_source=campaign_monitor_uk&utm_term=Coronavirus%20is%20growing%20exponentially%20%20heres%20what%20that%20really%20means%5BAccessed 5 April 2020]
10. Jarvis, I.C., van Zandvoort, K., Gimma, A., Prem, K., CMMID COVID-19working group., Klepac, P., Rubin, G.J., Edmunds, W.J. (2020) Quantifying the impact of physical distance measures on the transmission of COVID-19 in the UK. London School of Hygiene & Tropical Medicine Centre for Mathematical Modelling of Infectious Diseases (CMMID) Repository. (31^st March 2020) [online.] Available from: https://cmmid.github.io/topics/covid19/current-patterns-transmission/reports/LSHTM-CMMID-20200401-CoMix-social-contacts.pdf  [Accessed 5 April 2020]
11. BBC News. (2020) ‘Coronavirus: Public urged to follow ‘mission-critical’ rules.’ BBC News (5^th April 2020.) [online.] Available from: https://www.bbc.co.uk/news/uk-52172035 [Accessed 5 April 2020]
12. Gov.UK (2020) ‘Number of coronavirus (COVID-19) cases and risk in the UK.’ (Updated daily.) [online.] Gov.UK. Available from: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public [Accessed 5 April 2020]
13. Barr, C., Duncan, P., McIntyre, N. (2020) ‘Coronavirus UK death toll: why what we think we know is wrong.’ (4^th April 2020) The Guardian. [online.] Available from: https://www.theguardian.com/world/2020/apr/04/why-what-we-think-we-know-about-the-uks-coronavirus-death-toll-is-wrong [Accessed 5 April 2020]
14. Petherick, A. (2020) Developing antibody tests for SARS-CoV-2.  The Lancet Vol 395, April 4 2020. [online.] Available from: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30788-1.pdf [Accessed 6 April 2020]
15. Devlin, H. (2020) ‘Coronavirus ‘game changer’ testing kits could be unreliable, UK scientists say.’ (5^th April 2020) The Guardian. [online.] Available from: https://www.theguardian.com/world/2020/apr/05/coronavirus-testing-kits-could-be-unreliable-uk-scientists-say [Accessed 5 April 2020]
16. McKIe, R. (2020) ‘Coronavirus ‘game changer’ testing kits could be unreliable, UK scientists say.’ (29^th March 2020) The Observer. The Guardian. [online.]  Available from: https://www.theguardian.com/world/2020/mar/29/the-two-tests-that-will-help-to-predict-spread-of-covid-19 [Accessed 5 April 2020]
17. Huang Y. THE SARS EPIDEMIC AND ITS AFTERMATH IN CHINA: A POLITICAL PERSPECTIVE. In: Institute of Medicine (US) Forum on Microbial Threats; Knobler S, Mahmoud A, Lemon S, et al., editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington (DC): National Academies Press (US); 2004. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92479/ [Accessed 6 April 2020]
18. WHO. (2020) Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19.) (16-24 February 2020.) World Health Organisation. [online.] Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf [Accessed 6 April 2020]
19. Local Government Association. (2020) COVID-19 Cases Tracker – Overview for England. Local Government Association. [online.] Available from: https://lginform.local.gov.uk/reports/view/lga-research/covid-19-case-tracker [Accessed 6 April 2020]
20. Campbell, S. (2020) Councils put new lockdown laws into practice. Chartered Institute of Environmental Health. (6^th April 2020) [online.] Available from:  https://www.cieh.org/public-health-and-protection/2020/april/councils-put-new-lockdown-laws-into-practice/?utm_campaign=11455694_EHN%20Extra%2006.04.2020&utm_medium=email&utm_source=CIEH&dm_i=1RSV,6TJ9Q,B8736W,RBEEQ,1%5BAccessed 6 April 2020]

Graph:

1. Graph 1. Cumulative COVID-19 cases per 100,000 people for all English regions and England last seven available days. Available from: https://lginform.local.gov.uk/reports/view/lga-research/covid-19-case-tracker [Accessed 6 April 2020]

Selective Licensing: Managing the Private Rented Sector

Fresh from their December election victory the newly formed Government have announced a number of pledges in relation to housing, including improvements to building safety and protection of tenants.   In January the government announced a £4m fund to crackdown on criminal landlords to be shared amongst 100 Councils across England.  It was heavily criticised by Labour describing it as “puny” and a “drop in the ocean,” a sentiment echoed by the Residential Landlords Association (RLA) who say it is “nowhere near enough”  and who believe that the solution lies in providing more funding throughout the year, sufficient to upskill and increase numbers of trained Environmental Health Officers thus enabling councils to better prepare their investigative approaches towards criminal landlords.  

The RLA and Safeagent (who represent lettings and management agencies) are both critical of Local Authority run Landlord Licensing Schemes which are used by Local Council’s to impose better standards of management upon landlords in areas where rented properties are being managed inefficiently and are used to address antisocial behaviour and crime.   

The RLA’s notion of ‘better funded enforcement strategies’ is that they should be prioritised against criminal landlords and not used to tie up good landlords in licensing schemes, which they claim do “nothing to protect tenants.”     Through Freedom of Information searches carried out by Safeagent across the 32 London Boroughs and the City of London they estimate there are a 130,000 unlicensed rental properties in the capital.   In addition to this, it was claimed that a total of 24,000 licence applications had yet to be processed across the council’s surveyed.  Whilst this might sound like a large figure, it is unclear whether these applications were complete and valid, or awaiting further information from the landlord (or payment) before they can be processed, or even if a surge in applications has arisen in response to an early discount incentive for licensing.  In my experience all of these factors can contribute to a temporary backlog.  

Safeagent believe that another tier of regulation will remedy the issue by creating what they describe as a ‘simple streamlined licensing process.’   The RLA on the other hand argue that since 2010 there has been a 32% increase in the number of regulatory laws creating obligations on landlords and call for scrapping of licensing in favour of better use of existing enforcement powers.  So, who is right?  

The discretionary powers Local Authorities use to designate and enforce Licensing schemes were enabled sometime before 2010 in the 2004 Housing Act.    Local authorities were initially slow in using these powers, until the Government broadened the criteria for licensing to additionally include other factors such as rundown properties, high levels of migration, deprivation and crime.  By this time Local Authorities were beginning to seize the initiative and introduce licensing whilst the private rented sector continued to grow.  

Newham Council had already piloted a licensing scheme in the Little Ilford area during 2010 and went onto designate the rest of the borough for property licensing in 2013.     Other boroughs were soon to follow and as of now there are at least 55 schemes across the country, 35 of which operate in London.    

A Freedom of Information request made by the Guardian in 2018 to all Councils in England and Wales revealed that 53 local authorities had not taken a landlord prosecution in three years some in whose areas contained numerous rented properties in substantial disrepair.  Lack of resources was cited as a factor and it should be noted that whilst the RLA criticise housing regulation for being burdensome on landlords, there is little acknowledgement of the fact that it is equally burdensome upon local authorities.  In fact, one of the reasons that Newham chose to employ licensing powers was precisely because the existing enforcement legislation was found to be  complex, costly and time consuming making it difficult for local authorities to act quickly.  

When local authorities were acting against criminal landlords the Local Government Association found that very often the fines issued by Magistrates courts were too low.  In response to this the Government introduced more regulation (sorry RLA!) to enable fines to be increased, so that they are potentially unlimited.   Despite this, the level of fines issued in housing prosecutions were variable, often on the low side.   Since this was highlighted in the media, it now appears that courts are  recognising the need to take these offences more seriously by issuing higher fines.    

In April 2017, Local Authorities were given further powers  to issue Civil Financial Penalties of up to £30,000 against criminal landlords for certain housing offences including failing to licence a property, and breach of any licence or HMO management regulations.   A year later a Freedom of Information act request made by the RLA found that 90% of local authorities had failed to issue any fines.   

The Mayor of London’s Rogue Landlord Database keeps a public record of Criminal Landlords and the offences committed for a period of 12 months after conviction, and shows which London Borough acted.  The amount of Civil Financial Penalties recorded as being issued over the last 12 months across London totals a staggering £531,850.  From this figure £333,310 (62.7%) of the total amount of fines issued were for failing to licence a rented property.  

Local Authorities may have been slow to embrace these powers but it is becoming increasingly evident that application of a licensing designation for all Landlords allows Local Authorities to learn more about the make-up of their own private rented sectors, and a distinction can be made between good Landlords who deserve a light touch approach, and the rogue criminal element who don’t wish to licence or be found and upon whom Local Authorities are now working hard to regulate.

And yes, some more money would be nice!  

Paul Oatt is the Author of Selective Licensing: The Basis for a Collaborative Approach to Addressing Health Inequalities, available now from Routledge, Taylor & Francis.