Anaraki S

Coles S

Dabrera G

Duncan CJA

Foster K

Gent M

Holden B

Hughes GJ

Hutchinson C

Li A

Lillie PJ

Manley P

Morton W

Padfield S

Quinney A

Schmid ML

Wensley A

Zambon M

\ua9 2020 Journal of Physical Chemistry. All rights reserved.We report key learning from the public health management of the first two confirmed cases of COVID-19 identified in the UK. The first case imported, and the second associated with probable person-To-person transmission within the UK. Contact tracing was complex and fast-moving. Potential exposures for both cases were reviewed, and 52 contacts were identified. No further confirmed COVID-19 cases have been linked epidemiologically to these two cases. As steps are made to renew contact tracing across the UK, the lessons learned from earlier contact tracing during the country\u27s containment phase are particularly important and timely

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Epidemiology and Infectioncambridge.org/hygFrom the FieldCite this article: Holden B et al (2020). COVID-19: public health management of the first twoconfirmed cases identified in the UK.Epidemiology and Infection 148, e194, 1–4.https://doi.org/10.1017/S0950268820001922Received: 15 May 2020Revised: 11 August 2020Accepted: 25 August 2020Key words:Coronavirus; COVID-19; emerging infections;respiratory infectionsAuthor for correspondence:B. Holden,E-mail: ben.holden@phe.gov.uk© The Author(s), 2020. Published byCambridge University Press. This is an OpenAccess article, distributed under the terms ofthe Creative Commons Attribution licence(http://creativecommons.org/licenses/by/4.0/),which permits unrestricted re-use,distribution, and reproduction in any medium,provided the original work is properly cited.COVID-19: public health management of thefirst two confirmed cases identified in the UKB. Holden1 , A. Quinney2, S. Padfield1, W. Morton1, S. Coles1, P. Manley3,A. Wensley2, C. Hutchinson4, P. J. Lillie5, C. J. A. Duncan6, M. L. Schmid6, A. Li7,K. Foster8, S. Anaraki9 , G. Dabrera10, M. Zambon10, G. J. Hughes2and M. Gent11Public Health England Yorkshire and the Humber, Health Protection Team, Leeds, UK; 2Field Epidemiology, FieldService, National Infection Service, Public Health England, Leeds, UK; 3Field Epidemiology, Field Service, NationalInfection Service, Public Health England, Newcastle, UK; 4Public Health England Yorkshire and the Humber,Communications Team, Leeds, UK; 5Hull University Teaching Hospitals NHS Trust, Department, Hull, UK;6Department of Infection and Tropical Medicine, The Newcastle Upon Tyne Hospitals NHS Foundation Trust,Newcastle, UK; 7Department of Microbiology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust,Newcastle, UK; 8Public Health England North East, Health Protection Team, Newcastle, UK; 9Public HealthEngland North East and North Central London, Health Protection Team, London, UK and 10Public Health EnglandNational Infection Service, Colindale, UKAbstractWe report key learning from the public health management of the first two confirmed cases ofCOVID-19 identified in the UK. The first case imported, and the second associated with prob-able person-to-person transmission within the UK. Contact tracing was complex and fast-moving. Potential exposures for both cases were reviewed, and 52 contacts were identified. Nofurther confirmed COVID-19 cases have been linked epidemiologically to these two cases. Assteps are made to enhance contact tracing across the UK, the lessons learned from earlier contacttracing during the country’s containment phase are particularly important and timely.IntroductionIn December 2019, an outbreak of a novel coronavirus disease (COVID-19) caused by theSARS-CoV-2 virus was reported in Wuhan, China [1]. The severity of this respiratory diseasevaries from a mild self-limiting condition, to a serious and potentially fatal illness [2]. The firsttwo confirmed cases of COVID-19 were detected in the UK on 30 January 2020 [3]. Thisarticle describes the public health management of those cases. The learning discussed maybe relevant to the management of future cases of any high consequence infectious disease(HCID) as well as COVID-19 cases and clusters.As of 19 July 2020, there had been a cumulative total of 254 519 laboratory-confirmed casesof COVID-19 diagnosed in England. Weekly numbers of new laboratory-confirmed cases (byspecimen date) peaked at 27 907 in the week commencing on 23/04/2020 and has declinedsince then to 3693 in the week commencing 15/07/20 [4]. The highest cumulative rate since30 January 2020 occurred in the North West of England (588/100 000 population) and thelowest in the South West of England (228/100 000). As of 7 July 2020, where ethnicity wasknown, the largest numbers of cases occurred in the White ethnic group (81.5%), followedby the Asian/Asian British (10.0%) and Black/Black African/Black Caribbean/Black Britishgroup (4.6%). The highest number of cumulative deaths occurred in the 80 years and olderage group (23 364).The UK pandemic response started with a contain phase and then transitioned to a delayphase [5]. During the contain phase, over 5000 people were followed-up as contacts in Englandalone [6]. During the delay phase, the UK implemented social and physical distancing mea-sures, similar to many countries [7]. In addition, persons defined as extremely vulnerable toserious illness were asked to stay at home and minimise interactions (‘shielding’) [8]. TheNHS test and trace service facilitates testing of persons with symptoms compatible withCOVID-19 and undertakes contact tracing of those who test positive [9].The index case (Case 1) arrived in the UK in late January from the Hubei province inChina. They travelled with another person (co-traveller) and both were asymptomatic duringthe journey. Three days after arrival in the UK; Case 1 developed a fever, dry cough and sorethroat. Case 2, a UK resident and close contact of Case 1, developed a fever and malaise 2 dayslater.Case 1 and Case 2 made contact with the National Health Service. Discussion with localhealth protection services identified both cases to be at risk of COVID-19. Both cases wereadmitted to an infectious diseases unit for isolation, assessment and diagnostic sampling.https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268820001922Downloaded from https://www.cambridge.org/core. IP address: 92.29.153.79, on 09 Dec 2020 at 16:34:51, subject to the Cambridge Core terms of use, available atTesting and sequence confirmation using methods describedby Corman et al. was carried out the same day, and SARS-CoV-2 infection was confirmed [10]. Rapid laboratory supportto confirm cases of COIVD-19 was essential in a complex tracingarrangement.Further investigation and contact risk assessmentCase 1 and Case 2 were interviewed with a translator to identify allcontacts between symptom onset and hospital admission.Relevant settings and identified contacts are summarised inFigure 1. Case 1 and Case 2 had limited social contact with otherswhilst symptomatic. Please note that Case 2 is not included as acontact in Figure 1 as the timeline groups all contacts of Case 1and Case 2.Case 1 and Case 2 were admitted to hospital on 29 January2020. This was after following the recommended guidance for ini-tial telephone contact with healthcare services and a plannedadmission as possible cases.Potential exposures for both cases were reviewed, and 52contacts were identified (excluding Case 2 but including theco-traveller of Case 1). This included 45 healthcare workers(HCWs). As the cases were managed as possible cases, the major-ity (43) of these HCWs had low-risk exposures, and required onlypassive follow-up, while two required active follow-up on a pre-cautionary basis. Those receiving active follow-up were contacteddaily for 14 days to ensure they remained well. Those under pas-sive follow-up were provided with information and requested tocontact PHE if they became symptomatic. A further six contactsin the community were identified with different categories ofexposure, as described in Table 1.Of all contacts under follow-up (excluding Case 2), two devel-oped mild symptoms compatible with COVID-19. No identifiedcontacts (excluding Case 2) tested positive for SARS-CoV-2.From the start of the investigation up until hospital discharge,the co-traveller of Case 1 remained asymptomatic for COVID-19.As a close contact, they were regularly tested by PCR on upperrespiratory specimens for SARS-CoV-2. All tests were negative,despite them being a close household contact of both cases.Serological testing was not undertaken at the time of follow-up.Accommodation sites where the cases had residential-typeexposures were assessed as being potentially higher risk. If notpreviously cleaned, these were restricted from use for a minimumof 5 days after last use. This was in order to minimise the risk toothers and based on the limited available evidence about environ-mental contamination at the time [5–7, 11–13].VirologyWhole-genome sequencing data were made available for Case 1and Case 2 and uploaded to GISAID [14]. Although no furtherconfirmed COVID-19 cases have been linked epidemiologicallyto these two cases, this assertion may yet be tested genomically.Supported by the UK government, the COVID-19 GenomicsUK (COG-UK) consortium has been created to deliver large-scaleand rapid whole-genome virus sequencing to guide UK publichealth interventions and policies [15].Biological materials from the first cases have given rise to aninfectious virus isolate which has been shared safely with inter-national partners. This virus isolate is being used as a prototypevirus strain internationally and will be important in the develop-ment of diagnostics and potential vaccines.DiscussionWe report the public health management of the first two con-firmed cases of COVID-19 in the UK. The first case imported,and the second associated with probable person-to-person trans-mission within the UK. This response was part of the contain-ment phase of the UK government COVID-19 response.This early experience reinforces key learning from elsewhere inthe pandemic, such as the high risk of transmission to close con-tacts as well as the lower risk to HCWs when infection preventioncontrol measures are appropriately followed.A small number of contacts had exposures with potentiallyhigher risks such as those cleaning environments which werepotentially contaminated. These groups were placed under activefollow-up but did not develop COVID-19. Although the overallnumbers were small, this contributes further to the evidencebase needed to inform future public health strategies. Initialadvice was based on the precautionary principle, to prevent mem-bers of the public from any potential risk of exposure to theSARS-CoV-2 virus.Managing environments which cases had inhabited in aresidential-type setting was a challenge. In the absence of signifi-cant published data on environmental contamination related tocases at that stage of the pandemic, this required application ofthe precautionary principle based on previous experience fromhigh consequence coronaviruses, to inform a practical approach.These cases brought to the surface the importance of data onenvironmental survival of viruses to inform practical decontamin-ation guidance for future public health management. Thisdemonstrates the importance of detailed risk assessments forthe first identified cases in any novel disease outbreak.Current technology provides further information about pos-sible exposure settings, and opens the door to previously unusedmethods of identifying potential contacts [16]. In this instance,taxi drivers were identified through journey records held withinthe case’s online taxi booking application. A data-sharing agree-ment was agreed with the taxi company and Public HealthEngland (PHE) were able to contact the taxi drivers to recom-mend self-isolation and commence active follow-up. However,these additional information sources can only supplement otherdata sources such as case questionnaires rather than act as a directreplacement.This experience also reinforced previous learning from otherdiseases, in relation to the reliance on self-reporting and indivi-dual’s recollection of face-to-face interactions [17]. To maximisecontact identification for these cases, repeat interviews were con-ducted to confirm information gathered and contextual promptswere used.There was significant national, regional and local media andsocial media interest regarding the public health management ofthe first two confirmed cases identified in the UK. PHE communi-cations colleagues provided a 24/7 media handling service through-out the response in liaison with the relevant local governmentauthority. Due to the high-profile nature of the first confirmedcases of COVID-19 in the UK, the initial media response was lednationally, by the Department of Health and Social Care.Contact tracing was complex and fast-moving. Additionalchallenges were encountered through media and national interestand having to rapidly review the available evidence and developscientific consensus to inform actions. Despite these challenges,no further confirmed cases linked to Case 1 and Case 2 were iden-tified in the UK.2 B. Holden et al.https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268820001922Downloaded from https://www.cambridge.org/core. IP address: 92.29.153.79, on 09 Dec 2020 at 16:34:51, subject to the Cambridge Core terms of use, available atConclusionsThe manuscript discusses the public health management of thefirst two confirmed cases of COVID-19 identified in the UK.We believe that the learning discussed may be relevant to themanagement of future cases of any HCID as well asCOVID-19 cases and clusters. As steps are made to renew con-tact tracing across the UK, the lessons learned from contacttracing during the country’s containment phase are especiallyimportant.Our manuscript examines the complex and fast-moving contacttracing efforts, in addition to the challenges encountered at an earlystage of the epidemic. We have also described the epidemiologicallinks between the identified cases, and refer to the future work thatmay be pursued to test epidemiological findings using genomics.Fig. 1. Timeline detailing key settings and exposures where contact tracing took place; and the number of identified contacts of the first two confirmed cases ofCOVID-19 identified in the UK, January 2020. Please note: Case 2 is not included as an identified contact of Case 1 in this timeline.Table 1. Categorisation and number of identified contacts of Case 1 and Case 2 (numbers do not include Case 2 as an identified contact of Case 1)Category Description Follow-up Self-isolationNumber ofidentifiedcontactsA Household contact – living or spending significanttime in the same householdActive follow-up for 14 days afterlast exposureYes 1B Persons in healthcare settings (e.g. healthcareworkers, visitors) who have not worn recommendedPPE orlaboratory workers who have not used appropriatelaboratory precautionsActive follow-up for 14 days afterlast unprotected exposureYes 2C Persons in healthcare settings who have wornrecommended PPEPassive follow-up for 14 days afterlast exposureNo 43D For any other (non-aircraft) exposure notsatisfying categories A-C:Direct contact or face-to-face contact with case, e.g.talking, being coughed on for any length of timeFor exposures in this categorywithout recommended PPE:Active follow-up for 14 days afterlast unprotected exposure.For exposures in this categorywith recommended PPE:Passive follow-up for 14 days afterlast exposureActive follow-upgroup: YesPassive follow-upgroup: No6Total contacts: 52Epidemiology and Infection 3https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268820001922Downloaded from https://www.cambridge.org/core. IP address: 92.29.153.79, on 09 Dec 2020 at 16:34:51, subject to the Cambridge Core terms of use, available atTo date, there has not been any published data regarding contacttracing and public health management of COVID-19 in England.This would be the first publication of such data.Acknowledgements. We are grateful to the cases described for providinginformed consent for this report to be published. Our thanks go to our collea-gues from the many local government, health and social care organisationsthat contributed their time, effort and expertise to the public health and clin-ical management of these cases.Financial support. The authors received no specific funding for this work.Conflict of interest. The authors report no potential conflict of interest.Data availability statement. The data analysed during this study are notpublicly available due to a need to protect individual’s anonymity. Thesedata are confidential, but fully anonymised data may be available from the cor-responding author on reasonable request.References1. Wu JT et al. (2020) Estimating clinical severity of COVID-19 from thetransmission dynamics in Wuhan, China. Nature Medicine 19, 1–5.2. Heymann DL and Shindo N (2020) COVID-19: what is next for publichealth? The Lancet 395, 542–545.3. Lillie PJ et al. (2020) Novel coronavirus disease (Covid-19): the first twopatients in the UK with person to person transmission. Journal ofInfection 80(5), 578–606.4. Public Health England (PHE). National COVID-19 surveillance report:23 July 2020 (week 30). – United Kingdom 2020 July 23. Available athttps://www.gov.uk/government/publications/national-covid-19-surveil-lance-reports (Accessed 29 July 2020).5. Department of Health & Social Care. Coronavirus action plan: a guide towhat you can expect across the UK – United Kingdom 2020 Mar 3.Available at https://www.gov.uk/government/publications/coronavirus-action-plan/coronavirus-action-plan-a-guide-to-what-you-can-expect-across-the-uk (Accessed 29 July 2020).6. Public Health England (PHE). Public Health England response toSunday Telegraph coverage – United Kingdom 2020 May 31. Availableat https://www.gov.uk/government/news/public-health-england-response-to-sunday-telegraph-coverage (Accessed 29 July 2020).7. Public Health England (PHE). [Withdrawn] Guidance on social distan-cing for everyone in the UK – United Kingdom 2020 Mar 30. Availableat 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 29 July 2020).8. Public Health England (PHE). Guidance on shielding and protectingpeople who are clinically extremely vulnerable from COVID-19 – UnitedKingdom 2020 July 14. Available at https://www.gov.uk/government/publica-tions/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 (Accessed 29 July 2020).9. Department of Health & Social Care. NHS test and trace: how it work.United Kingdom 2020 May 27. Available at https://www.gov.uk/guid-ance/nhs-test-and-trace-how-it-works (Accessed 29 July 2020).10. Corman VM et al. (2020) Detection of 2019 novel coronavirus(2019-nCoV) by real-time RT-PCR. Eurosurveillance 25, 2000045.11. Chan KH et al. (2011) The effects of temperature and relative humidity onthe viability of the SARS coronavirus. Advances in Virology 2011, 734690.12. Lai MY, Cheng PK and Lim WW (2005) Survival of severe acute respira-tory syndrome coronavirus. Clinical Infectious Diseases 41, e67–e71.13. Van Doremalen N, Bushmaker T and Munster VJ (2013) Stability ofMiddle East respiratory syndrome coronavirus (MERS-CoV) under differ-ent environmental conditions. Eurosurveillance 18, 20590.14. GISAID: Global initiative on sharing all influenza data. Munich (Germany).c2020. Available at https://www.gisaid.org/ (Accessed 01 April 2020).15. COVID-19 Genomics UK Consortium (COG-UK) (2020) WellcomeSanger Institute. Cambridgeshire (UK). Available at https://www.cogcon-sortium.uk/ (Accessed 01 April 2020).16. Kamel Boulos MN and Geraghty EM (2020) Geographical tracking andmapping of coronavirus disease COVID-19/severe acute respiratory syn-drome coronavirus 2 (SARS-CoV-2) epidemic and associated eventsaround the world: how 21st century GIS technologies are supporting theglobal fight against outbreaks and epidemics. International Journal ofHealth Geographics 19(8), 1–12. https://doi.org/10.1186/s12942-020-00202-8.17. Farrahi K, Emonet R and Cebrian M (2014) Epidemic contact tracing viacommunication traces. PLoS ONE 9(5), 1–11.4 B. Holden et al.https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268820001922Downloaded from https://www.cambridge.org/core. IP address: 92.29.153.79, on 09 Dec 2020 at 16:34:51, subject to the Cambridge Core terms of use, available at

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COVID-19: Public Health management of the first two confirmed cases identified in the UK

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COVID-19: Public Health management of the first two confirmed cases identified in the UK

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