Preparing for a second wave of coronavirus

The consensus from health professionals, academics and experts is that a second wave is very likely.  Previous pandemics have been characterised by waves of infection spread over months, and there’s no reason to think that COVID-19 will be any different. Coronavirus simulations conducted by Brunel University in August 2020 predicted a second wave in "almost all cases". In these models the wave looks much less deep than the first wave, but it could be more prolonged.  

The UK’s Government Office for Science commissioned a report from The Academy of Medical Sciences, entitled “Coronavirus: preparing for challenges this winter”, which was published on 14 July 2020. This report predicts a gradual rise in cases from September 2020, with the peak projected to occur in January/February 2021, coinciding with a period of peak demand on the NHS.  

The Academy of Medical Sciences arrived at a reasonable worst-case scenario for the winter COVID-19 epidemic in the UK, that assumes R rising to 1.7 from September 2020 through to July 2021.   

However, they observed that even scenarios with R in the range 1.1-1.5 are likely to stretch NHS capacity over the winter. As we are already seeing, large local or regional resurgences are possible, which could stretch health and social care systems locally rather than nationally. 

Although progress toward a vaccine is promising, there’s little chance of a vaccine before the end of winter 2020/21. As with flu, different strains of the COVID-19 virus may occur and require repeat vaccination, and a global response. The message is that even after a second wave, it isn’t over - the issues will remain with us for some time to come. 

To mitigate the potential impact of a COVID-19 pandemic running alongside an influenza pandemic this winter, the number of people eligible to the national flu immunisation programme has been greatly extended.   

This winter, it will be a priority to increase the uptake of the influenza vaccination programme for eligible groups, including high risk groups who are vulnerable to influenza. Children are a key group for influenza vaccination as they amplify community spread. Influenza vaccinations in schools have been suspended and if attendance at primary schools continues to be impacted after September 2020, this will make delivery of the schools-based influenza programme more challenging. 

Transmission of COVID-19 (and all viruses) is dominated by transmission that takes place indoors, and people spend significantly more time indoors during the winter. Some of the indoor factors are:    

Direct person-to-person transmission of viruses 

• Due to less daylight and adverse weather, more people stay indoors for longer periods and are more likely to drive or use public transport than walk or cycle. 

Aerosol transmission 

• People are less likely to open windows, meaning poor ventilation and overcrowding could increase the density of virus particles accumulating in a room, both in the air and on surfaces – leading to greater risk of transmission. This can be a particular challenge in modern airtight buildings which have very low infiltration rates for energy efficiency, and for people on low incomes who are trying to keep heating costs down. 

Surface contact transmission 

Lower humidity, cooler temperatures and darker conditions during winter months are likely to favour the persistence of the virus on contaminated surfaces and objects. 

Changes in susceptibility 

Low temperatures can reduce the body’s immunity to all viruses as well as favour virus survival. Furthermore, poorer quality housing tends to have lower temperatures due to poor insulation, inadequate heating or inappropriate use of heating – which is important to consider alongside long-term home working and potential further isolation of vulnerable people. 

Exposure to air pollution is associated with increased morbidity and mortality. Some of the same conditions have also been identified as increasing the risk of severe COVID-19 symptoms. Atmospheric pollutants in cities are expected to rise again as restrictions are eased.  

For every 1°C temperature drop below 5°C, respiratory infections increase by 10-20%, with high local variation, and emergency hospital admissions increase by approximately 1%. However, the negative health effects of cold temperature start at 4°C- 8°C and, due to the number of such days, it is this temperature band within which the greatest health burden occurs.   

A possible winter influenza epidemic - flu  

The winter months are likely to result in an increase in influenza and other seasonal infectious diseases. 

Influenza and other respiratory infections consistently cause substantial NHS pressures and excess mortality each winter. These respiratory viruses have very well described seasonal patterns, with excess winter mortality due to respiratory infections typically concentrated between November and February. 

The common cold also has a much higher transmission in winter than in summer. And the severity of influenza in winter 2020/21 will be particularly difficult to project. The winter of 2017/18 was the most recent significant influenza season with an excess winter mortality of approximately 49,410 deaths. 

It is not clear whether the incidence of influenza infection will continue to be suppressed by physical distancing in winter 2020/21 or may be high because of a mild influenza season in 2019/20. 

Co-infection and novel viruses 

A resurgence of COVID-19 this winter is likely to coincide with outbreaks of other respiratory viruses such as the flu. Co-infections, which are not an unusual occurrence, might enhance disease, and the mechanisms and consequences underpinning such interactions are not known. Co-infections could facilitate recombination events and give rise to new viruses.   

Other diseases 

The winter burden on the healthcare system is not only affected by increased incidence of infectious diseases, but also non-infectious conditions that increase in prevalence or are exacerbated during the winter months, such as asthma, chronic obstructive pulmonary disease (COPD), ischaemic heart disease, myocardial infarction and stroke. 

Seasonal/winter weather has a significant effect on mental health for many.  Severe winter weather events (e.g. flooding) have major impacts on mental health, and are linked to depression, anxiety and suicides. Future restrictions on social contact may be felt particularly in winter, when reduced daylight and bad weather make it more difficult to use outdoor space.  

In addition to the mental health burden mentioned above, severe weather events, such as snow fall and flooding, may impact COVID-19 related logistics (e.g. delivery of tests and test results). 

Although schools re-opening is known to increase the transmission of influenza, this has not yet been demonstrated for COVID-19, and there is substantial uncertainty around the likely impact of schools re-opening on the R rate. There have been widely reported outbreaks of COVID-19 amongst students with the return of universities.

The decrease in international travel during lockdown is likely to have a substantial impact on reducing the international spread of influenza and other infectious diseases; however, international movement usually increases during the Christmas season. 

Indoor celebrations held over autumn and winter, such as Diwali and Christmas, may reduce adherence to physical distancing and other measures, and this could lead to an increased number of infections. 

In the winter, pressures on NHS services are generally high, while availability of NHS staff and facilities may be reduced due to winter health impacts and winter weather disruption. The health and social care systems have been reconfigured to respond and reduce transmission of COVID-19, but this has had knock-on effects on the ability of the NHS to deal with non-COVID-19 work. 

NHS Test and trace is a key component of efforts to suppress the virus. An unknown is how resilient the service will be by the winter. What’s certain is that there would be a tipping point at which the service would be overwhelmed – for example by a conflation of COVID-19 outbreaks; an influenza pandemic and a severe weather event. 

The degree to which immunity is conferred by past infection remains unknown.  T cell immunity may also be important, generating memory responses to combat the virus upon re-infection. 

There is currently little evidence that vitamin D reduces the risk of COVID-19 infection. However, vitamin D has been associated with a protective effect against acute respiratory tract infections and is known to be important to bone and muscle health.  The UK government has advised that everyone should consider taking 10 micrograms of vitamin D daily during the COVID-19 pandemic due to the decrease in sunlight exposure as more time is spent indoors. The government also advises that people whose skin has little to no exposure to sunlight, and ethnic minority groups with dark skin should consider taking a vitamin D supplement all year round. 

Mortality rates are likely to continue to be highest in older adults, those with chronic diseases, those from BAME groups, those in high exposure occupations, and urban areas with high levels of poverty. It is not yet known the extent to which excess BAME mortality is due to increased risk of infection, or increased risk of death if infected, or both. 

• Organisations should explicitly consider plans for winter as part of their COVID-19 secure risk assessment 
• Businesses must ensure that  risk assessments remain current and that  business continuity plans have been refreshed 
• Follow government guidance on making your work environment COVID secure. 

The most effective strategies for reducing transmission in the workplace are structural. The least effective strategies are those that rely on individual effort alone. 

• Optimise ventilation into the building to ensure fresh air supply  
• Increase exposure to sunlight, and maintain higher temperatures and humidity 
• Limit physical overlap and movement between zones 
• Consider active containment measures, including physical distancing and good hand hygiene  
• Encourage or mandate the wearing of face coverings where appropriate so that this becomes a social norm
• A key component of any COVID secure plan is social distancing - ensure you remind employees of the government social distancing guidance and their importance. 

• Some forms of travel are safer than others when it comes to minimizing the chances of transmission 
• As we move into the winter, it’s important to remain mindful of the prevailing R rate, how your employees travel as well as their risk profile. Our factsheet on commuting to work has more information. 

• Businesses should consider the benefits of an employee flu vaccination programme and seek to maximise take-up  
• Do talk with your provider to confirm vaccine availability 
• Consider how to address the issue of ‘vaccine hesitancy’ where individuals defer or avoid vaccination for a variety of reasons.    

• Build the possibility of local and national lockdowns into your business continuity plans, and if you’re impacted ensure you understand the restrictions and respond with clear communications; our  factsheet on local lockdowns has more information 
• Keep yourself up-to-date with the R rate – both nationally and in your business locality; any rapid increases or rates above 1 are warnings of significant problems coming
• Public Health England includes a local authority ‘watch list’ within its weekly National COVID-19 surveillance reports
• The government has provided information on local COVID alert levels (also called tiers), including what they mean, why they are being introduced and what the different levels are.
• The new national restrictions for England from 5 November 2020 are found here
• For restrictions in Wales see here 
• For restrictions in Scotland see here 
• For restrictions in Northern Ireland see here 

Despite the systems in place for infection prevention and control, outbreaks may happen.  Businesses should familiarise themselves with the governments outbreak management guidance. 

As cases rise, the potential for business to be impacted by NHS Test and Trace will grow proportionately.  Our factsheet explaining NHS Test and Trace has more information. 

A person’s willingness to name their contacts in the Test and Trace programme may be compromised by concerns of putting friends and family in quarantine for 14 days – with potentially substantial childcare, economic and social implications – and self-quarantine may be compromised by similar issues. Businesses should communicate their approach when staff are asked to self-isolate by NHS Test and Trace, to avoid presenteeism that might risk business operations and increased transmission to others. 

Understand where your employees need to use PPE to remain safe at work, and ensure those actions are being taken. Our factsheet on using PPE in the workplace has more information. 

• As an employer, you have the same health and safety responsibilities for home workers as for any other workers - the HSE has published guidance on this 
• To mitigate against viral infection it’s important that those working from home can achieve adequate ventilation and heat their homes effectively 
• Since household transmission is one of the highest risks for Covid-19 transmission businesses should reinforce guidance on how to self-isolate within the home to prevent infection to household members; the NHS has guidance on how to avoid spreading the virus to those you live with. 

• Physical and mental health has likely been negatively impacted during lockdown, due to reduced activity levels, increased calorie and alcohol intake, and environmental factors  
• It will be important for businesses to consider how to improve staff morale and boost resilience as we enter the winter period 
• Businesses should consider encouraging employees to take positive action before winter to improve their physical and mental health 
• For more information, read our factsheet on mental health and wellbeing in a crisis. 

The tests that identify current coronavirus infections, as well as the antibody tests that detect an immune response to previous infections, are evolving at pace. For high risk environments, testing every three days has been the emerging pattern. However, affordability remains an issue.

Those organisations currently engaged in workplace testing are those with a huge daily cost from shutdown. Many employers are already layering temperature testing on arrival into their COVID-secure plans. As the tests for coronavirus itself evolve further to enable rapid testing and become more affordable, businesses should consider whether to incorporate workplace testing into their plans.