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expert reaction to Boris Johnson outlining proposed new three-tier alert system and what the measures will be

In a statement to the house of commons the Prime Minister outlined a  proposed new three-tier system of COVID-19 alert and restrictions, and what the new measures will be for certain areas this week.


General comment about evidence on transmission and hospitality, which some of you have asked about today:

Prof Dame Anne Johnson FMedSci, Vice President (International) at the Academy of Medical Sciences and Professor of Infectious Disease Epidemiology, said:

“Understanding the role that hospitality venues have in the transmission of COVID-19 is complex and more detailed data are needed to paint a comprehensive picture of where people are getting infected.  When people are meeting up in a range of environments, like homes, restaurant and pubs, it is very difficult to assess the relative contribution of virus transmission between each of these places.

“Office of National Statistics (ONS) data show that the risk of infection increases with the number of people you have contact with outside of your household, that is to say the more people you meet up with who you don’t live with.  This is especially evident for those under 35 who are currently at highest risk of infection.

“Data from Public Health England (PHE) show that going out to a hospitality venue is a common activity reported by people who have contracted the virus – this does not prove this was the source of infection.

“Since restrictions were reduced after lockdown ONS data show that there has been a steady increase in the amount of socialising at home, outside and in hospitality venues, although since the September restrictions these have begun to decline.  All these settings will likely favour transmission because they increase the number of people we have contact with.  The ‘rule of six’ and greater restrictions on any household mixing in high-risk areas are all about reducing the number of contacts we have with one another.  Nevertheless infection rates continue to rise.”

Data links:


Prof Derek Hill, Professor of medical imaging science, UCL, and expert in medical devices, said:

“The UK’s new three tier approach has parallels with what France introduced last month, with the UK levels corresponding roughly to the middle three levels (alert, high alert, maximum alert) of the French 5 level system.

“In both countries, universities and schools remain open but bars are closed in the very high (max alert) tiers.

“Notably France has already announced a ‘Health Emergency’ level triggered when over 60% of ICU beds are occupied with covid-19 in an area, with likelihood of local lockdown,  though no areas are yet at this level.  It seems inevitable that a corresponding 4th tier in the UK might be introduced in due course.

“The UK is a little behind France in this wave as in the first wave.  Perhaps today’s announcement of a tiered approach indicates that the UK is paying more attention to neighbouring countries than in the first wave.”


Dr Bharat Pankhania, Senior Clinical Lecturer, University of Exeter Medical School, said:

“The three-tier system is an attempt to introduce order in how the Coronavirus pandemic is managed in different parts of the country.  The tiers range from level 1 to 3.

“The persistent, never ending failure, despite several variations on control strategies is the failure to delegate fully the ability for either local or regional experts to deal with the outbreaks.  PM Johnson still retains the centralised testing and tracing models’ and thus control in distant parts of the country is not easy to achieve.

“If there was the option to test locally, as determined by local expert outbreak control teams and also trace by locally developed teams, the response would be much more nimble and responsive, late testing, late delivery of results and later still contact tracing is a waste of time effort and money.  Cases in circulation unaware they are infectious, contact created who then become cases and the situation escalates, lockdown occur, and case numbers go down temporarily, only to surge up once restrictions have been lifted.  This is not sustainable.

“The Government determines the level an area is in.  If the formula for what level an area is put in is determined by the test results, in high density poor areas there will be undercounting.  As poor access to tests, for whatever reason, will not show the true picture of infections.

“There is no clarity on positive test results and the level and area is assigned and no clarity on when the area moves into higher or lower tiers.

“Nowhere in the announcement is there any mention that to sustain a lower level of circulating virus, it is important for all people at all times to adhere to strict infection control measures all the time and moving down a tier does not translate to it is now safer to drop the infection control guard.

“There is a lot of tension and stress in the system with schools and universities, it would be prudent to plan and fund more remote teaching, especially school students.

“What is required is:

1. Local / Regional control of outbreaks.

2. NHS testing, locally to be expanded.  Increase NHS and local testing capacity and slowly wind down the central testing.

3. Local / Regional tiers in charge of the contact tracing operations, disband the central tracing operations, fund local and regional tracing operations instead.

4. Get the messaging clear, moving down a tier does not mean drop the infections control guard.

5. Excellent individual and personal infection control measures can have a dramatic positive national impact.

6. Messaging must include importance of personal infection control and that for example mask wearing and wearing it properly is going to be enforced.”


Prof Igor Rudan, Joint Director of the Centre for Global Health and WHO Collaborating Centre, University of Edinburgh, said:

“The problem with the large second wave of the COVID-19 pandemic in the whole of Europe, as well as in the UK, is that the objectives of national government responses are no longer as clear as they were earlier this year.  When the first wave struck Europe, the objective was clear: saving as many lives as possible, supporting the economy during lockdowns and learning as much as possible about the virus.  We needed to understand infection-fatality rates and the speed of spread much better, as well as the modes of transmission and opportunities for prevention.  Lockdowns in March and April were buying us time to develop tests for diagnosing both the presence and of the virus and the exposure status.  It also bought us the time to develop and test PPE, improve guidelines to reduce transmission through so-called “precision public health”, provide health education on the pandemic to the general public, test the effectiveness of the existing medicines and accelerate the development of the new vaccines.  In the second phase of the pandemic, over the summer, the objective across much of Europe was to try to save as much of the tourist season as possible while containing the numbers of cases – some countries, like Croatia, were really successful at this.

“However, in this, the third phase, the objectives are no longer clear because it is so difficult to know when we may get effective vaccines or medicines distributed broadly.  As a result, a strategy is required which simply minimises the risk of either health system breakdown or economic breakdown.  This is why the proposed strategy seems sensible under the circumstances.  In several years’ time, it may be possible to scientifically assess whether a strategy of no measures at all would have been less costly or damaging to the societies of the western world across all dimensions in comparison to this “middle way” approach, or a full lockdown.  However, at this point in time, we cannot know this with certainty.  We can only try to model the future based on the parameters that are still rather uncertain.  Under such circumstances, taking a path that tries to balance between the risk for the breakdowns of the economy and the health system seem sensible.

“There is also another approach worth mentioning, that has been used in the countries of Asia, which is far more reliant on very strong systems and procedures for testing, tracing and isolating, careful monitoring and tracking of all contacts, mask-wearing, social distancing and tight border controls.  That approach seems superior in its results so far to those that we are considering in Europe.  However, as there doesn’t seem to be sufficient capacity in European countries to implement similar measures, nor sufficient support from the general public to implement such strict measures, then the strategy proposed by the PM seems quite transparent, sensible under the circumstances and grounded in what we learned so far about the virus.”


Dr David Strain, Senior Clinical Lecturer, University of Exeter, said:

“The Prime Minister has elected to keep the majority of the country with an intervention that is clearly not working, indeed increases the likelihood of people legitimately widening their potential infection circle.  The Rule of 6 is fundamentally flawed, permitting potential spread to 5 other households as many times per day as the individual sees fit.  The majority of the country has been observing this as a minimum for over a month, and yet cases continue to increase, indeed Prof Van-Tam highlighted that the situation had worsened between his briefing in the commons at the end of last week and this mornings press conference.  Whilst he presented evidence that a large number of infections are occurring in the hospitality sector, and uses that as a reason for tighter restrictions, he ignores the fact that the “where” and for that matter the “when” is much less important than the “who”.

“The introduction of restrictions at the High risk tier are sensible, indeed limiting social interaction to exclusive support bubbles (maximum two families) would be useful earlier.

“At the very high risk tier, there is already confusion with mixed messages about whether all of the interventions suggested apply universally, or some just to Liverpool.  At this time of national crisis we need clarity.  Our Prime Minister has again failed to deliver this.”


Prof Jackie Cassell, Deputy Dean, Brighton and Sussex Medical School, University of Brighton, said:

“A simpler system is to be welcomed.  Hospital admissions have reached alarming levels in several parts of the country and the new measures are likely to play a part in reducing avoidable admissions and deaths in what may be a short window before vaccination is available for those at greatest risk.

“However there was a notable silence on age related recommendations and guidance on ‘what the alert levels mean for clinically extremely vulnerable people’ is to follow.  This is an interesting omission on a controversial topic.  Death and serious illness are so strongly related to older age and to underlying illness that in my view the Tiers are not fully specified without new guidance for these groups.”


Prof Linda Bauld, Professor of Public Health, University of Edinburgh, said:

“The introduction of a three tier system does provide greater clarity on what will happen in parts of England to try and address the current rise in Covid-19 cases.  There has been some debate about why hospitality venues will be closed in the ‘very high’ tier and it’s important to understand why that is occurring.  These closures are already in place in the central belt of Scotland.

“It’s difficult to identify precisely where people come into contact with SARS-CoV-2 when we use information from contact tracing and haven’t sequenced viral samples.  People who test positive and then discuss with a contact tracer where they have been are likely to have visited several types of different venues.  A recent evidence paper from the Chief Medical Officer and colleagues in Scotland1 reported that, overall, hospitality is the second largest category after family (household) clusters in Scotland, although as a proportion this category has fluctuated a bit over the weeks.

“However, it is not as straightforward as ‘counting’ settings.  People are likely to spend longer in a pub or restaurant than in a shop, for example, and there is more face to face contact without face coverings on when people are eating and drinking.  Hospitality venues are indoors where ventilation may be more limited and physical distancing may not always be maintained when alcohol is involved.  It’s also the case in other countries, unfortunately, that case numbers and clusters have been linked to hospitality venues and we can see that other countries and cities in Europe have taken the difficult decision to close pubs and restaurants as case numbers have risen.”




All our previous output on this subject can be seen at this weblink:


Declared interests

Prof Igor Rudan: “Co-Editor-in-Chief, Journal of Global Health.  President, International Society of Global Health.  Adviser on COVID-19 response, The Government of the Republic of Croatia.”

None others received.

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