Tag: Covid-19

General practitioner perceptions of using virtual primary care during the COVID-19 pandemic

Whether it be a simple telephone call or more sophisticated video conferencing systems, virtual care tools have been in use in primary care settings worldwide in one form or another throughout the past two decades. Over time, these tools have grown in availability, matured in their capabilities, but played a largely supportive role as an alternative option to traditional face-to-face consultations. This all changed in early 2020 with the onset of the COVID_19 pandemic.

The COVID-19 pandemic presented a unique opportunity globally which put virtual care tools at the forefront of primary care delivery. The need for social distancing to limit disease transmission resulted in virtual care tools becoming the primary means with which to continue providing primary care services. Hence, our study’s goal was to capture the spectrum of GP experiences using virtual care tools during the initial months of the pandemic so as to better understand the perceived benefits and challenges, and explore what changes are needed to allow them to reach their fullest potential.

We carried out a global study to investigate this further, published in the journal PLOS Digital Health. We received 1,605 responses from 20 countries globally. Our results demonstrated that virtual care tools were beneficial in limiting COVID-19 transmission, improved convenience when communicating with patients, and encouraged the further adoption of virtual care tools in primary care. Challenges included patients’ preferences for face-to-face consultations, digital exclusion of certain populations, diagnostic challenges associated with the inability to perform physical examinations, and their general unsuitability for certain types of consultations. Practical challenges such as higher workloads, payment issues, and technical difficulties were also reported.

Learning from this global natural experiment is critical to both updating existing and introducing new health technology policies concerning virtual primary care. Doing so will be imperative to supporting and promoting the better use of these novel technologies in our evolving healthcare milieu.

DOI: https://doi.org/10.1371/journal.pdig.0000029

Data from the NHS is playing a key role in guiding vaccination policies globally

Throughout the pandemic, the UK’s covid-19 data systems have been guiding global as well as local policies. The well-established health information systems combined with the more recently established National Immunisation Management System in England provided timely information on infections, emergence of new variants, and the value of different interventions. But one of the most important contributions from the UK came from the ability to rapidly track vaccine effectiveness.

Vaccination is the best method for societies to reduce the severity of illness and number of deaths from covid-19; and to start to return to a more normal way of living, working, and studying.[1] But vaccination programmes need to be evidence-based, so that vaccines and healthcare resources are used appropriately, and there is equitable vaccine delivery. The covid-19 pandemic has shown the importance of data from medical records and the National Immunisation Management System in guiding national vaccination policies. Clinical trials can provide initial data on the efficacy and safety of vaccines. However, because of their relatively small size and short duration of follow-up, they cannot provide longer-term data on vaccine effectiveness or on rare adverse events.[2] Furthermore, because covid-19 vaccines were designed to target the original strain of SARS-CoV-2, the trials are also unable to provide data on protection against new variants that emerged after the trials were completed. Nor were they able to provide data on the need for booster doses of vaccines to maintain protection from serious illness and death.

Clinical trials are also generally unable to provide data on smaller subgroups of the population such as people who are immunocompromised; or how different vaccines compare in their long-term safety and effectiveness. This data has to largely come from national immunisation systems and from medical records, as does data on vaccine uptake in different groups of the population. These are areas where the UK has excelled during the covid-19 pandemic in work led by government organisations such as the UK Health Security Agency and the UK Office for National Statistics.

In England, the UK Health Security Agency has assessed vaccine effectiveness against symptomatic covid-19 infection using community testing data linked to vaccination data from the National Immunisation Management System (NIMS); with further linkage to data from electronic NHS secondary care datasets;  sequencing and genomics data; travel information; and mortality records. These data have allowed analysis of how well covid-19 vaccines protect against outcomes such as hospitalisation and death as well as against symptomatic infection during the course of the pandemic.[3] With the linkage of secondary care datasets and NIMS data, it has also allowed for timely epidemiological safety signal assessments to be rapidly carried out in response to passive reports of adverse events after vaccination from the MHRA yellow card system. The large size of the English population allows for more precise estimation of these effects; something that is not always possible in data from countries with smaller health systems. Data from the UK also allowed identification of people at highest risk from the complications of covid-19, which helped in deciding which groups would be prioritised for vaccination. UK data also allowed the tracking of breakthrough infections following vaccination better than any other country; and confirmed that delaying the second dose of vaccine was likely to lead to better protection from serious illness.

Most recently, the data has allowed analysis of how well vaccines protect against new variants of SARS-CoV-2 such delta and omicron. The latest data confirm that three doses of vaccines provide good protection from hospitalisation and death from an omicron infection; but that the level of protection is not as high as against the delta variant that was previously predominant in many parts of the world. [4] Protection against infection is also less against newer variants than against the original strain of SARS-CoV-2, which meant that breakthrough infections in vaccinated people were common, particularly at times when community infection rates are high.[4] The data also show that longer-term protection is better with the mRNA vaccines in use in the UK (Pfizer-BioNTech and Moderna) than with the AstraZeneca viral vector vaccine. Ongoing work will show how well this protection from serious illness and death is maintained; and whether further booster doses may be needed in the population more widely after the implementation of a fourth dose in older people and the clinically vulnerable.[5] In addition, epidemiological assessments of safety signals will continue to support and maintain confidence in the covid-19 vaccine programme.

Other data can be linked to the NIMS to allow estimation of vaccine uptake by age group, area of England and by ethnic group. This has proved essential in identifying population groups and geographical areas with lower than average vaccine uptake. For example, the data has shown that vaccine uptake is generally lower in younger age groups than among older people; and lower in large, urban areas such as London than in other parts of England.[6] The development of a public-facing “data dashboard” has allowed easy viewing of this data at national, local and regional level; thereby supporting public health teams to identify areas and communities with lower vaccine uptake.[7]

Looking forward, it is important that we maintain our data collection, linkage, analysis and publication abilities for the longer-term.[8] Although we must now all learn to live with covid-19, SARS-CoV-2 will still pose a threat to global health for some time, especially if new escape variants emerge.[9] Furthermore, with population-level immunity after vaccination waning and covid-19 control measures ending, there is a risk that later in the year we may see a surge in infections in the UK and elsewhere; in recent weeks, we have already seen an increase in covid-19 infections and hospital admissions in the UK. In addition, changes in testing behaviour and guidance may affect how vaccine effectiveness is monitored in the future. The data systems, scope for data linkage, and the analytical capacity in the UK will prove essential in tackling the long-term threat to global public health from covid-19; and lessons from the UK’s data systems should continue to be shared with the rest of the world to support the global response to covid-19.[10]

Azeem Majeed, Elise Tessier, Julia Stowe, Ali Mokdad

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o839 


  1. Majeed A, Molokhia M. Vaccinating the UK against covid-19. BMJ. 2020 Nov 30;371:m4654. doi: 10.1136/bmj.m4654.
  2. Majeed A, Papaluca M, Molokhia M. Assessing the long-term safety and efficacy of COVID-19 vaccines. Journal of the Royal Society of Medicine. 2021;114(7):337-340.
  3. Monitoring reports of the effectiveness of COVID-19 vaccination.https://www.gov.uk/guidance/monitoring-reports-of-the-effectiveness-of-covid-19-vaccination
  4. Andrews N, Stowe J, Kirsebom F, et al. Covid-19 Vaccine Effectiveness against the Omicron (B.1.1.529) Variant. N Engl J Med. 2022 Mar 2. doi: 10.1056/NEJMoa2119451.
  5. Walker P, David N. UK: over-75s and vulnerable people to be offered additional Covid booster jab.https://www.theguardian.com/society/2022/feb/21/uk-older-vulnerable-people-to-be-offered-covid-booster-vaccine
  6. Office for National Statistics. Coronavirus (COVID-19) latest insights: Vaccines.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/vaccines
  7. Official UK government website for data and insights on coronavirus (COVID-19).https://coronavirus.data.gov.uk/
  8. Tapper J. Dismay as funding for UK’s ‘world-beating’ Covid trackers is axed.https://www.theguardian.com/world/2022/mar/12/dismay-as-funding-for-uks-world-beating-covid-trackers-is-axed
  9. Murray CH, Mokdad AH. After the Mandates End. Preparing for the next COVID-19 variant.https://www.thinkglobalhealth.org/article/after-mandates-end
  10. Dowd JB. The UK’s covid-19 data collection has been “world beating”—let’s not throw it away. BMJ 2022; 376 :o496.

Testing NHS Staff for Covid-19

There was no mention from the Chancellor, Rishi Sunak, in his speech on Wednesday 23 March 2022 about the continued funding of Covid-19 testing for NHS staff in England. We need the government to clarify this urgently and confirm whether twice weekly testing of healthcare workers will continue or stop in April 2022.

Under current guidance, NHS staff are required to test for Covid-19 twice weekly and report their results before coming to work. If testing is to continue from April onwards, then the NHS will have to find this funding from its existing budgets, reducing funding for other areas of care.

There has been discussion about staff paying for their own testing. My view is that if testing is required by NHS employers, they will need to fund the tests. Staff cannot be asked to fund their own tests if this is a condition of their employment.

Ending regular Covid-19 testing of NHS will increase the risk of infection spreading to vulnerable patients. But there are also costs associated with testing and we need a robust assessment of the evidence on which to base future testing policy for NHS staff.

Protecting yourself from Covid-19

The recent increase in Covid-19 rates in the UK is concerning although, to some extent, an increase in rates was expected now that control measures have ended in England, with the other three UK countries also ending most control measures as well.

We are also seeing signs of increased NHS pressures with more presentations of people with suspected or confirmed Covid-19 in primary care and hospital admissions increasing. The number of NHS staff off work due to Covid-19 is also adding to NHS pressures.

A key message for the public is that vaccination is essential. Many people have not come forwards for a booster vaccine, particularly in London and other large cities. Three doses of vaccine are essential to reduce the risks of serious illness and death from Covid-19.

A second booster programme is also now starting for the most vulnerable people in our society: people aged 75 years and over this living in care home and people who are immunocompromised. The additional booster will provide these people with greater protection from serious illness and death.

I also advise people to continue to wear a mask (preferably a FFP2 mask) when in shops and on public transport. People should also continue to self-isolate if they test positive for Covid-19 to reduce the risks of infection to others.

Given that infection rates are increasing again, people who are clinically vulnerable through age or their medical history need to be cautious about entering places where there is a high-risk of infection (i.e. crowded, indoor venues with poor ventilation).

The government should also continue with PCR testing for people with symptoms of a possible Covid-19 infection and not scale back testing as it seems to be planning from April onwards. Unfortunately, there is no easy way out of the pandemic and testing along with good infection control measures remain essential.

Why should I other getting a Covid-19 vaccine booster?

I have much bigger healthcare concerns than getting COVID-19, and the NHS doesn’t help me with them. Why should I bother to help them by getting this vaccine?

This is a question that some people often ask. By getting the Covid-19 vaccine, you are protecting yourself as well as reducing pressures on the NHS. Over 10 billion Covid-19 vaccines have been giving globally; and they have proven to be very safe and effective. The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill or dying from Covid-19.

By getting vaccinated against Covid-19, you are substantially reducing your risk of a serious illness that may lead to you requiring hospital treatment or even dying. Even if you don’t need hospital treatment, Covid-19 can still be an unpleasant illness that can make you unwell for a few weeks or leave you with long-term complications.

The risks from Covid-19 are particularly high in those who are over 50 years of age, obese or who have underlying medical problems such as diabetes or kidney disease. Vaccination reduces all these risks to you. Furthermore, if too many people remain unvaccinated, this will increase the likelihood of the government having to introduce measures to control the spread of Covid-19 and reduce pressures on the NHS. This could mean, for example, bringing in restrictions on people attending large, indoor gatherings – or closing pubs, night clubs and restaurants – like the measures we have seen at times over the last two years.

It could even lead to another lockdown if pressures on the NHS were very high. These measures have had a big impact on people’s social lives and mental health, as well as on the economy, and we don’t want to see them brought back.

Finally, many countries across the world are now requiring proof of vaccination for tourists and visitors. If you are not vaccinated, you will find it difficult to visit these countries, thereby limiting your leisure opportunities or the chance to meet friends and family living overseas. So by getting vaccinated, you are not only helping the NHS. You are also helping yourself.

UK scales back routine Covid-19 surveillance

On 24 February 2022, the UK government removed the legal requirement for people in England to self-isolate after a positive covid-19 test result, with the other UK nations also easing restrictions.1 In doing so, the UK is acting ahead of many of its international peers to embark on a “vaccines only” strategy, hoping that existing immunity in the population will allow a “return to normal.” This view is in sharp contrast to public opinion. In a recent poll by market research company YouGov, only 17% of respondents thought that ending mandatory self-isolation was appropriate.2

The removal of legal restrictions makes the people of England part of an experiment in which much remains uncertain.3 This is acknowledged by chief government advisers Chris Whitty and Patrick Vallance, who accompanied Boris Johnson’s announcement with a warning that rates of covid-19 infection and hospital admission remain high.4 Of equal concern, the government’s announcement also introduced plans to scale back two crucial pillars of the UK’s covid-19 surveillance: the Office for National Statistics’ (ONS) covid-19 infection survey and daily reporting of data on the UK Health Security Agency (UKHSA) covid-19 dashboard.15 When, and to what extent, these important resources will be scaled back remains unclear.

The ONS survey is a world leading example of random population sampling to estimate covid-19 prevalence over time.67 The UKHSA dashboard has been a vital resource for the public, clinicians, journalists, and researchers, allowing them to identify local trends as well as providing national data. The dashboard received up to 19 million hits a week in September 2021.8 Data to understand and promptly respond to covid-19 outbreaks are essential for public health and the NHS, as well as for the wider public.

We remain in the middle of a global pandemic caused by a novel pathogen and complicated by the repeated emergence of new variants. Policy decisions to manage new outbreaks rely on robust and timely data—the alpha, delta, and omicron variants all became dominant in the UK within weeks of the first reported cases.9 Although omicron is associated with a significantly lower risk of hospital admission and death than previous variants, the government’s Scientific Advisory Group for Emergencies (SAGE) acknowledges that this may be the exception rather than the rule, emphasising the need for ongoing vigilance to detect future variants.10

From 1 April 2022, when universal free covid tests are withdrawn leaving only limited testing in place, most SARS-Co-V infections in England will remain undetected and unreported. Our ability to track the emergence of new variants or trends in the incidence of infection and disease will become more reliant on robust, cross sectional surveys such as the ONS survey. Scaling back the survey, as proposed, risks missing emerging variants or concerning rises in prevalence that could herald the need for further restrictions; moreover, the survey cannot provide accurate and timely local data, as currently provided by the UKHSA dashboard. The detrimental effects of delayed action are now abundantly clear, and we must not fall behind at this critical moment when the UK’s pandemic is gradually coming under control.11

In announcing the latest relaxation of restrictions, the prime minister asked the public to take individual responsibility for their actions, yet informed decisions are reliant on the availability and accessibility of information. Throughout the pandemic people have relied on regional reporting of covid-19 cases on government dashboards and in news media, and they will continue to need such accessible information for the foreseeable future.

While most people have received two or more doses of a covid-19 vaccine, almost 10% of adults in England have not received a single dose and around 30% have not had a booster.12 Many others remain at high risk of disease despite vaccination because of underlying health conditions. The public health implications of immunity waning over time remain uncertain.1314 As we move into a period of largely optional (and paid for) testing and voluntary self-isolation, it is crucial that people have easy access information to guide their actions and help minimise covid-19 risks to themselves and their families.

The UK has been a world leader in the routine surveillance of covid-19 and the transparent reporting of covid-19 data. Scaling back vital data systems prematurely is a false economy and may need to be reversed to manage future waves of infection. The UK has the resources and infrastructure to continue existing surveillance, which has clearly identifiable benefits. We need to sustain our existing surveillance capabilities until we are certain that the pandemic is over in the UK, which won’t be until covid-19 is controlled globally.

Jonathan Clarke, Thomas Beaney, Azeem Majeed

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o562

Covid-19: Implications of ending the legal requirement to self isolate for employers and people who are clinically vulnerable

The government has just announced that all covid-19 restrictions in England are set to end. Boris Johnson, the UK prime minister, told MPs that he plans to remove the remaining restrictions, including the legal requirement to self isolate for people infected with covid-19. Instead of legislation, voluntary guidance will “advise” people with covid-19 not to attend workplaces. Employers will once again need to develop and implement new rules for their workplaces when the legal requirement to self isolate with covid-19 comes to an end. They should consider carefully how to develop and implement new policies fairly and safely in the workplace so that staff and customers—particularly those who are clinically vulnerable—are not put at risk.

Presenteeism occurs when employees go to work despite not being well enough to perform their duties. The NHS is the largest employer in England and the NHS Staff Survey showed a drop in presenteeism in 2020 compared to preceding years. This is likely an effect of covid-19, which forced workers and employers to endorse sick leave to prevent workplace outbreaks and has therefore gone some way to changing attitudes to calling in sick. Despite this, around 40% of NHS staff surveyed still reported coming to work in 2020, despite not being well enough to work.

Reasons why employees attend work while unwell include financial pressures. Statutory sick pay (currently £96.35 per week in England) is the minimum amount employers must pay to unwell employees; though not all workers are entitled to statutory sick pay—loopholes include agency work and zero hour contracts in certain situations. Though some workers are entitled to contractual sick pay which is closer to their normal salary, for many workers in England, taking sick leave means taking home less money; and sometimes no money at all.

Now that the legal requirement to self isolate will be scrapped, the government has announced that they will return to pre covid provisions of sick pay, with self isolation payments ending. Statutory sick pay and employment support will no longer be paid immediately, but only after four and seven days of absence. Workers who voluntarily decide to self isolate, but are unable to work from home, will in some cases face a loss in pay. The end to financial support for people to self isolate, or take sick leave, is concerning as people will no longer be financially supported to stay at home if they are ill. Those workers who are unable to work from home are more likely to be older, from lower socio-economic groups, and from ethnic minority backgrounds—factors that have cumulatively contributed to a higher occupational risk of death from covid-19 over the last two years.

The need for local health and safety policies will also leave employers with a dilemma. Should employers develop internal policies mandating self isolation for those infected with covid-19 to protect their workforce and their customers? The Health and Safety at Work Act 1974 places responsibility upon employers to ensure “as far as reasonably practicable” that both employees and non-employees are protected from workplace risks. The Equality Act 2010 mandates that employers make “reasonable adjustments” for employees with disability to protect them from workplace discrimination. For example, a retail assistant undergoing chemotherapy for cancer, for whom working from home is not possible, may be at high risk of acquiring covid-19 at work with significant medical complications now that the legislation mandating self isolation is going to be withdrawn. Who takes on the responsibility for this risk, and how can discrimination along the social gradient or against those with disability be avoided?

Presenteeism is not good for the individual attending work while unwell, nor is it good for the organisation. Covid-19, even when asymptomatic, brings risks of workplace outbreaks with significant impact on the operation of services due to sickness absences. Employers should consider workforce wide policies to encourage self isolation with fair pay when employees are infectious with covid-19, now that the legal mandate will be removed. Where this is not possible, individual occupational health risk assessments for employees vulnerable to severe covid-19 infection and its consequences should inform reasonable adjustments to their workplace duties. This will include, for example, examining how many people are allowed into the workplace at one time, ensuring good indoor ventilation, and mitigation measures such as high quality face masks are used as appropriate.

Employers will also need to consider factors such as the vaccination status of their staff and current community covid-19 infection rates in their health and safety policies. Most adults in the UK have now had two covid-19 vaccinations, but a large proportion (around one in three) have not yet come forward for a booster vaccine. Recent data show that the booster dose is essential in reducing the risk of serious illness, hospital admission, and death from a covid-19 infection caused by the omicron SARS-CoV-2 variant. Employers will need to work with their staff to promote covid-19 vaccination, but as the recent reversal in government policy for mandatory vaccination of healthcare workers shows, this is not straight forward. For the time being, community covid-19 rates are falling from the very high levels we saw in late 2021; and may remain at tolerable levels during the spring and summer of 2022. By next winter, however, we can expect a seasonal increase in respiratory viral infections, which will coincide with waning population immunity, placing more people at risk from covid-19.

Losing progress away from presenteeism will be a backwards step in all sectors of the economy as well as putting the most vulnerable members of society at greater risk. By ending mandatory self isolation while also removing financial support packages, the government is failing to adequately support people in lower paid occupations to protect themselves and others from covid-19, and risks widening existing socio-economic and health inequalities

Lara Shemtob, Kaveh Asanati and Azeem Majeed

A version of this article was first published in the British Medical Journal

DOI: https://doi.org/10.1136/bmj.o461

Questions and Answers on the New Covid-19 Rules in England

If you only have mild symptoms how safe is it to go into an office or other workplace?

The question you should ask yourself is would you be comfortable being in the same office as someone who had a positive Covid-19 test the day before? Now that the legal requirement to isolate after a positive test in England is ending, employers will need to carry out risk assessments and implement their own infection control policies. My advice would be for employers to remain cautious for now and advise employees with symptoms or a positive Covid-19 test to stay off work for a period until we have more experience about the effect of the change in rules.

I’ve had plans to go for dinner and drinks with friends for a birthday party but have tested positive. If we’re all triple vaccinated how big a risk is it if I still go?

People who are fully vaccinated can still become infected. If you test positive for Covid-19, I would advise not attending the event, particularly if it is going to be in a crowded indoor venue where there is a significant risk of infecting others who are present. Although Covid-19 vaccination does substantially reduce the risk of serious illness and death, there is still a risk to older people and those who are clinically vulnerable even if they are fully vaccinated.

Will GPs and hospitals still only see you if you have no Covid symptoms?

If you have Covid-19 symptoms, you should inform your GP or hospital before they see you so they can take suitable precautions. We are still awaiting guidance for the NHS on how the new rules will operate for them, such as whether face masks will still be required in healthcare settings. However, because they deal with people who are clinically vulnerable, the NHS will need to take appropriate precautions to prevent someone with Covid-19 infecting other patients.

I was told to shield during the lockdowns, and now triple jabbed. Is it safe for me to go to places where people might have Covid?

If you are in a group that was advised to shield during lockdowns, Covid-19 still poses a risk to you even if you are fully vaccinated. You should continue to wear a well-fitting FFP2 mask in places like shops and on public transport. Whether you go to places with a higher risk of Covid-19 such as nightclubs is a personal decision that you need to take but I would advise being cautious until infection rates in the community fall further.

I work in a care home. What if I test positive, do I go into work as normal?

People living in care homes are at very high risk of a serious illness and death if they become infected for Covid-19. Care homes should therefore keep appropriate infection control measures in place, such as asking staff who test positive for Covid-19 to self-isolate for a period.

If everyone is going about normal life even if they have Covid, what’s likely to happen to infections and could it lead to herd immunity?

In recent weeks, the number of Covid-19 cases, hospital admissions and deaths have been falling. The high level of immunity in the population from vaccination and previous infection should keep the number of serious cases of Covid-19 at a manageable level. However, people’s immunity does decline over time, which is why the government has just announced that those at highest risk from Covid-19, people aged over 75 years and those with weak immune systems, will be offered another booster vaccination. The long-term future remains uncertain and we don’t yet know if an additional booster will be offered to a wider group of people later in the year. We also don’t know what will happen next winter when there may be a lower level of immunity in the population. Finally, there is always the risk that a more infectious variant of the coronavirus may emerge like the Omicron variant that we faced late in 2021. Unfortunately Covid-19 will remain with us for the foreseeable future and become part of our lives, like other respiratory infections such as flu.

These comments were first published in the Daily Mirror.

Reducing the covid-19 isolation period in England: a policy change that needs careful evaluation

How long people with covid-19 should self-isolate depends on the period for which they remain infectious. On 4 January, the US Centers for Disease Control (CDC) updated covid-19 isolation and quarantine recommendations with shorter isolation (for asymptomatic and mildly ill people) and quarantine periods of 5 days to focus on the period when a person is most infectious, followed by continued masking for an additional 5 days.1 This policy was based on a modelling study from the United Kingdom by Bays et al which showed that after the 5th day after a positive test, an estimated 31% of persons remained infectious.2 All the authors of this modelling study, which was published as a pre-print on 24/12/2021, work for UK Health Security Agency (UK HSA).

On 22 December 2021, the UK HSA reduced self-isolation for covid-19 cases in England from 10 to 7 days following negative lateral flow tests on days 6-7. The UK HSA stated that that a 7-day isolation period alongside 2 negative lateral flow tests had nearly the same protective effect as a 10-day isolation period without testing for people with covid-19.

On 1 January, the UK HSA published a blog on using lateral flow tests to reduce the self-isolation period.3 The blog provides background to explain the reasons for the difference between the policies. It also stated that after 10 days self-isolation, 5% of people will still be infectious; and that ending self-isolation after 7 days and two negative lateral flow tests resulted in a similar level of protection.

The two negative test results are essential in safely supporting the end of self-isolation. Without testing, modelling suggests that 16% of people would still be infectious after day 7.  On 13 January, the Health Secretary Sajid Javid stated that from 17 January people will be able leave isolation from the start of day six after two negative lateral flow tests on days 5-6.

Both the US CDC and the UK HSA have based their length of isolation policy mainly on a single modelling study. The data on which the modelling was based It is therefore very important. Bays et al provide a single reference for “infectious period distribution”, a UKHSA modelling paper by Birrell et al published on 31 May 2021.4 Hence, it did not contain any information about the Omicron variant of SARS-CoV-2. It gives as a data source: “the Wuhan outbreak additionally provides information on epidemiological parameters: the duration of infectiousness, the mean time from infection to symptom onset; the probability of dying given infection and the mean time from symptoms onset to death”.

The Wuhan report by Li et al was published in New England Journal of Medicine on 26 March 2020.5 It does not contain any empirical information on the time for which cases were infectious. It only estimates the mean serial interval (MSI), based on six cases only, which represents the average time between the time of symptom onset of a primary case and that of a secondary case.6 The MSI is widely used in infectious disease surveillance and control because it allows investigators to identify epidemiologic links between cases and to diagnose new cases that have such epidemiologic links with laboratory-confirmed cases.  The MSI in Li et al is 7.5±3.4 days (95% CI, 5.3 to 19). There is no information specifically about infectious periods.

Policies in both the UK and US are based on limited data and only on the wild-type SARS-CoV2 variant. Ideally, there should be population-based studies which included daily monitoring of culturable Omicron variant viral shedding (or even better actual transmission, which should be available from large databases) and PCR and lateral flow testing. A 2020 (so pre-Delta) rapid scoping review and analysis from Ireland of available evidence for serial testing asymptomatic and symptomatic cases showed substantial variation in the estimates, and how the infectious period was inferred.7 One study provided an approximate median infectious period for asymptomatic cases of 6.5–9.5 days. Median pre-symptomatic infectious period across studies varied over <1–4 days (and there are several recent studies of the Omicron incubation period showing it is short). Estimated mean time from symptom onset to two negative RT-PCR tests was 13.4 days (95% CI 10.9 to 15.8), but was shorter when studies included children or less severe cases. The only currently available study of the Omicron variant is a small Japanese report which showed the number and percentage of Omicron variant virus isolation positive samples as 7/17 (41.2%) after three to six days and 2/18 (11.1%) at seven to nine days.10

The change in isolation policy for people with covid-19 in England is a pragmatic step that will allow people to return to productive work, education and social activities more quickly. People may also be more likely to comply with a shorter isolation period. But the changes should have been based on careful monitoring and review based on new data on the Omicron variant, not on data on the wild type of SARS-CoV-2. We therefore need careful evaluation of the new shorter isolation period to ensure that people are following the guidance on self-testing and symptoms, and not ending their isolation period too early, and thereby putting others at risk of infection from covid-19.

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o184


  1. US Centers for Disease Control. What We Know About Quarantine and Isolation: Why CDC Shortened Isolation and Quarantine for the General Population: US Centers for Disease Control, 2022.
  2. Bays D, Whiteley T, Pindar M, et al. Mitigating isolation: The use of rapid antigen testing to reduce the impact of self-isolation periods.medRxiv2021:2021.12.23.21268326. doi: 10.1101/2021.12.23.21268326
  3. UK Health Security Agency. Using lateral flow tests to reduce the self-isolation period: UK Health Security Agency, 2022.
  4. Birrell P, Blake J, van Leeuwen E, et al. Real-time nowcasting and forecasting of COVID-19 dynamics in England: the first wave.Philosophical Transactions of the Royal Society B: Biological Sciences2021;376(1829):20200279. doi: doi:10.1098/rstb.2020.0279
  5. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia.New England Journal of Medicine2020;382(13):1199-207. doi: 10.1056/NEJMoa2001316
  6. Vink MA, Bootsma MCJ, Wallinga J. Serial Intervals of Respiratory Infectious Diseases: A Systematic Review and Analysis.American Journal of Epidemiology2014;180(9):865-75. doi: 10.1093/aje/kwu209
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Isolation for people with Covid-19 in England: Follow the guidance carefully

The UK government has announced that people in England self-isolating because of a Covid-19 infection will be able to end their isolation period after 5 full days instead of the previous 7 days if they test negative on both day 5 and day 6 with a lateral flow test and do not have a temperature. The change comes into force on Monday 17 January 2022. What are the implications of the government’s decision to reduce the isolation period to 5 days for people in England with Covid-19? In summary, it’s a pragmatic step with some benefits but there are also some caveats and concerns that the government needs to address.

A shorter isolation period will allow people to return to work, education and social activities more quickly than the previous 7-day or 10-day isolation periods that we had in England. This will help address workforce shortages in the economy and will also allow children and students to resume their education. A shorter isolation period may also lead to greater compliance, as many people do not comply with longer isolation periods.

But some people will remain infectious after 5 days, so there are risks from this policy. A lateral flow test will identify many of the people who are infectious but some will be missed by the tests. It’s essential therefore that people also focus on their symptoms and not just rely on the results of their lateral flow tests. We need to remember the expression that doctors have: “Treat the patient and not the test result.”

If you remain unwell after 5 days – for example., if you have a high temperature or a bad cough – you should continue to isolate. Although many people of working age will have a mild infection – particularly if fully vaccinated – some people will have a more prolonged illness. The government does not mention cough as one of the symptoms that should lead to a longer isolation period – probably because a cough can persist for some time after a respiratory infection. If you feel well and have a mild cough, that is acceptable. But if you have a severe cough, you should consider extending your isolation period to longer than five days.

People should also not rush back to work and other activities too quickly. Take the time you need to fully recover from your illness before you return to work or education. Everyone is different and we recover at different speeds from an illness. This is irrespective of the results of your lateral flow tests. Base your recovery on how you feel and not just on your test results.

The government’s new policy is largely based on one modelling study which estimated that people with negative lateral flow tests on day 5 & day 6 are as likely to be infectious as people after a 10-day isolation period (7% v. 5% is the government’s estimate). Ideally, we would have stronger evidence from real-world studies about people’s infectivity after different isolation periods (5, 7 & 10 days) and what extra information is obtained about infectivity from lateral flow tests. But this research would take some time to complete and review. The government has therefore taken the decision to act now – but it must assess the impact of its new policy and collect the data needed to do this.

We need careful evaluation of the new shorter isolation period to ensure that people are following the guidance on self-testing and symptoms, and not ending their isolation period too early, and thereby putting others at risk of infection. We also need to consider how the guidance would be applied for people dealing with clinically vulnerable people. This would include guidance for NHS staff, those working in care homes, and people providing social care.

Finally, would you want to share a room with someone who was 5 days past the start of their Covid-19 infection and who was coughing all over you? Follow the guidance, particularly on symptoms, and don’t just rely on the results of the lateral flow tests to predict how infectious you are to avoid placing others at risk of infection.