Piecing together evidence from the wealth of social science on Covid, we can see that household and home played a big and under-recognised role in Covid infections and deaths. Household and home affected who got infected and died, and shaped Covid inequalities in the UK and around the world. Their importance was known early in the pandemic. However, until vaccinations arrived, staying at home was the main policy to reduce Covid-19 infection across the world. Staying at home reduces the risk of infection in other places, but obviously means increased exposure to risk at home.
Did people get infected at home?
You may know many people who caught Covid from other members of their households – perhaps including you. In January 2020, before any case had been found in the UK, the first family cluster of cases had been identified in China. A June 2020 systematic review found that 57% of clusters were in families, and said, “prevention of infection among household members is an important strategy”. Other international studies found that after the first infection in a household, 5-51% of other household members also become infected.
The UK’s Covid Social Study found that in the first UK national lockdown, most people were at home for at least 23 hours a day, and many didn’t go out for days at a time. The three million ‘shielders’ in England who were at the highest risk stayed at home the most. However, the ONS found that 74% of shielders lived with others, including people still working outside the home. 14% received personal care at home, and 35% received at least doorstep visits from friends or family. Similarly, most people who had to self-isolate with Covid also lived with others.
Amongst the first few hundred cases in Britain, 51% of those infected in Britain lived with other cases, and researchers concluded, “the household [is] a high risk setting”. As national contact tracing stopped on 13 March 2020, there was a gap in evidence. In September 2020, the SPI-B sub-committee of SAGE said, “we recommend that data on household clusters is collected through contact tracing and made available”. This recommendation was not followed, but 78% of close contacts reported to NHS Test and Trace were household members. In March 2021, Public Health England (PHE) published adverts which said, “most people catch Covid-19 from the people they spend most time with, like family”. However, this was a year after the first evidence on household transmission, and after the vast majority of deaths.
Which were the riskiest homes and households?
Covid-19 replicated and added to existing inequalities in health and mortality, and this was partly through household and home. Households in areas with high case rates were at higher risk. Household type mattered. SAGE was able to draw on five very large UK studies of Covid infection – ONS, REACT-Imperial, Biobank, QResearch and OpenSAFELY– to say that there was “compelling evidence” for the independent effect of household composition on infection risk. Bigger households, households with vulnerable people, where care was being given, and where people were working outside the home were at more risk. In summer 2020, 5% of people in one-person households had antibodies, compared to 13% in 7-person households. In the first wave, people receiving domiciliary care at home had a similar death rate to care home residents. And family members of people in patient-facing NHS jobs were at double the average risk of hospitalisation. Area data show that housing factors including rented tenure, multi-generational households, neighbourhood deprivation and population density partly explained higher death rates among disabled people and some ethnic groups. Households with less than one room per person had 2.3 times the infection rate of others, after controls.
What was done to reduce infection at home?
Starting with two days’ notice in March 2020, more than 37,000 rough sleepers and hostel residents were provided with self-contained accommodation through ‘Everyone In’ in England. Albeit after deadly delay, the roughly half a million people in care homes were tightly locked down and received some priority for PPE and tests. However, people in private households, the vast majority of the population, had very little help to avoid infection at home.
There was authoritative advice on how to reduce risk at home, but it was not all well-publicised, or backed up by policy. According to the World Health Organisation, Public Heath England, and SAGE, all households should have been washing hands, catching coughs, cleaning more, ventilating more. So far, so familiar – but did you know about not shaking laundry, double-bagging rubbish and waiting three days before leaving it out? Shielders and isolators should have had their own room and own bathroom. Failing that, they should have had food brought to the door, used the bathroom first or last, and had their own towels, and all household members should have worn masks and maintained one-metre distancing. In a household with both a shielder and an isolator, the shielder should have been moved to another home.
Special Covid questions added to the British cohort studies allowed respondents to describe their pandemic experiences. From early 2020, people of all generations were well aware of the risk of infection at home and made considerable efforts to reduce it. A woman aged 19 who worked in a hospital said, ‘I have had to move out… due to my dad having numerous health issues and currently staying in my boyfriend’s aunt’s holiday cottage’. A woman aged 62 said, ‘I am a bit over the top with cleaning’. The mother of a 19-year-old said her parents had “let go of their [domiciliary carers] and are coping themselves”. A 62-year-old man complained about his lodger: ‘he is not washing hands regularly and is always going shopping or seeing friends, hence more arguments…. he’s my main risk of Covid but I don’t want to make him homeless and besides I need the money’.
However, PHE acknowledged that not everyone would be able to follow their advice. A special Covid-focused version of the English Housing Survey found that 47% of multi-person households where someone had to isolate did not have a spare bedroom. 65% of isolators who lived with others had to share a bathroom. The lowest-income households were the most likely to have someone shielding or isolating – but the least likely to have the means to do this safely.
In November 2020, SAGE came up with ideas for policy to reduce risk at home. They wanted emergency accommodation for isolators, especially in households with shielders. They wanted advice for home carers to match that for paid workers (for example they should use goggles and hot clothes washes) and should have access to respite care. They wanted emergency housing regulation and improvement, and structural policy change including reduced deprivation and more affordable housing. However, these recommendations were not acted on. Meanwhile, a study showed that the Everyone In policy prevented almost 300 Covid deaths just in its first three months. Isolation accommodation for people living with shielders would have saved many more lives. If all in-household infections could have been avoided, there would have been perhaps 1.1m fewer positive tests and perhaps 30,000 fewer deaths in the UK (assuming that the first person with Covid infected 37% of other household members as found by a transmission dynamics study in 2020).
Social science identified the risks of Covid-19 infection at home, and potential mitigations, and documented the results of leaving risk management to individuals. But there remains a task for social science in explaining why more was not done about the risks, given what was known by researchers, SAGE, and the public.
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About the author
Becky Tunstall is Professor Emerita of Housing at University of York. She is also University of York’s former Director of the Centre for Housing Policy and Joseph Rowntree Professor of Housing Policy. During her career Becky has worked on and led projects for clients including: Communities and Local Government (CLG), the Joseph Rowntree Foundation (JRF), the Nuffield Foundation, the Housing Corporation, the Homes and Communities Agency, the Tenant Services Authority, the National Housing Federation, the Scottish Government, and others. Becky is also on the Policy and Evidence Advisory Panel for the Social Mobility Commission, and the Campaign Board of the Campaign for Social Science.