Last night I got told off for grumbling at the TV; I think this was a little unfair as I thought I had good reason to grumble. The news was all about coming out of lockdown… again! So why was I grumbling? Surely, I’m as fed up as everyone for not being able to go out and do the things I normally do? The lockdown has worked, case numbers are falling. So, what is my problem with coming out of lockdown?
Is it too soon!?
Last year I wrote blogs about coming out of lockdown (part 1 and part 2), and then later I wrote about how it all happened too quickly and we ended up back in a mess, just in time for winter! Well my opinion hasn’t changed much….
Whatever way we come out of this lockdown we must do it slowly and monitor the effects of any relaxation of restrictions BEFORE making further changes. Remember it takes 3-4 weeks at least (and probably more like 6 weeks) before we see the effects of any change. That is singular “change” not changes, doing too much all at once means we don’t know what is the “problem factor” when numbers start to climb. Locally the rates of infection have been reducing for the past week or so, 5 weeks after the start of the 3rd lockdown on the 6th January (or longer if you count that many of us had increased to Tier 4 restrictions just before Christmas). Even with the “good news” that case numbers are dropping, the Intensive Care Units (ICU) are still busy… patients with severe Covid-19 do not get better quickly… (IF they survive), they take many weeks to leave ICU. The NHS is not back at baseline capacity yet and would probably not cope with a third surge of cases! I cannot cope with the prospect of a 3rd surge in cases!!!
On top of this we now have a long backlog of “normal” NHS work to catch up on, with 100x more people waiting for routine treatments than a year ago, and a stressed workforce on the verge of burnout; we just don’t have the capacity for further surges of Covid-19. We’ve been so patient and waited so long, so what’s a bit longer? Being this little bit cautious may actually be the “thing” that keeps us safe!
Even though daily rates are down (20% in the last 7 days) there are still a lot of new cases occurring in the community (81,472 in the last 7 days). If the virus is allowed to transmit freely again (open it all up) it won’t take long to get up to huge numbers of cases again… just 4-6 weeks remember.
But we have lots of game changing treatments, so people aren’t getting as sick!
Errrrrr… no. We have 1 really effective treatment, steroids. There are other treatments such as Remdesivir (disappointing) and Tocilizumab (not as good as the “experts” say… but that’s for next week’s blog). The main stay of treatment is respiratory support and steroids.
At the end of the day steroids are the most effective drugs for reducing mortality from Covid-19, but the mortality in severe Covid-19 treated with steroids is still 33%. Let me say that again; even with steroids 33% of patients with severe Covid-19 die! That is why I said IF they survive earlier, let’s not forget 1 in 3 do not survive severe Covid-19.
Yeh, but everyone is getting vaccinated, so we don’t have to worry
Errrrrr… no. So far the UK has given 16.8 million 1st doses of vaccine (correct as of 19th February 2021) or to put it another way we have vaccinated 25% of the population (66.65 million UK population). Reports from Israel suggest that a single dose of the Pfizer vaccine only protects about 52% of recipients rather than the 94% Pfizer declared from 2 dose trial data; so effectively in the UK (with our single dose protocol) we have protected about 13% of the population from infection. That’s very big vaccination numbers but a small percentage of the population! So, what level of vaccination or herd immunity is required to stop the pandemic?
The level of herd immunity needed to prevent ongoing transmission of SARS CoV2 isn’t yet known but it’s a hot topic and one which many experts are trying to work out. You reach a point of herd immunity when the number of people susceptible to infection brings the R0 value to less than 1; to flip this around, if enough people are immune then then R0 will fall below 1 and the pandemic will burn itself out. But the news says we have achieved an R0 of 0.6-0.9… yes, but this is not R0 = 0.9 in “resuming normal activity” circumstances, it’s reaching that R0 when we have all been locked up in our houses since the 6th January! Most estimates suggest that 70% of the population need to be immune to prevent the virus spreading, and even if we give everyone in the country 1 dose of the vaccine (that’s 66.65 million doses), with one dose vaccine protection of 52%, we are “successfully protecting” only 52% of the population… we’re no way close to the magical 70% protected herd! This may be why Pfizer stated the second dose should be administered.
And that doesn’t take into account the concerns that vaccination doesn’t prevent transmission very well. You are “protected” from disease or falling ill but it still means you can infect someone else. Added to this YOUR immunity may not be long-lasting (only up to 6-9 months in some studies) and as SARS CoV2 is genetically changing the vaccines may be even less effective than the already disappointing 52% from 1 dose seen in Israel.
Now you can be forgiven for thinking that the has been enough people infected to give natural herd immunity, after all the media appear to be suggesting that everyone has Covid-19 and we’re all dying! But in fact, the number of people who have been infected is actually much lower than the magical 70% herd immunity needed to stop the pandemic. In most European countries only 5-10% of the population have been infected (including studies of healthcare workers); to put this another way, we would have to have at least 6-7x MORE cases (that’s 488,832 - 570,304 people every week) for natural immunity to occur… any volunteers!? No way!!!!! Encouraging “herd immunity” would not be good public health management.
Are we causing further problems?
There is a concern that we should NOT be vaccinating, or more correctly we should not be vaccinating NOW, it’s the wrong time! Let me explain; it’s a bit tricky, so stick with me.
Viruses don’t self-replicate and so they don’t mutate outside of their host cells, and their only “purpose” is to transmit to another cell. The virus “wants” to transmit so if we prevent transmission we are placing a selective pressure on it, which it reacts to (it’s a bit like a teenager who wants to go out, but their mum and dad say no, so the teenager climbs out the bedroom window and goes out anyway).
Now at the beginning of the pandemic there was nothing to stop the virus transmitting, there was no selective pressure, and therefore no reason for the virus to mutate. Lockdown made it harder for the virus to transmit and this brought infection numbers down which was great but we did nothing else, and so when lockdown was relaxed case numbers went up again but to even higher levels. Why? Because the virus, “stuck in its room not allowed out” mutated in the hope to make itself more transmissible… it had evolved in response to the selective pressure of lockdown.
Then what happened? When case numbers were very high at the end of December, and there were vast amounts of virus around with the potential to mutate and evolve, we started to vaccinate. With all of this virus around we have introduced another selective pressure, the vaccines. THIS IS THE CONCERN: we have started to vaccinate at the time when there is lots of virus capable of mutating to get around the vaccine. Think of it as teenagers who have gone off to school for the day and then refused to come home, therefore they evade mum and dad telling them to stay in!
And what have we seen? There are now variants of SARS CoV2 cropping up that are less susceptible to the vaccine induced immunity. This is no surprise, its evolution! It would probably have been a better idea to bring case numbers down again with a period of lockdown and then start vaccinating when there was much less virus around capable of mutating, that way the vaccines would be more effective. But this is hindsight and the vaccine excitement may have drowned out this line of thought!
Gosh, this is getting pretty depressing… time for a cup of coffee and a biscuit and see if some caffeine and sugar can cheer me up!
Okay, let’s try and look on the bright side… vaccination and herd immunity may not be able to prevent all infections, but they may be able to limit the number of severe infections. The studies on the vaccines, including the Astra Zeneca and Pfizer vaccines, all showed a reduction in severity of infection, and at the end of the day this is what really matters. Severe Covid-19 infections lead to people being admitted to hospital, overwhelming the NHS and dying. Non-severe infections lead to people having a cold-like illness and feeling rough, but otherwise they generally get better (not-withstanding long-Covid which seems to occur in as many as 1 in 10 cases) and life goes on. Populations can cope with mild infections; we cannot cope with severe infections.
The only real problem for having lots of mild infections is that this could still have a pretty big effect on the economy and children’s education due to high levels of absenteeism from work and schools. It would depend on how sick people were and what level of less severe Covid-19 we would accept as a population; would we be happy with people with Covid-colds being at school or work? How many of you used to “happily” struggle in to work with a cold?
But then again this “let it go” approach could all go horribly wrong, and that’s what the politicians and their advisers will be worrying about.
This is no time for complacency
It’s easy to see why we all want to get out of lockdown and put Covid-19 behind us, but this is no time for complacency. Yes, we have some treatments, we have vaccines, and we will be heading back into summer when viruses naturally transmit less as we spend more time outdoors and humidity rises (making droplet transmission less effective). However, the sense of invulnerability vaccines and treatments seem to give some people as well as boredom and, in some cases, outright denial about the significance of Covid-19, creates a recipe for a third wave of infections. We mustn’t be complacent; we have to see this through to the end.
What would I do?
I think now is the time to put in a concerted effort to bring Covid-19 really under control. We need to get numbers of cases down really low; well below 1,000 cases a day (current daily rate 12,000), and then we need to press ahead with vaccinating as many people as possible.
I think the lockdown should continue, as well as the new travel quarantine, in some shape or form for as long as possible whilst we vaccinate as many people at risk of severe Covid-19 as possible with TWO doses (primarily the elderly and the top 4 categories of risk, and if we want kids back in schools - teachers). NB in the UK the Government have only just put in place quarantine for overseas travel to the UK in order to prevent the introduction of new variants of SARS CoV2. I guess better late than never (I believe this should have been done a year ago!)
Once the most vulnerable who are at risk of severe infection have been vaccinated TWICE it might be better to start “ring vaccinating”; that is vaccinating all people surrounding small outbreaks to prevent those outbreaks spreading into the wider population. This is the strategy that was used to manage outbreaks of smallpox and polio in the past, as well as Ebola more recently. It could be done at the same time as continuing to vaccinate the wider population, but ring vaccinating would prevent case numbers building up and reduce the selective pressure on the virus. Think of it a bit like the vaccine equivalent of a local lockdown… only less unpopular with local people.
Once those most at risk of severe infection have been “successfully protected” with the vaccines I think it may be okay to let children go back to school “once all of the education staff have been vaccinated” but I would then wait and see what happens over the next 4-6 weeks before doing anything else. Some studies suggest that children are less susceptible to SARS CoV2 and are not the main source of transmission, others argue the opposite. I suspect this comes down to people twisting similar data to fit their current agenda (remember confirmation bias?); some want children back in school and some don’t, using the bits of data they want to support their message.
In my opinion children are much less likely to die from Covid-19; evidence suggests 0.001% of infections in school aged children or 1 in 100,000 cases (about the same risk of dying from being struck by lightning) compared to up to 15% in the over 80 year olds. I think this risk of attending school is offset by the substantial damage being done to children’s mental health and education by the current lockdowns. For me this isn’t about children being the guinea pigs of what happens when you reverse lockdown, but more this group is being the most damaged by the current restrictions and therefore the group who will benefit the most from getting back to normal.
As I have said many times before, “unlocking” needs to be done slowly and carefully, evaluate each step before taking the next step, keeping R0 as low as possible!
Whilst all of this is going on, I would have a heightened surveillance system for detecting new variants resistant to vaccines as well as “break-through” infections in people who have been vaccinated. In fact this system already exists in the UK, all of the “normal” vaccine-preventable infections are notifiable to Public Health England, and so the deployment of ring vaccination could be directed through this pre-existing system (as long as it is properly resourced and not dismantled or outsourced to the private providers! Maybe I’m showing my bias here!!!).
Okay, so I’m a pessimist but consider this paper from Manaus in Brazil published in the Lancet. In October 2020 it was calculated that 76% of the population of Manaus had had Covid-19, that’s more than the 70% needed for herd immunity… so were they all protected I hear you cry? Well, apparently no as in January case numbers shot up again! The authors propose a number of possibilities for why this might have happened, none of them very reassuring:
Whatever the reason, it’s a scary piece of research…
Whatever happens with next week’s “road map out of lockdown 2.0” in the UK, I think it’s going to take months and maybe longer, before SARS CoV2 becomes a mild infection that circulates “unnoticed” through the population. I just hope Boris has the “courage” not to not spoil all of the good work and struggle that has gone before. Let’s be patient and continue to put up with some restrictions and maybe by the end of this year, yep I mean December 2021, we can all look back with relief that this is all over.
Last year I wrote blogs about coming out of lockdown (part 1 and part 2), and then later I wrote about how it all happened too quickly and we ended up back in a mess, just in time for winter! Well my opinion hasn’t changed much….
Whatever way we come out of this lockdown we must do it slowly and monitor the effects of any relaxation of restrictions BEFORE making further changes. Remember it takes 3-4 weeks at least (and probably more like 6 weeks) before we see the effects of any change. That is singular “change” not changes, doing too much all at once means we don’t know what is the “problem factor” when numbers start to climb. Locally the rates of infection have been reducing for the past week or so, 5 weeks after the start of the 3rd lockdown on the 6th January (or longer if you count that many of us had increased to Tier 4 restrictions just before Christmas). Even with the “good news” that case numbers are dropping, the Intensive Care Units (ICU) are still busy… patients with severe Covid-19 do not get better quickly… (IF they survive), they take many weeks to leave ICU. The NHS is not back at baseline capacity yet and would probably not cope with a third surge of cases! I cannot cope with the prospect of a 3rd surge in cases!!!
On top of this we now have a long backlog of “normal” NHS work to catch up on, with 100x more people waiting for routine treatments than a year ago, and a stressed workforce on the verge of burnout; we just don’t have the capacity for further surges of Covid-19. We’ve been so patient and waited so long, so what’s a bit longer? Being this little bit cautious may actually be the “thing” that keeps us safe!
Even though daily rates are down (20% in the last 7 days) there are still a lot of new cases occurring in the community (81,472 in the last 7 days). If the virus is allowed to transmit freely again (open it all up) it won’t take long to get up to huge numbers of cases again… just 4-6 weeks remember.
But we have lots of game changing treatments, so people aren’t getting as sick!
Errrrrr… no. We have 1 really effective treatment, steroids. There are other treatments such as Remdesivir (disappointing) and Tocilizumab (not as good as the “experts” say… but that’s for next week’s blog). The main stay of treatment is respiratory support and steroids.
At the end of the day steroids are the most effective drugs for reducing mortality from Covid-19, but the mortality in severe Covid-19 treated with steroids is still 33%. Let me say that again; even with steroids 33% of patients with severe Covid-19 die! That is why I said IF they survive earlier, let’s not forget 1 in 3 do not survive severe Covid-19.
Yeh, but everyone is getting vaccinated, so we don’t have to worry
Errrrrr… no. So far the UK has given 16.8 million 1st doses of vaccine (correct as of 19th February 2021) or to put it another way we have vaccinated 25% of the population (66.65 million UK population). Reports from Israel suggest that a single dose of the Pfizer vaccine only protects about 52% of recipients rather than the 94% Pfizer declared from 2 dose trial data; so effectively in the UK (with our single dose protocol) we have protected about 13% of the population from infection. That’s very big vaccination numbers but a small percentage of the population! So, what level of vaccination or herd immunity is required to stop the pandemic?
The level of herd immunity needed to prevent ongoing transmission of SARS CoV2 isn’t yet known but it’s a hot topic and one which many experts are trying to work out. You reach a point of herd immunity when the number of people susceptible to infection brings the R0 value to less than 1; to flip this around, if enough people are immune then then R0 will fall below 1 and the pandemic will burn itself out. But the news says we have achieved an R0 of 0.6-0.9… yes, but this is not R0 = 0.9 in “resuming normal activity” circumstances, it’s reaching that R0 when we have all been locked up in our houses since the 6th January! Most estimates suggest that 70% of the population need to be immune to prevent the virus spreading, and even if we give everyone in the country 1 dose of the vaccine (that’s 66.65 million doses), with one dose vaccine protection of 52%, we are “successfully protecting” only 52% of the population… we’re no way close to the magical 70% protected herd! This may be why Pfizer stated the second dose should be administered.
And that doesn’t take into account the concerns that vaccination doesn’t prevent transmission very well. You are “protected” from disease or falling ill but it still means you can infect someone else. Added to this YOUR immunity may not be long-lasting (only up to 6-9 months in some studies) and as SARS CoV2 is genetically changing the vaccines may be even less effective than the already disappointing 52% from 1 dose seen in Israel.
Now you can be forgiven for thinking that the has been enough people infected to give natural herd immunity, after all the media appear to be suggesting that everyone has Covid-19 and we’re all dying! But in fact, the number of people who have been infected is actually much lower than the magical 70% herd immunity needed to stop the pandemic. In most European countries only 5-10% of the population have been infected (including studies of healthcare workers); to put this another way, we would have to have at least 6-7x MORE cases (that’s 488,832 - 570,304 people every week) for natural immunity to occur… any volunteers!? No way!!!!! Encouraging “herd immunity” would not be good public health management.
Are we causing further problems?
There is a concern that we should NOT be vaccinating, or more correctly we should not be vaccinating NOW, it’s the wrong time! Let me explain; it’s a bit tricky, so stick with me.
Viruses don’t self-replicate and so they don’t mutate outside of their host cells, and their only “purpose” is to transmit to another cell. The virus “wants” to transmit so if we prevent transmission we are placing a selective pressure on it, which it reacts to (it’s a bit like a teenager who wants to go out, but their mum and dad say no, so the teenager climbs out the bedroom window and goes out anyway).
Now at the beginning of the pandemic there was nothing to stop the virus transmitting, there was no selective pressure, and therefore no reason for the virus to mutate. Lockdown made it harder for the virus to transmit and this brought infection numbers down which was great but we did nothing else, and so when lockdown was relaxed case numbers went up again but to even higher levels. Why? Because the virus, “stuck in its room not allowed out” mutated in the hope to make itself more transmissible… it had evolved in response to the selective pressure of lockdown.
Then what happened? When case numbers were very high at the end of December, and there were vast amounts of virus around with the potential to mutate and evolve, we started to vaccinate. With all of this virus around we have introduced another selective pressure, the vaccines. THIS IS THE CONCERN: we have started to vaccinate at the time when there is lots of virus capable of mutating to get around the vaccine. Think of it as teenagers who have gone off to school for the day and then refused to come home, therefore they evade mum and dad telling them to stay in!
And what have we seen? There are now variants of SARS CoV2 cropping up that are less susceptible to the vaccine induced immunity. This is no surprise, its evolution! It would probably have been a better idea to bring case numbers down again with a period of lockdown and then start vaccinating when there was much less virus around capable of mutating, that way the vaccines would be more effective. But this is hindsight and the vaccine excitement may have drowned out this line of thought!
Gosh, this is getting pretty depressing… time for a cup of coffee and a biscuit and see if some caffeine and sugar can cheer me up!
Okay, let’s try and look on the bright side… vaccination and herd immunity may not be able to prevent all infections, but they may be able to limit the number of severe infections. The studies on the vaccines, including the Astra Zeneca and Pfizer vaccines, all showed a reduction in severity of infection, and at the end of the day this is what really matters. Severe Covid-19 infections lead to people being admitted to hospital, overwhelming the NHS and dying. Non-severe infections lead to people having a cold-like illness and feeling rough, but otherwise they generally get better (not-withstanding long-Covid which seems to occur in as many as 1 in 10 cases) and life goes on. Populations can cope with mild infections; we cannot cope with severe infections.
The only real problem for having lots of mild infections is that this could still have a pretty big effect on the economy and children’s education due to high levels of absenteeism from work and schools. It would depend on how sick people were and what level of less severe Covid-19 we would accept as a population; would we be happy with people with Covid-colds being at school or work? How many of you used to “happily” struggle in to work with a cold?
But then again this “let it go” approach could all go horribly wrong, and that’s what the politicians and their advisers will be worrying about.
This is no time for complacency
It’s easy to see why we all want to get out of lockdown and put Covid-19 behind us, but this is no time for complacency. Yes, we have some treatments, we have vaccines, and we will be heading back into summer when viruses naturally transmit less as we spend more time outdoors and humidity rises (making droplet transmission less effective). However, the sense of invulnerability vaccines and treatments seem to give some people as well as boredom and, in some cases, outright denial about the significance of Covid-19, creates a recipe for a third wave of infections. We mustn’t be complacent; we have to see this through to the end.
What would I do?
I think now is the time to put in a concerted effort to bring Covid-19 really under control. We need to get numbers of cases down really low; well below 1,000 cases a day (current daily rate 12,000), and then we need to press ahead with vaccinating as many people as possible.
I think the lockdown should continue, as well as the new travel quarantine, in some shape or form for as long as possible whilst we vaccinate as many people at risk of severe Covid-19 as possible with TWO doses (primarily the elderly and the top 4 categories of risk, and if we want kids back in schools - teachers). NB in the UK the Government have only just put in place quarantine for overseas travel to the UK in order to prevent the introduction of new variants of SARS CoV2. I guess better late than never (I believe this should have been done a year ago!)
Once the most vulnerable who are at risk of severe infection have been vaccinated TWICE it might be better to start “ring vaccinating”; that is vaccinating all people surrounding small outbreaks to prevent those outbreaks spreading into the wider population. This is the strategy that was used to manage outbreaks of smallpox and polio in the past, as well as Ebola more recently. It could be done at the same time as continuing to vaccinate the wider population, but ring vaccinating would prevent case numbers building up and reduce the selective pressure on the virus. Think of it a bit like the vaccine equivalent of a local lockdown… only less unpopular with local people.
Once those most at risk of severe infection have been “successfully protected” with the vaccines I think it may be okay to let children go back to school “once all of the education staff have been vaccinated” but I would then wait and see what happens over the next 4-6 weeks before doing anything else. Some studies suggest that children are less susceptible to SARS CoV2 and are not the main source of transmission, others argue the opposite. I suspect this comes down to people twisting similar data to fit their current agenda (remember confirmation bias?); some want children back in school and some don’t, using the bits of data they want to support their message.
In my opinion children are much less likely to die from Covid-19; evidence suggests 0.001% of infections in school aged children or 1 in 100,000 cases (about the same risk of dying from being struck by lightning) compared to up to 15% in the over 80 year olds. I think this risk of attending school is offset by the substantial damage being done to children’s mental health and education by the current lockdowns. For me this isn’t about children being the guinea pigs of what happens when you reverse lockdown, but more this group is being the most damaged by the current restrictions and therefore the group who will benefit the most from getting back to normal.
As I have said many times before, “unlocking” needs to be done slowly and carefully, evaluate each step before taking the next step, keeping R0 as low as possible!
Whilst all of this is going on, I would have a heightened surveillance system for detecting new variants resistant to vaccines as well as “break-through” infections in people who have been vaccinated. In fact this system already exists in the UK, all of the “normal” vaccine-preventable infections are notifiable to Public Health England, and so the deployment of ring vaccination could be directed through this pre-existing system (as long as it is properly resourced and not dismantled or outsourced to the private providers! Maybe I’m showing my bias here!!!).
Okay, so I’m a pessimist but consider this paper from Manaus in Brazil published in the Lancet. In October 2020 it was calculated that 76% of the population of Manaus had had Covid-19, that’s more than the 70% needed for herd immunity… so were they all protected I hear you cry? Well, apparently no as in January case numbers shot up again! The authors propose a number of possibilities for why this might have happened, none of them very reassuring:
- The estimated case numbers might be lower than expected and therefore below the 70% threshold
- Immunity due to past infection may not last
- The virus may have become more easily transmissible and therefore the threshold for herd immunity may be higher than expected
- The virus may have mutated to escape the immunity from past infection
- All of the above…
Whatever the reason, it’s a scary piece of research…
Whatever happens with next week’s “road map out of lockdown 2.0” in the UK, I think it’s going to take months and maybe longer, before SARS CoV2 becomes a mild infection that circulates “unnoticed” through the population. I just hope Boris has the “courage” not to not spoil all of the good work and struggle that has gone before. Let’s be patient and continue to put up with some restrictions and maybe by the end of this year, yep I mean December 2021, we can all look back with relief that this is all over.
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