#MSCOVID19 Endemic musings

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Fudging the issues or bumbling along is how the public, opposition politicians and the journalists are interpreting the Government’s handling of the exit strategy for the COVID-19 epidemic in the UK. I don’t agree. I think the Government has a clear plan, which is being driven primarily by economic considerations. 

The primary objective of the lockdown was to protect the NHS and this has been successful. Well done! The primary objective of handling the epidemic’s tail is to get the country back to work and to try and turn COVID-19 into an endemic disease. 

For those of you who are not epidemiologists, an epidemic is the rapid spread of disease to a large number of people in a given population within a short period of time compared to endemic infection when that infection is maintained at a constant baseline level in the population.

Making COVID-19 endemic is like walking on a tightrope. By allowing very young children back to school first who are unable to self-isolate effectively is asking them to spread the infection amongst themselves, their siblings and their parents who will all be relatively young and at low risk of severe COVID-19. This will allow the gradual spread of infection to continue in the community and the gradual build-up of herd immunity. Most people I speak to don’t seem to understand this.

At the same time, the more vulnerable groups in the population have been asked to continue shielding and to be extra cautious about avoiding getting infected with SARS-CoV to reduce the risk of a second surge in the epidemic, protect the NHS and to keep the death rate relatively low. 

The Government is also putting in place the whack-a-mole strategy of active case finding and contact tracing to try and control local COVID flares. The whack-a-mole strategy is working well in China, South Korea and Singapore and it will almost certainly work well here if it is properly resourced.

The introduction of widespread antibody testing, with a reliable assay, to see who has been infected with SARS-CoV-2 will allow epidemiologists to track herd immunity and to finesse the Government’s strategy. The idea of getting a COVID-19 passport to show that you have been previously infected and are now immune to getting further infections, at least in the short-term, is unlikely to happen within the UK but may be required for safe international travel or to attend outpatient clinics or be admitted to cold (COVID-negative) hospitals for invasive procedures, etc. The latter is analogous to what happens with multi-drug resistant staphylococcus in clean surgical units in the NHS. Before you are allowed to be admitted for elective surgery you have a nasal swab taken to make sure you are not carrying the multi-drug resistant bacterium.

If the Government can allow herd immunity to gradually increase and to keep the R-value for the whole population at about 0.8 to 1.0 they will achieve their aims of making COVID-19 endemic, getting the economy going again and protecting the vulnerable. Clearly, this strategy will be a bit hit-and-miss and there will be collateral damage, i.e. people will continue to get severe COVID-19 and a proportion of them will die as a result. To expect anything else is unrealistic, which is why I find the posturing of the opposition politicians bewildering, to say the least. What is their solution; perpetual lockdown until we get a vaccine?

Most people think that a vaccine is the government’s end-game. I don’t want to disappoint you but there is no guarantee that a vaccine will work. I also worry that if the whole world exits lock-down with a trickle of cases we may not be able to test vaccines in an efficient manner. 

To develop and test an effective vaccine we really need the COVID-19 epidemic to be in full swing, i.e. on the upside of the curve and not on the tail. A vaccine trial is like a drug trial; subjects are randomised to an active or SARS-CoV-2 vaccine arm or a comparator arm (placebo or another vaccine) and then you see whether or not there are fewer cases of COVID-19 on the active arm compared to the comparator arm. However, if there are too few cases developing COVID-19 because of social distancing, using face masks, hygiene measures, etc. it will take too long to get enough events or trial subjects getting COVID-19, to show the vaccine is working. There is a way around this and that is to shift to an active-challenge vaccine paradigm, i.e. to get groups of young volunteers who are anti-SARS-CoV-2 antibody negative and to randomise them to receive the vaccine or placebo and to then challenge them with the live virus. This is how they test the effectiveness of the seasonal flu vaccine each year. You may ask why would anybody take the risk of getting COVID-19 and severe COVID-19 voluntarily? The answer is money. These volunteers tend to be paid very handsomely for their time. 

Another factor that may help the Government is that summer is on its way and as the temperature rises the less infectious coronaviruses become. SARS-CoV-2 viral particles are temperature sensitive and are viable for much shorter periods of time outside the body in hot climates. This may explain why we haven’t seen such rampant spread of the virus in warmer climates. 

I think Boris Johnson’s recent bumbling performances when questioned about the Government’s exit strategy is deliberate so as to avoid questions about herd immunity, whack-a-mole and collateral damage. The sad truth is that at some point we as a society are going to have to realise that quite a large number of people are still going to have to die from COVID-19 as part of the exit strategy to get us to a point when we can chop off the tail of the UK’s COVID-19 epidemic. The consequences of not doing this are potentially far worse for the UK in the longterm. For example, some epidemiologists predict that the increase in poverty and inequality that the COVID-19 epidemic has caused will result in more excess deaths than the number of people dying from severe COVID-19. This may be hard to comprehend, but the social determinants of health have a powerful effect on health, health outcomes and survival. The challenge for the government is getting the balance right, which is what they are trying to do.

I would be interested to know if any of you have any thoughts on these issues. 

CoI: none

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

37 comments

  • People find it hard to get their head around the fact that the government might not be trying to minimise deaths but actually the government never does (not at any cost anyway). We’d have fewer deaths on the road if we drove slower but we like getting places more quickly so we accept some extra deaths. We don’t want to tax people any more than we already do so we don’t pay for all the drugs / treatments that are available for all diseases and some people die as a result. This is no different particularly but it’s new and people are paying attention so it’s very upsetting for everyone to be confronted with the difficult choices.

    The government needs to help vulnerable people shield and people who are young and healthy need to adopt a more proportionate attitude to the virus. It seems to me we went from total denial (it’s just like the flu!) to full blown hysteria and we need to be measured and nuanced in our response. Feels like a big leap from where we are but fingers crossed it will take shape.

  • I am very confused now . I thought that very young children do not easily get it if you compare to university young people going everywhere

    • Young children almost certainly get infected and spread the virus· However, they don’t necessarily get symptomatic infections, which is why it is confusing.

      • What about the kawasaki disease found in children that come after they are exposed to the corona virus but had no symptoms

    • There are badies that get infected however the point is that they generaly recover and their is the Strawberry tounge variant in kids

  • I agree with everything you’ve said. Perpetual lockdown is not an option. We have to accept that deaths from Covid 19 will continue to occur and ‘herd immunity’ is our only way out. As we didn’t lockdown instantly, it’s too late to follow S.E Asia. Deaths from the economic and social effects of lockdown will outweigh Covid 19 deaths if we don’t get out of lockdown. Brutal and harsh fact.

  • “The challenge for the government is getting the balance right, which is what they are trying to do.“

    One of your most balanced pieces. I’m not a member of a political party, but get fed up with the “government bad, NHS good” assessment of how this crisis has panned out. “The Government” consists of c.100 people drawn mostly from the House of Commons and a small number from the House of Lords. Elections (which we vote in) determine which political party (if there’s a majority) form the government. The government spend our money (paid by taxes) or money borrowed. Government itself has no money. Anything that goes wrong – blame the government!

    When the lockdown was announced some groups (political, media, experts) criticised the government for not locking down sooner. As the lockdown starts to be eased some groups are criticising the government for being too quick in easing the lockdown. The government cannot win. PPE has been an issue in all countries. If the U.K. government had purchases thousands of tonnes of PPE a decade ago and stored it in huge warehouses, there would have been criticism (before the Coronovirus pandemic) that the government had squandered taxpayers money on an unlikely event (I’m almost 50 and this is my first experience of a pandemic).

    No member of the government wants to see anyone die from this disease. However, given the available resources, decisions had to be made on where these resources (PPE, testing) had to be targeted. My aunt with dementia is in a care home and I know if she could gather her thoughts that she would have agreed with the tough decision to target the resources at the younger generations (by targeting hospitals and health sector staff) rather than those who had lived a long life.

    We need to get beyond the Punch and Judy approach – government / NHS senior managers bad v doctors, nurses carers good. We are all in the same boat and all trying to do our best in challenging circumstances. The balance between saving lives and saving livelihoods is a challenge I would not like to call the shots on. There’s no right or wrong, but there’s an army of experts who have made a career waiting for decisions to be made (by the government) and then wading in with the “I wouldn’t have done it like that”, “you should have done it sooner / later / not at all”. Government accountability will come at the next general election, not by the army of experts (who never have to make decisions) who undertake this real-time auditing of every government action and decision.

  • Your musing make perfect sense. Without wishing to apportion blame, does the retrospectoscope reveals that the shut down of the so much of the economy has been too severe? If it does then I honestly think it cannot be repeated. Indeed many of the different degrees of late lockdown, or not, across Europe seeming to have the same effect in curves flattening everywhere, albeit with different heights.
    Perhaps it’s behaving like a seasonal virus, in which case we need to plan for the winter. Al la 1918. Care homes need to be kept COVID free, as many are in Plymouth, and intermediate care established for those moderately affected or recovering and still shedding.
    Its history in the making, yet climate change lurks with far more menace in the background; perhaps the recovery needs to be built around addressing that too.

    • I agree. If we are going to get a second surge it is likely to be around October/November when the temperatures drop and we get bored with social distancing. Hopefully, by then we will have a cocktail of drugs to take the edge of severe COVID-19 and to reduce the mortality rate. Having seen what COVID-19 does to the body in the cases on the medical wards that have stepped-down from ITU you don’t want to get severe COVID-19.

  • My thoughts are that if there is indeed such a strategy then it is imperative this is shared with the people, rather than strategy by subterfuge and obsession with secrecy. It is also sad that (as ever) those who will pay the heaviest price for such a strategy are those who are most vulnerable ie ethnic moinorities, the lowest paid in precarious emplyment and the elderly.

    • Hear, hear MD2. Why oh why do the Government not just tell us what their strategy is? Why all the secrecy? Personally, I had thought it was because they don’t have a clue what they are doing, except giving in to the pressure from their donors and the likes of The Telegraph to ‘end lockdown’ and ‘give us back our liberty’ (plus their income streams). But maybe they have a plan and maybe it is, ultimately, the only realistic and reasonable one. If so, they should spell it out. You never know, we might actually understand it.

  • Gawd, I can’t visit this blog any more. COVID-crystal ball gazing, wannabe epidemiologist fodder, opinion presented as fact and f-all on black swans or progressive MS.

    • Yes, I do consider myself a self-taught epidemiologist. I had to run a very active working epidemiology unit when I was conscripted into the South African Defence Force in 1990. I had to learn how to model and track disease outbreaks (TB, syphilis, gonorrhoea, malaria and HIV) and implement intervention and education programmes. In relation, to our HIV work, I had to produce a policy document for the military that was sadly never implemented. I actually underestimated the peak prevalence of HIV in South Africa. I am now co-director of the preventive neurology unit at my university. Most of the work we are doing in this unit is epidemiological including an MS prevention programme. A lot of our EBV and MS risk factor posts on this blog are epidemiological.

  • As you say ProfG the NHS has been protected by the lockdown as it has not been overwhelmed. However, all the emerging evidence would appear to indicate that the vast majority of clinicians on the frontline have been psychologically overwhelmed, beyond the appalling number who’ve died. There’s support in place isn’t there from March on Stress who are more familiar with offering trauma support to veterans and victims of things like terror attacks.
    Then there’s the disproportionate impact on care homes and the likes of London bus drivers.
    Added to this there’s the issues of lack of attendance at A&E, metal health, domestic abuse, impact on education, levels of deprivation, recession, long term government debt – the list goes on and on!
    The poor sods who are trying to wade through all this – who are those predominantly regular folk we voted into position – I agree that the posturing is not valid because it is definitely a case of damned if you do and damned if you don’t and trying to do the correct things whilst on a tightrope over the abyss!

    I feel the need to add the personal – my sister who has Sarcoidosis and received one of the shielding letters. Talking to her each week via Zoom and observing how focussed she is on remaining positive and engaged and then to see the tears roll down her cheeks as she admits she’s petrified. I agree with your position statement concerning the need to accept many more deaths as part of an exit strategy. Well, the rational and logical side of me does, except when I stop to think of my sister.
    May I ask: does this same dichotomy apply to your thinking when it comes to your sister?

    • Yep, my sister is shielding she is vulnerable. This thinking is not mine it is my interpretation of the Governments.

    • In a few weeks time, I will be doing a live debate for the MS Academy on “COVID-19 issue of saving lives vs. saving the economy and its relevance to neurology”. I am taking the position that saving lives should be a priority and Richard Davenport from Edinburgh is supporting the position that the economy should take priority.

      • My question reflects that the reality for both of us is accepting that many more nationally and internationally will have to die, but just how differently we experience it when it comes to our sisters.

        Those with vulnerable loved ones, or severe MS themselves must feel the same – the rational versus the emotive. Until Covid my sister and I were so much on the same page: MS and Sarcoidosis, meaning we could benefit from mutual support. Now, she is extremely vulnerable and I am not nearly so much so, especially with lymphocytes at 0.89.

        Interestingly saw an American guy interviewed on C4 news some weeks back who stated that the US cities that locked down early and the longest in the 1918 flu pandemic not only had the lowest mortality rates, but also bounced back the quickest economically.

        Tho I’d also quote the German philosopher Georg Hegel: ‘What we learn from history is that we learn nothing from history’

        • Re: “Interestingly saw an American guy interviewed on C4 news some weeks back who stated that the US cities that locked down early and the longest in the 1918 flu pandemic not only had the lowest mortality rates, but also bounced back the quickest economically.”

          Yes, this is correct. But the epidemiology of the flu virus is likely to different to coronavirus. Flu is more seasonal and is associated with greater antigenic drift.

  • “By allowing very young children back to school first who are unable to self-isolate effectively is asking them to spread the infection amongst themselves, their siblings and their parents“

    Prof G – if you were young and fit on ocrelizumab would you allow your littles to go back to school? (I hope the answer is yes as mine are already there on key worker places as I’m also a HCP working from home currently but looking to go back in some way)

  • “By allowing very young children back to school first who are unable to self-isolate effectively is asking them to spread the infection amongst themselves, their siblings and their parents“

    Prof G – if you were young fit and on ocrelizumab would you let your little ones go to school? I’m really hoping the answer is yes as mine are already there on key worker places because I’m also a HCP working from home and hoping to go back soon in some way…

  • Thank you for your post. Although I understand your sentiments, its a bitter pill to swallow as a young person with MS on myelosupressive treatment, who has a young child. Would you send your child back to school?

    • Jenny, what treatment are you on? We really stopped using myelosuppressive therapies to treat MS more than a decade ago. Mitoxantrone being the only myelosuppressive therapy that got licensed. Although the different HSCT protocols still use myelosuppressive therapies for mobilisation and depletion, they are only given upfront and once your bone marrow function recovers your immune system in fine. All of our other MS therapies leave bone marrow function relatively intact and they look pretty safe in terms of COVID-19 and severe COVID-19 in pwMS.

      The only DMT we worry about is alemtuzumab (non-myelosuppressive), but then the risk is only present whilst your lymphocyte counts are low (<500/mm3) post alemtuzumab, i.e. for 3-6 months after each course.

      My advice for my patients with MS on licensed DMTs will be to send their kids back to school. The tail of this epidemic is going to last years; keeping them out of school for this long is not a solution.

  • Any comment on the epidemiological model created by Neil Ferguson from Imperial? This was the model that predicted the 2 million deaths in the US that the main stream media quoted extensively. This model was used to drive the call for lockdowns and the shut down of the US economy. He was in the news recently about breaking quarantine to hook up with a married woman. She is apparently in some kind of cuck marriage and works for a far left NGO. How odd…

    How accurate was this model? It appears to have seriously over forecast the situation. What is the kind of academic oversight here? Where is MDs video about the third reviewer? Why so little coverage of this in the main stream media?

    The code is available in GitHub so you can take a look, I see that someone committed a change yesterday to remove unused variables – that’s reassuring. I would have hoped that code of this importance would have problems like that resolved. You can see that there are folks committing changes to fix the model. Which is also reassuring.

    • The Imperial model is probably correct the prediction of 2M deaths in the US is why US locked-down. The model predicted different scenarios depending on what is done. The US is already at 86,000 deaths with many more months to run.

    • He was in the news recently about breaking quarantine to hook up with a married woman. She is apparently in some kind of cuck marriage and works for a far left NGO. How odd…

      Oh, dear. Today’s post was brought to you courtesy of Infowars.

    • The Imperial model at the time was valid, but it did assume a naive population. And I feel that this assumption needs to be changed. For example we now know the virus was being passed by community transmission in mid Jan in the US, and deaths occured in France in December. So its almost a guarantee that the virus was in the UK population earlier than we thought. In addition, we have the research from the University of Manchester suggested up to 25% of the population has been infected. It will be interesting to see how the new antibody tests reflect this finding. If so that model needs to be adjusted given its impact on the social and public health policies.

  • Another factor that may help the Government is that summer is on its way and as the temperature rises the less infectious coronaviruses become. SARS-CoV-2 viral particles are temperature sensitive and are viable for much shorter periods of time outside the body in hot climates. This may explain why we haven’t seen such rampant spread of the virus in warmer climates.

    Will warmer temps help contain coronavirus? Two studies say, ‘not really’

    https://medicalxpress.com/news/2020-05-warmer-temps-coronavirus.html

    How about Iran?

    Brasil?

    Are they cold countries?

    • In winter Iran is cold (~1-9C); I visited both Tehran and Isfahan in Winter it was cold. Brasil no. You could argue that 14,000 deaths may be relatively low considering the size of the country. I suspect once it becomes endemic the SARS-CoV-2 will behave like other coronaviruses and have seasonal peaks and troughs. The latter is what the WHO is predicting. The worst-case scenario is if we get a double-whammy and get a more virulent strain of flu this winter. I wonder if public health officials are taking this into account?

  • Prof G
    Everything you say makes sense except your charitable assessment of Boris Johnson’s performance
    Even if the bumbling act is deliberate obfuscation, is it really right?

    Why not be clear and transparent? Like many other leaders, for example in Germany, Singapore, New Zealand. And like some of the state chief ministers here in India. Our prime minister has been opaque, but some chief ministers have been great. They have discussed the dilemmas and explained their policies, including reasons for changes in policy

  • Remarkably kind to Johnson. The messages from the Government have been obfuscation as they have contrary views within the Conservative Party which rely on saying yes to everyone while climbing the slippery pole like Johnson has done. He continues to look to his own position as the power grabbing selfish sort that he prove to himself to be.

    We do have to get going again economically but make no mistake it will be the working class that will pay and pay as they always do. It is not a matter of government bad NHS good but people who have not a clue what it is like to be working class are making decisions for the majority.

    There is no chance of getting out of this pain for another 5 years and, given how unbelievably dumb the body politic is in England, the turkeys will probably vote for Christmas again.

    And damn right I’m an angry lefty.

  • Nabarro, the World Health Organisation’s special envoy for Covid-19, told the BBC: “Comparing Scotland with other parts of Europe, other parts of the world, I’d say you’re doing good because you are tackling it carefully and logically. There are some countries which are saying it’s either the economy or people’s health and they are presenting it as a choice. It’s not a choice.”

    https://news.stv.tv/scotland/world-health-organisation-tells-scotland-you-are-doing-well?top

  • I understand the points you make, but as someone in the shielding group (due to v low lymphocytes post Lemtrada) also with a shielded daughter, I feel we have been given up on, and that “protecting us” in order to allow others to get back to normal is creating a huge gulf between us and the society we have always belonged to. Instead of trying to make anything safer for us or helping us to manage our risk we are ignored – it’s a lazy government strategy and to dress it up as caring for us is mishearing (As it’s to protect the nhs really not us as people). Has created a feeling in the public that this is acceptable – has already set back years of progress towards inclusivity of all kinds.

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