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.