MIL-OSI United Kingdom: expert reaction to delay announced to step 4 of the roadmap out of lockdown

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Source: United Kingdom – Executive Government & Departments

The Prime Minister Boris Johnson has announced a 4-week delay to stage four of England’s roadmap out of lockdown, originally set to take place on the 21 June.

Dr Raghib Ali, Senior Clinical Research Associate, MRC Epidemiology Unit, University of Cambridge; Honorary Consultant Physician in Acute Medicine, Oxford University Hospitals NHS Trust, said:

“Firstly, I think the Prime Minister has made the right decision to postpone step four of the roadmap for four weeks – my approach throughout this pandemic has been that any restrictions should minimise overall harm and the benefits of these restrictions should outweigh the harms for overall health – not just Covid – and based on the evidence presented, a four-week delay achieves that for the reasons outlined below.

“All the data over the last week has shown rapidly increasing cases (by 64%) and hospitalisations (by 50%) confirming that although the link between cases and hospitalisations has been weakened, it has not been broken.  And all the models agree – as well as the actual experience from countries like Chile where levels of vaccination are similar to here – that while millions of people are still either unvaccinated or have only had a single dose, the greater transmissibility of the Delta variant means that cases and hospital admissions will continue to increase.  And it is clear that a further relaxation of restrictions, particularly with increased household mixing that would result, will mean that hospital admissions will increase faster.

“The NHS is already at the busiest has been since the beginning of the pandemic – with emergency departments last month having had the highest attendance for years with delayed presentations and other specialities catching up with the huge backlog which has resulted from the previous two Covid peaks.  Therefore the patients who will really suffer from an increase in Covid admissions are our non-Covid patients particularly those with serious conditions like cancer and heart disease who have suffered enough already.

“A four week delay allows all adults to receive one dose and all over 40s to receive two doses and this will result in a 30 to 50% reduction in the total number of hospital admissions and deaths – crucially these are not admissions or deaths postponed but averted.  The very good news was that the vaccines are extremely effective in reducing hospital admissions from the Delta variant – 57-85% from 1 dose and 85-98% from 2 doses.

“A four-week delay also means that more children will be able to stay in school as delaying step four does mean that infection will not spread as rapidly, and as we saw in Bolton one third of children already were missing school due to the Delta variant and we need to reduce the risk of that happening across the country – children have already suffered enough during this pandemic.

“Finally in terms of the impact on our mental health and the economy, it would be much worse to allow the virus spread faster now and then have to reverse step three – we all want an end to restrictions and a return to normality – but not just for a few weeks – and this delay makes it more likely that this will be permanent.”

Dr Michael Head, Senior Research Fellow in Global Health, University of Southampton, said:

“The Delta variant (first spotted in India) is the dominant variant of concern in the UK, and it is more transmissible than other VOCs.  One dose of a vaccine provides lower protection against becoming ill from the delta variant of COVID-19 (about 30%), but protection from two doses is still high, at about 60% for AstraZeneca and 80% for Pfizer.  The really good news is that it looks like protection against hospitalisation is very high for both vaccines (>90%), but that’s only observed after both doses.  So, it is incredibly important that we all complete the two doses.

“Right now, around one-fifth of the adult population haven’t received their first dose yet, and around two-fifths have had one dose so far.  So, there are still many susceptible people vulnerable to a COVID-19 infection.  Whilst the overall reductions in deaths are great news, younger populations do sometimes get ill enough to need hospitalisation, and these numbers are increasing.  For every hospital bed with a COVID-19 patient, that means fewer beds and staff available for non-covid health issues.  Long covid is also prevalent across all ages and an increasing burden on primary care services.

“So, it makes sense right now to limit the reopening of society, particularly reducing capacity (or keeping shut) indoor spaces like nightclubs or cinemas, which is where new outbreaks are seeded.  This will give us time to advance the vaccination rollout.”

Comments specifically on the modelling papers published by SAGE today:

Dr Nick Davies, Assistant Professor of Mathematical Modelling, London School of Hygiene and Tropical Medicine, said:

“I think it can be hard to understand how the modelling can suggest we may be facing a third wave of a comparable magnitude to previous waves, when so many people have been vaccinated.  Surely, we would expect a smaller wave this time around because of vaccines?

“The crucial difference is that wave 1 in April 2020, and wave 2 in January 2021, were both stopped short by lockdowns, which prevented either peak from reaching their full heights.  For this third wave, we are returning to almost-normal behaviour, and the projections are showing what would happen if no further action was taken by policymakers to attenuate any resulting third wave.  So these waves are reaching their full height rather than being cut short by any lockdowns.

“Another important difference is the increase in transmissibility, lower efficacy of vaccination, and (in some scenarios we prepared) increase in severity for the Delta variant relative to previous variants.”

Prof Mark Woolhouse, Professor of Infectious Disease Epidemiology, University of Edinburgh, said:

“Projecting the course of the Covid-19 pandemic remains a challenge.  The UK government is being guided by epidemiological models calibrated to the latest data for the delta variant, which is significantly harder to control than the alpha variant.  These models generate projections – and the (very large) uncertainties around these projections – of the next phase of the UK epidemic, for scenarios where Stage 4 relaxations are implemented on June 21st or are delayed, for periods of up to several months.  These projections have been published by SAGE today.

“Despite considerable uncertainty, there is a consistent pattern that delaying Stage 4 for 4-5 weeks has a significant public health benefit.  It reduces (by 20-30% in the central scenarios) the total number of Covid-19 hospitalisations over the coming year.  It has a bigger impact on the peak (40-50% reduction) and pushes the peak further into the autumn.

“However, the same models also generate a significant wave even without any Stage 4 relaxations at all.  If we do progress to Stage 4, in the worst case hospital admissions could be on a comparable scale to the past winter.

“The model outputs also show – but do not highlight – the expected situation on July 21st.  Daily numbers of cases are projected to be several times higher than they are now and to still be increasing at that date.  Though the number of hospitalisations may still be low, the models generate a rapid increase after July 21st.  On the basis of the data we should see if these projections are correct, this could make it extremely difficult for the government to decide that it is safe to lift restrictions on July 21st.  Conversely, if daily numbers of cases are falling by July 21st then that will indicate that the more pessimistic model projections were not accurate and the delay was only precautionary.”

Prof Rowland Kao, the Sir Timothy O’Shea Professor of Veterinary Epidemiology and Data Science, University of Edinburgh, said:

“The modelling of the impact of the delta variant was conducted by three independent research groups working with different modelling approaches.  That the three models agreed on the potential for a considerable increase in the impact of the delta variant on serious illness and deaths, is a good indicator of the seriousness of the situation.  The considerable uncertainty associated with the outcomes is a real indicator of the uncertainty in the data – there is much we simply don’t know.  Any decisions announced today reflect that uncertainty, and thus it is entirely possible that the outcome over the next few weeks will be substantially fewer cases and deaths than the extremes of the modelling scenarios – while all models can of course be wrong, such an outcome should not in itself be an indicator of fundamental flaws in the models themselves.”

Comments sent out on Monday morning in response to media reports suggesting what the Prime Minister was set to announce, before the detail was published:

Dr Peter English, Retired Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice, Immediate past Chair of the BMA Public Health Medicine Committee, said:

“In the UK we are experiencing an exponential rise in cases of the Delta variant of the SARS-CoV-2 virus which causes Covid-19 disease.

“This variant is considerably more infectious or “transmissible” than previous variants – about 1.6 times as transmissible as the Alpha variant, which in turn was considerably more transmissible than the original and first wave variants.  There are indications that it is more likely to cause severe disease, and PHE data shows more symptomatic disease in children (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/993198/Variants_of_Concern_VOC_Technical_Briefing.pdf or https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-20201201).  And current vaccines appear to be less effective against it, particularly after a single dose.

“For all these reasons, we are already seeing a considerable rise in cases.  Although vaccination has blunted the severity of the disease at population level, the level of the rise is such that we will, nevertheless, see rising hospital admissions, ICU admissions, and (in due course), deaths, even if we continue as we are.  Younger people are at considerably less risk of serious disease, and may be at lower risk of “long covid”; but the risk to them is far from negligible.

“Continuing the current restrictions, or something very similar, will mitigate the consequences of this concerning variant.

“Given the huge backlog in treatments and the immense strain that the NHS was under, even before the start of the pandemic (and it is much worse now), we cannot afford to place any avoidable burden on the NHS, so it is essential that we at the very least continue the current restrictions.

“There may be some scope for considering which aspects of the restrictions are most effective and thus most essential to continue, and possibly to consider other approaches.  It is much less likely that somebody who is fully vaccinated will be infected or infectious; and the risks of somebody becoming infected, infectious, or seriously ill following vaccination are also much reduced.  So some countries permit people who are fully vaccinated (e.g. at least two weeks since the second vaccine, with the second vaccine given at least 4 weeks after the first; or ≥two weeks after a single vaccination following confirmed infection at least 6 weeks previously) to mix freely, as the risks are considerably lower.

“It might be worth considering an approach along these lines.  However, such an approach would place an added burden on venues and event organisers, and would require an effective “immunity passport”.  It is not clear whether the NHS App will suffice for this purpose.  There are, of course, equity issues with this approach; many younger people have not yet had the opportunity to be fully vaccinated.  This has to be set against the fact that they are and have been at considerably lower risk of serious illness if they are infected, whereas older people have experienced most of the serious illness, hospitalisations and deaths.

“As a greater proportion of the population is vaccinated, and as evidence accumulates to help us understand how effective the vaccine is both at protecting vaccinated individuals, and at reducing transmission (by providing indirect protection – if unvaccinated individuals are less likely to be infected by people who have been vaccinated), it is likely to become safer to relax restrictions.  And if people who are likely to be immune (as above) have fewer restrictions, more people will move into the fully-vaccinated and less restricted categories.

“There may also be scope for reviewing the JCVI’s risk categories, for example, by adding pregnancy to the list of “underlying conditions”, so that young women who become pregnant become eligible for vaccination before their age group, and/or for a second dose at 6-8 weeks after the first dose.

“Scientists and vaccine manufacturers are actively involved in developing and testing vaccines that are likely to beat least as effective against variant strains such as the Delta variant.  My guess would be that, following priming with one or two doses of the original vaccines, a single booster dose will provide excellent protection against the Delta and Beta  (B.1.351) variant, first identified in South Africa, which has also shown signs of some degree of vaccine escape.”

Dr Julian Tang, Honorary Associate Professor/Clinical Virologist, Respiratory Sciences, University of Leicester, said:

“From a virological viewpoint, this is a wise decision.  The delta (Indian) variant has been often compared to the alpha (Kent) variant – but remember that this alpha variant has already proved 50% more transmissible than the original Wuhan virus – and the delta variant is 50% more transmissible than the alpha variant – so it is much more transmissible.

“You will never completely ‘sever’ the link between infection and hospitalisations.  This is more misleading, binary messaging that has been so damaging during this pandemic.

“With increasing numbers of COVID-19 cases – we will see an increase (albeit much smaller now) in hospitalisations.  But you will never sever the link completely – even with vaccines – because as we saw from some figures last week (42 deaths due to the delta variant of which 12 were in those with two vaccine doses), the vaccines are not 100% protective – and new variants can always arise that can escape from them.

“My main concern is how much long COVID we will start seeing as we open up completely – as emerging data suggests that this can affect 10-20% of adults and children – to varying degrees, but some people can have debilitating symptoms, such that they can no longer work (adults) or attend school (children).

“If such long COVID case numbers start to rise, the healthcare burden will shift to the community – GPs – with a proportion of patients referred to specialist clinics like infectious disease, neurology, psychiatry, endocrine, cardiovascular and respiratory teams – to deal with the more severe aspects of these long COVID symptoms.

“We see this already to some extent in patients with chronic fatigue syndrome after glandular fever and Lyme disease – so COVID-19 cases may add to this burden.

“But neither can we keep oscillating between lockdowns forever, so we may have to accept some annual morbidity/mortality from COVID-19 – as we do for flu – with the appropriate government support and financing for these patients, their family and their careers.”

Dr Audrey Tang, a chartered member of The British Psychological Society, said:

“Uncertainty is a source of stress because it means we cannot make clear plans for our future…or rather more, we cannot anticipate future threat and possibly do something to eliminate it.  This year has demonstrated to many of us that we are resilient beings, uncertainty is mentally and emotionally uncomfortable.

“Further to this, it has not been an easy year for anyone, and many have been through a great deal of sadness, loss and fear as well as constant upheaval.  We had little to balance the sadness either – with weddings, christenings, parties either curtailed or cancelled/postponed; few opportunities to even reach out and feel the warmth or a hug from our friends and families – especially if for those who have had to shield; and it’s just not the same to try and share in the joy of a new baby or exciting life change over an online platform – and that’s even if everyone was comfortable using them!  And many people are likely to be looking forward to a sense of “Predictability” – rather than normality i.e. When I book a holiday it’ll definitely happen, or if I have theatre tickets I can look forward to the show.

“It is also notable that even in those who have perhaps have planned around the uncertainty i.e. as we were always told June 21st was the earliest date for lifting the final restrictions, this does not mean that they haven’t hoped that the 21st would be the day because perhaps they could “hold on” until then, but perhaps not much longer, and they were going to take that chance. It’s not necessarily that people failed to plan for uncertainty, but rather than the 21st was a last hope.

“In contrast though, we must also remember that there may also be some people who were wary, and even fearful of lockdown lifting – and who may experience a sense of relief that there is to be a further delay. Added to that a further complication is that we often become comfortable with a behaviour that we have had to do for a while.  As such where being in lockdown might have been difficult to adjust to at first, not only are there very reasonable fears around it lifting despite much of the population being vaccinated, and some distancing restrictions still present, but some of us may have become used to it. So perhaps a little longer to ready ourselves before opening the doors – figuratively and literally, may be welcomed.”

Dr Simon Kolstoe, Senior Lecturer in Evidence Based Healthcare at University of Portsmouth, and Chair PHE & NHS (Hampshire A) Ethics Committees, said:

“Mass vaccination is clearly working, but the really important thing we do not yet know is whether enough vaccines have been given to reduce hospital admissions.  This is complicated by the Delta variant which certainly increases transmissibility, but we are not sure yet about severity.  We can only be confident in lifting all restrictions once we know that the link between large scale infections and hospital admissions has been broken.  The vaccine certainly seems to be doing its job in breaking this link, but a few more weeks to get more people vaccinated certainly seems like a sensible option.”

Prof Ivo Vlaev, Professor of Behavioural Science, University of Warwick, said:

“The reported changes may negatively affect some people, while majority others may not be affected at all.

“Those who will lose something (those with businesses and livelihoods in areas who hadn’t yet been allowed to open, or maybe because they booked wedding or other celebration) will feel disappointed.  Do not promise someone something, unless you can deliver it, because people will feel sense of ownership and sense of loss when you take it away.  This is likely because of what we describe in psychology as ‘loss aversion’ – we dislike losses more than we like gains of an equivalent amount.  The opportunity to gain something is highly pleasurable but the fear of losing something is emotionally intense and provokes strong negative feelings.  Our aversion to losses leads to what is known as the endowment effect or mere ownership effect, which is the observation that people who own something tend to evaluate it more positively than people who do not.  So, the mentality of some people may be ‘You (the government) promised me my freedoms and associated pleasures after 21st June, now you are taking it away’.  This disappointment will likely erode trust in government which is the main driver of compliance with regulations.

“But for many others, the public attitudes towards social contact will remain unchanged.  For them, this will be life-as-usual a bit longer.  Overall, people do stick and will stick to obeying restrictions.  With a few exceptions here and there, the population is obeying the rules.  And the more they stick to the new way of life, the more likely they are to develop new habits and routines.  Research shows it takes up to 2 months on average to develop a habit, so we just need to continue a bit longer with our daily routines.

“Research also shows that we are also creatures who like to rationalise, like to explain away what happens.  We need reasons.  Give me a credible reason for why something unpleasant is happening and I’m experiencing less distress and my well-being suffers less.  The worst thing is unexplained and random pain.  So, the government needs to continue communicating clear and robust reasons for the policy.  There is already general consensus that we will need to learn to live with this virus as we do with other infectious diseases.”

Prof Mark Woolhouse, Professor of Infectious Disease Epidemiology, University of Edinburgh, said:

“An announcement that Stage 4 of the road map is to be delayed would be justified.  The arrival of the delta variant has changed the assessment of the risks of re-opening: it is more transmissible, causes more severe disease and the vaccines are less effective against it.  The current situation can be said to fail the fourth of the four tests the UK Government set out in February.

“There would be two main advantages to delaying.

“First, a delay would provide time to increase the proportion of UK adults who have received both doses of vaccine.  This is important because the second dose significantly increases levels of protection against the delta variant.

“Second, a delay would give more time to fully assess the potential of the delta variant to cause a serious public health problem that could overwhelm the NHS.  This could happen because a large wave of infection (mainly in younger adults who have still not been vaccinated) would inevitably spill over to the small percentage of vulnerable people who have not been vaccinated and to vulnerable people who have been vaccinated (for whom the vaccines gives high protection but not 100%).

“We will know more about the UK government’s expectations of the size of any new wave when the epidemiological modelling is published later today.  However, there are several points of concern about the current situation:

– Number of cases are increasing rapidly;

– Numbers of hospitalisations are very low and but they are increasing slowly, as would be expected in the earliest stages of a large wave;

– Hospitalisations and deaths are occurring in people who have had one and even two doses of vaccine and, though the rates remain low, if there were a large wave this could add up to a significant public health problem – a small percentage of a very large number is still a large number.

“Nor do we yet know the government’s expectations of the situation in one month’s time.  It is possible that there will not have been a positive change in the trajectory of the epidemic, in which case it could be hard to justify removing restrictions at that time too.  If a new wave does materialise then it may not peak for several weeks more (unless some restrictions are re-imposed, which would be contrary to current government policy), implying the possibility of further delay.

“The vaccines are a crucial – but not the only – tool for reducing the size of any new wave.  The original target for the vaccine roll out was to fully vaccinate those most vulnerable to Covid-19.  This was achieved several weeks ago.  A new target might be to fully vaccinate all adults – this looks unlikely to be achieved before August.  A further target might be fully vaccinate everyone, including children – this would  likely extend the end point until the autumn.  The arrival of the delta variant has made it harder to reach the herd immunity threshold, even if the entire population has been vaccinated.  If the herd immunity threshold cannot be reached then further measures could still be needed to limit the frequency and scale of outbreaks.

“There are several ways to further reduce the long term public health burden of Covid-19:

– Intense efforts to vaccinate the small percentage of vulnerable individuals who are eligible to be vaccinated but have not been.  As an example, increasing coverage from 96% to 98% reduces the number in this risk category by half.

– If cases do rise, concerted efforts to put in place other ways of protecting vulnerable individuals for whom vaccination is not advised on clinical grounds.

– Continued measures to reduce transmission rates through case finding, mass and targeted testing and use of hygiene and PPE, with an emphasis on making activities safe rather than stopping them outright.

“The nature and timing of the transition from a major epidemic to living with Covid-19 was never likely to be straightforward.  The delta variant has made the process considerably more difficult.”

Prof Sir Simon Wessely FRS, Regius Professor of Psychiatry, King’s College London, said:

“Wearing my epidemiologist hat I agree that there was little choice in this decision.  And speaking as a psychiatrist I do not think that a one month delay will have the same severe consequences for mental heath as before.  First, schools are not going to close.  The harm done by that has been immense and is becoming more and more clear.  The second worst feature of our efforts to control the pandemic has been the severe restrictions on social interactions and networks, removing the main way we cope with threat, stress and danger at the time when we most need it.  But the edge has definitely been taken off this in the last set of relaxations.

“So I doubt that there will be substantial negative effects from today’s reported decision.  Indeed, polling suggests that more people will be relieved than dismayed, with the decision.  For many it is continued relaxation of the rules, rather than postponement, that creates anxiety.

“What would be more damaging to morale and mental health would be if government goes backwards and starts reimposing rules that have been relaxed.

“However, whilst we remain on the road to coming out of the pandemic, if not quite as quicky as we hoped, we have accepted that the future is that Covid-19 will remain with us in an endemic form.  Something we are learning to live with.  I think that it would need something very catastrophic indeed to force the government to start going backwards to a policy of complete elimination, and the consequences then to our collective mental health would be grave.”

https://www.gov.uk/government/collections/scientific-evidence-supporting-the-government-response-to-coronavirus-covid-19

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MIL OSI United Kingdom