COVID-19: ENGLAND'S FIVE STRATEGIC OPTIONS

I have a confession to make.  I love music.  Playing music.  Listening to live music.  Dancing to music.

My daughter is a professional dancer.  Or would be if there was any work.  She's supposed to be on a cruise ship.  Many of my musician friends are also struggling, whatever their genre.

We all want live music to re-start.  And stay open.  But how?

It's not just live music and theatre.  We want schools and universities to re-open and stay open.  We want the economy to recover.  We don't want to die.  If we survive, we don't want LongCOVID either.

So how can England achieve all these objectives?

We looked at strategies here, four weeks ago.  But that's a long time in the battle against COVID-19, so now it's time for an update.

There are essentially 5 types of strategy.  Let's look at them in turn:

1. Herd immunity
2. Voluntary restrictions
3. Living with low-medium levels of infection
4. Strict Zero
5. Near Zero

HERD IMMUNITY

The idea of 'herd immunity' is that if enough of the population is immune, if someone becomes infected it will be more difficult to find anyone else to infect.  The R number would naturally drop below 1, and the infection die out.

Remove all restrictions, let people get on with their lives, and the disease will disappear. 

That's fine in theory, but to do it naturally without a vaccine, there are some serious drawbacks:

• It would take years at any reasonable infection rate
• There are major 'costs':
• A lot of people will die early
• An awful lot of people will suffer from LongCOVID
• Absenteeism through illness (and worse) will make it difficult for many organisations to function
• The health service would be overrun
• Resulting in services for cancer etc being unavailable

The result would be that society as we know it would likely be destroyed.

Usually herd immunity is achieved through use of a vaccine.  Indeed there is hope for vaccines, with well over a hundred initiatives worldwide, using at least four different basic approaches.  But there is still no guarantee that one or more will prove both safe and effective.  Like flu vaccines, an annual booster may be needed, to prolong immunity and cover new mutations of the virus.  We'll have to see.

In any case, a vaccine won't be available properly tested and in bulk quantities until next year, 2021, at the earliest. 

Restrictions could be avoided if there was a medicine that safely and reliably either:

• Avoided anyone catching the disease
• Avoided anyone getting serious symptoms, and/or
• Improved survival rates, without LongCOVID

There are some developments set out here, with some extras such as these since that was written. 

But no drug or other treatment has yet proved good enough.  There was certainly nothing suitable around in February or March

So no country has adopted a pure restrictions-free 'herd immunity' strategy. 

But if individuals ignore the virus, and carry on as if it wasn't there, they are effectively contributing towards a herd immunity strategy.  Undermining whatever other strategy is officially in place.


VOLUNTARY RESTRICTIONS

The most liberated strategy is that adopted by Sweden.  They have basically let schools and businesses carry on with two major restrictions:

• Prohibiting large gatherings over 50 people.  So little traditional indoor or outdoor entertainments
• Closing schools for over 16s, who are effectively adults from a viral perspective

Their justfcation for this approach is that COVID-19 is going to be with us for a very long time, and people cannot be expected to comply with restrictions imposed upon them for very long.  That is exactly what we see happening in Spain and elsewhere in Europe, where initial restrictions were very tough.  Easing restrictions has resulted in a very sharp rise in infections.

Sweden's populace did a voluntary lockdown, for example cutting travel as much as their Scandanavian neighbours.  But death rates have been higher, although eclipsed by Spain and others in deaths per million.

The restrictions mean it cannot be said to be a 'herd immunity' strategy, and their Chief Epidemiologist Anders Tegnell has made that clear.

Other aspects of their strategy have been more contentious, especially about wearing masks.  His view in this interview is this: "Everything tells us that keeping social distance is a much better way of controlling this disease than putting masks on people. We are worried (and we get at least tales from other countries) that people put on masks and then they believe they can go around in society being close to each other, even going around in society being sick [unwell]. And that, in our view, would definitely produce higher spread than we have right now."

It's a view, though many would disagree.  Indeed internally in Sweden there is growing pressure to increase the controls, such as wearing masks.

In the meantime Sweden is seeing infection rates fall as if they had almost reached herd immunity.  This maybe because of 'cross-immunity', but the evidence is not yet strong enough to suggest other countries should follow suit with the Swedish approach.


LIVING WITH LOW AND MEDIUM LEVELS OF INFECTION

The BBC have today published this graph of new confirmed cases:

This shows a rising trend in infections, which in August is no longer explained by a rise in testing capability.  This is a real rise which has reached a 7-day average of 1,190 per day in the UK.  This is inherently understated by a factor of about five, as explained here.  So a better estimate of infections is some 6,000 a day, around 9 per hundred thousand, and rising.

A 'very low' level is 2 per hundred thousand, as discussed below.  The UK is currently at a 'low' level.   Elsewhere the rates are higher than that, at what can be regarded as 'medium'.  Here's a graphic compiled by the Guardian from data from the European Centre for Disease Prevention and Control in early August.

The figure for the UK is more than double my daily estimate, as more than 10 times UK official figures, so these figures are likely to be per week:

Across Europe this means:

• Some restrictions are still in place in every country
• Attempts to ease restrictions are being met with an increase in infection rates, as seen in the UK and throughout Europe
• For countries that have attempted to reopen schools, some are getting infected and having to close again.  Open, close, open, close, etc obviously isn't good.
• Parents are not confident about sending their children to school.  The risk to them may be very low, but the risk to teachers, parents and other adults is a real problem for community infection levels.
• Many people are not confident to go to workplaces, especially if that involves public transport.  
• Those people who have been shielding are not confident about going out
• As a result, businesses are still struggling.  The economy isn't recovering as fast in the UK as would be liked

This part-open, part-closed merry-go-round isn't working.

In particular night-life is best-part closed.  Some events are taking place outdoors, but as the summer ends, getting indoor venues open is a real challenge.

The Night Time Industries Association, which represents they say 6% of the UK ecenmy and 8% of jobs, is not going to let that stop them.  Their latest report "Nightclub and Venue Re-opening Strategy" says:

Only just now a friend said he was thinking of going to an illegal rave, where there would be no controls, until I told him about the new penalties starting today in England. As the BBC say "Those who attend gatherings and those who do not wear face coverings where it is mandatory can be given a £100 fine, doubling on each offence up to £3,200." "Police in England will be able to fine organisers of illegal gatherings of more than 30 people such as raves up to £10,000".

Update 31/8/20: The first £10k fine was given to organisers of an illegal rave in South Wales over the weekend (29-30 August), inolving some 3,000 revellers.

There is a hell of a lot of frustration brewing amongst younger adults.  Maybe because they don't fully understand the risks of COVID-19.  Unless something is done soon, this isn't going to end well.

ZERO COVID / STRICTZERO

New Zealand recently celebrated 102 days without a single person getting infected with COVID-19 on New Zealand soil.  A couple of British ladies had brought COVID-19 into the country in June, but there wasn't any onward transmission.

Restrictions had been lifted, entertainments could restart, and people could hug each other again.  Life back to normal.  Hurrah!

Then a family of four were tested positive in August.  With the “go hard, go early” strategy for the virus, the government put Auckland into lockdown the next day, banning residents from leaving home for non-essential reasons.  That's some 1.6 million people for an outbreak that affected less than 100 people in all.


Even New Zealand's geographical isolation and their strict quarantine arrangements for people arriving from abroad, the virus had still got through.

Maybe people would accept a hard lockdown again once, maybe twice.  But surely they can't keep going into full lockdown every time there's an outbreak?  There will be other outbreaks.

If this SARS2 was like MERS, another coronavirus that has been known to kill one in three people who are infected, then New Zealand's strategy would be absolutely essential.  Indeed should a SARS3 or SARS4 come along that was both highly infectious and highly murderous, then there would be no hesitation in adopting New Zealand's strategy.  Why it is so important to find a vaccine against SARS 2 that would potentially provide immunity against future more murderous variants.

But SARS2 is not as dangerous.  Whilst New Zealand's strategy has worked so far, is it sustainable?  Somehow we need to live with the virus whilst opening most if not all of society.  Including nightclubs and entertainment venues where large numbers congregate indoors.


#NEARZERO

So we've concluded:

•  'Herd Immunity' is not achievable in reasonable timescales without a vaccine, which is not available yet.  In any case there are substantial drawbacks.  Such a strategy with limited controls would result in health services overrun with consequent detrimental affect on services for other ailments such as cancer.  Deaths and LongCOVID numbers would go through the roof. 
• Sweden's approach of voluntary lockdown has its merits.  But is being heavily criticised internally, and has not yet been shown to be suitable for other countries.
• Low and medum levels of infection, as in UK and most of continental Europe, makes it difficult to open all the economy, especially Night Time.  Schools are likely to have to close periodically, and generally life cannot function as it used to.
• A 'Zero COVID' strategy like New Zealand has been following has its attractions, but it's unlikely that it is sustainable.

So what do we do, in England and indeed throughout the world?

Back at the start of May the two co-chairs of the SAGE group of scientists suggested a 'very low' level of infections was appropriate.  That was understood to mean under 1000 new infections a day, being around 2 per day per hundred thousand.

Given the people tested is far less than actually have caught the disease, by a factor of about five, that's 2 per 5 days of official new confirmed cases.

This 'very low' level would be transformational:

• The chances of meeting someone else infectious would be much more acceptable.  In a town of a hundred thousand people such as Watford, only 8-10 people would be out and about infectious, instead of 40-45 with the UK average now.  That's if we assume 4-5 days' worth of people out and about infectious without knowing it. 
• Schools could reopen and much more easily stay open.  Even in Scotland, where infection rates are lower than England, schools are starting to have schools disrupted.  Universities too, more difficult as students are susceptible to COVID-19 as young adults.
• Everyone including those who have been shielding could go out with more confidence
• Public transport could be used freely, albeit better with masks.  A special problem for schoolchildren and students
• Offices, factories and other workplaces could be used with little chance of outbreaks
• Deaths and LongCOVID would be far less than at current infection levels
• The Night Time economy could readily implement the NTIA's recommendations 
• Testing would be at a far more sensible scale.  
• The economy could thereby recover.  Indeed the current level of infections is holding us back economically.

There would need to be some fairly strict arrangements:

• At the first sign of an outbreak, testing would need to be wheeled in, backed up by appropriate tracing and isolation support.  It's possible like we've seen in Oxford just today.   
• Control over incoming people and goods:
• Visitors from abroad, including returning citizens, would need to be carefully tested and quarantined.  Better than currently.
• Goods, foods and other objects brought into the country would need careful attention, if there's any indication that could be route for the virus to enter

GETTING TO #NEARZERO

So how do we get to that 'very low' level?   A second lockdown perhaps?  The first lockdown reduced infections to a sixth of peak levels in just three weeks , which is more than would be needed to get current UK levels down to 'very low'.

But would it be that simple?  European countries also now have far further to go.  Being geographically close, we're all in this together.  Certainly if infections are beginning to rise, the sooner action is taken the better.

A further discussion of #NearZero and how to get there is here.