COVID-19: DEGREES OF SUPPRESSION. THE ALTERNATIVES

Let's clamp down on COVID

On Monday 14 December, London went into Tier 3, the highest level of the English tiers.  The day before the Times disclosed what happened in September to sow the seeds.

According to the Times article, on Friday 18 September PM Johnson, Gove, Hancock and Cummings had been persuaded by the SAGE scientists that a short Circuit Breaker lockdown was necessary starting the following Monday.  But Sunak the Chancellor, understandably worried about the economic consequences, persuaded Johnson to listen to other scientists on the Sunday.  The Circuit Breaker did not then take place.  An opportunity to stem the increase in infection cases was lost.

At that time the data was looking like this, with rates starting to rise significantly across all age groups:

The SAGE group had just recommended a 2-week Circuit Breaker lockdown to check and reverse the rises, and avoid harsher measures later.  Which is exactly what has happened by not holding the Circuit Breaker, requiring a longer lockdown and punitive tiers.

On that Sunday SAGE was represented by Professor John Edmunds, of the London School of Hygiene and Tropical Medicine.  He presumably extolled the virtues of SAGE's advice.

But there were three other scientists presenting before him:

• Professors Sunetra Gupta and Carl Heneghan from Oxford University, who had been advocating "herd immunity" as formalised in the Great Barrington Declaration
• Anders Tegnell, Sweden’s leading epidemiologist and architect of their strategy

 

HERD IMMUNITY

An infection can produce an immune response in an individual, such that they fight off the disease and do not die.  In many cases that immunity lasts a significant period of time, preventing them catching the disease again.  That is if there isn't a new strain of the disease which the immunity does not fight.  

Where a significant proportion of a community has developed immunity, typically at some proportion over 60%, the infection has difficulty spreading and infection rates stop rising and then start falling as the proportion increases.  

With widespread use of vaccines, infection rates can fall to near zero, and let normal life take place.  That is how we live with influenza, although it still kills thousands a year in the UK.

The alternative to reach 'herd immunity' is to let the infection spread through the community until the required percentage of immunity has been exceeded.

But there is a much better way to get life back to normal before enough vaccinations have taken place, which will likely take months.

 

THE SWEDISH APPROACH 

 

The Swedish approach promoted there by Tegnell acknowledged two key aspects at the outset:

• COVID-19 would be around for the foreseeable future, in that respect much like flu.  So a long-term approach was needed
• Lockdowns cause significant harms socially and economically, so should be minimised.  Indeed restrictions have been light in Sweden, with most school age groups and businesses being kept open throughout

This strategy is best described as 'running hot' within the capacity of its health service, not 'herd immunity'.  Tegnell is on record as saying this was not herd immunity.  Indeed by restricting larger events to only 50 people and keeping older children off school, this was not in pursuit of herd immunity.  Any such effect would be an incidental bonus.

 

As discussed here earlier in September, Tegnell himself said this strategy was not applicable to the UK, primarily due to:

• Differences in culture
• Differences in density of population 

Since September new confirmed cases in Sweden have climbed substantially, making the situation for Sweden very serious.  They have now closed all high schools, with further restrictions coming into effect on 14 December.  Hospitals are being overrun, such that Sweden is now seeking help from neighbouring countries.

Whilst I thought their strategy may prove to be best for them over the course of a year or two, all things considered, this is now looking less plausible.  And certainly not appropriate for England.

Though we don't know what Tegnell told Johnson and Sunak in September.

HERD IMMUNITY AND THE GREAT BARRINGTON DECLARATION

As noted above, lockdowns cause significant harms socially and economically.

One idea is to aim for herd immunity before a vaccine is available.  Though this was not what Sweden was prepared to do.

The Great Barrington Declaration, promoted by Professor Gupta and others proposes "Focused Protection" which they say is "the most compassionate approach that balances the risks and benefits of reaching herd immunity" with two key aspects:

• Better protecting those who are at highest risk
• Allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection
  

There are four significant problems with this idea:

• It is difficult if not impossible to adequately protect those at highest risk, given they often share households and/or contact with others outside that category.
• Hospitals could quickly become overrun, to the detriment of everyone seeking medical care.
  
• LongCOVID can affect 5% (one in 20) for more than 8 weeks, according to the Kings College ZOE study.  This leaves people with debilitating symptoms for weeks if not months after infection.  But it is not clear who is at risk, as it affects the very healthy as much as anybody else, across all age groups including children.
• Basic maths, as follows
  

There are about 68 million people in the UK, of which most are in England.  Let's say 8 million would have to be 'protected', a very large number in its own right, leaving 60 million out and about. 
 
Let's say a significant herd immunity effect would be as low as 60% having been infected, and assuming that immunity lasts.  Gupta suggests achieving herd immunity in 3-6 months.  That's only 90-180 days.  60% of 60 million would take some 200,000 to 400,000 new infections a day on average.  Absurd numbers given high daily UK rates currently less than 35,000.  Even if deaths could be avoided by 'protection' there could be 10,000-20,000 new LongCOVID sufferers per day
 
Cross-immunity from the 4 COVID common cold viruses may exist, but certainly hasn't been enough to stop many COVID infections.  Nonetheless, if say 50% are immune that way, so only 10% more is needed for herd immunity, then still 33,000-67,000 a day would need to be infected with COVID-19.  Still very high, and would also result in thousands of LongCOVID sufferers.

Indeed the Lancet medical journal published correspondence in late October from over 80 scientists insisting herd immunity "is a dangerous fallacy unsupported by scientific evidence."

This is echoed by the World Heath Organisation "Attempts to reach ‘herd immunity’ through exposing people to a virus are scientifically problematic and unethical."

Natural herd immunity without vaccination is therefore not a realistic prospect.

 

DO LOCKDOWNS WORK?

Some people suggest lockdowns don't work, citing that disease graphs for COVID-19 are similar to flu.  But that ignores the evidence that lockdowns do work.

For example, the Welsh FireBreak in October/November reduced infection rates in higher infection areas by half, whilst across the border in England infection rates were rising.  As soon as the restrictions were eased, infection rates rose quickly again, such as in parts of South Wales:

Indeed an alternative conclusion is that if COVID-19 infection graphs under lockdown are compared with flu graphs from previous years where vaccination was in place, lockdowns act 'in loco vaccine'.  Lockdowns providing a similar affect to the size and shape of graphs as vaccines, provided the restrictions are tough enough.

 

THE EFFECT OF VACCINES

Vaccines do two things:

• Protect the individual being vaccinated, though this is not perfect
• By widespread vaccination of a community, enough people can become immune to create 'herd immunity', where infection rates drop to very low levels.  

That is what happens with influenza vaccines.  But as the focus is on the old and susceptible, 'flu still spreads amongst the rest of the population.  This means people often get ill, and infect others.  The result is that thousands die of 'flu each year in the UK.  

 

COVID-19 is a more severe illness than 'flu, with longer nastier initial symptoms for the initial iness, plus LongCOVID.  The idea is to vaccinate a much larger proportion of the population.  This will take months, not weeks, well into 2021.  Easter rather too optimistic.

When that has happened, life will begin to get back to normal.  But there are still months where COVID-19 rates are likely to remain high.

The other aspect of vaccines is that normality is achieved by suppressing the relevant virus.  This is what New Zealand and some other countries have achieved by other means, adopting a policy of "super-suppression".

THE NEW STRAIN OF COVID-19 VIRUS

Publication of this blog article was deferred by news that a significant new strain of the SARS-COV-2 virus that causes COVID-19 had been discovered. The consequences were unclear.

 

First identified in England, it has appeared in Scotland and a few other countries.

Whilst the new strain does not appear to be more lethal, the mutations in the virus cause a somewhat different 'spike protein' that the virus uses to attach to cells and infect them.  This has two potential consequences:

• There is circumstantial evidence that this makes the virus more infectious, as could explain why infection rates have climbed faster in London and the south east than in other places
• If it does infect cells more easily, that could mean more people affected by LongCOVID more severely.  Some long-term symptoms are due to the virus attacking cells in other organs such as liver and even brain

It is hoped that the changes in the spike protein do not make natural immunity or vaccines redundant.  

It is quite normal for viruses to mutate, and up to now this appeared to occur relatively rarely with SARS-COV-2.  One reason there is an annual flu vaccine to cover new strains, so this may also be required for COVID-19 vaccines. 

Laboratory tests and community observations will likely take weeks and maybe months to clarify these issues.  In the meantime we ought to err on the side of caution, and assume that this strain is indeed more infectious and potentially more cause for concern in respect of LongCOVID.

ALTERNATIVE STRATEGIES

As discussed above:

• COVID-19 is a worse disease than influenza
  
• Herd immunity without vaccines is not appropriate
• Vaccines promise low infection rates which allow life to get back to normal, but these will take months to roll out sufficiently to provide herd immunity
  

The response in England, as in much of Europe, has been to suppress the virus by trying to balance two "harms":

• The effects of the virus
• The harm to the economy and life in general
  

We have found that only reasonably tough restrictions suppress the virus, and so far we have avoided hospitals being overrun.  But on an overall scale, these restrictions are only 'light suppression'.  They have not allowed the economy to reopen fully, especially as the colder weather has favoured transmission of the virus, and far too many people still catch the virus.

Whereas super-suppression in countries like New Zealand has acted like vaccines, and allowed the economies to reopen and allow people to hug each other again.

The UK's geographical proximity to Europe and a different culture than countries in Asia means a "Zero COVID" strategy is effectively impossible.

But we can leverage the lifecycle of the virus, including the new variant, to drive down infection rates to very low levels.  Once very low, it is far easier to keep rates very low than if levels only drop to medium levels.  The Welsh FireBreak should have been a full three weeks for schools and businesses.  

This requires a change in mindset from the Government and its advisors to that of super-suppression using short and very sharp FireBreaks which allow the economy to reopen in between.  Details are here.

IMPACT ON EDUCATION

It has been agreed that education in schools and universities is a top priority.  The problem with the current 'light suppression' strategy is that education is being severely disrupted for two reasons:

• School children, especially in senior schools, are becoming ill and they and classmates are having to be sent home.  There is evidence that the disease then spreads to the local adult community
• Teachers are becoming either ill or are self-isolating, making it increasingly difficult to staff schools.  For example, one Oxfordshire school has 40% staff absent, and is struggling to keep open.  The problem exists across the country.
  

When parents and others become infected, that also disrupts their employment, or especially if self-employed.  Livelihoods and businesses seriously damaged.

So the current strategy is not keeping schools open and not benefiting the local communities.

IN CONCLUSION

 

The current strategy is neither letting education nor businesses operate properly.  Natural 'herd immunity' is not an option, yet we have months before vaccines become fully effective.  The new virus strain threatens to make matters worse.

 

It is time we looked more closely at a 'super-suppression' approach for the months ahead.  Especially now a relaxation of restrictions has been confirmed over Christmas.

Ideally a 3-week FireBreak straight after Christmas should be adopted.  Before schools and universities are allowed to return. 

Further details of the proposal here.