COVID-19: WHAT SHOULD WE DO NEXT IN ENGLAND? GREAT BARRINGTON OR WHAT?

With hospitals and ambulance services under immense pressure from this new variant, what is the answer:

• Can we actually hold the disease's spread?  Are we being forced to follow the Barrington Declaration of protecting those most at risk and letting it rip in the rest of society?
• Or should we stamp down hard with a very tough Firebreak immediately?

Updated 30/12/20: There's great news that the Pfizer/BioNTech vaccine has started to be provided to priority groups, and that the Oxford/AstraZeneca vaccine has now been approved.  I'm certainly keen to have my jab when the time comes.  With a massive vaccine roll-out expected in early 2021, when can any restrictions be relaxed?  What proportion of the public need to be immunised?

 

These questions are all linked.  Let me explain.

 

THE NEW VARIANT

The new variant of the virus is becoming dominant, showing it is far more transmissable.  For example:

People with the new variant have effectively become more infectious, notably before they display symptoms and know they have the disease.  Why it's important for everyone to wear a mask, to stop as many droplets bearing viruses getting into the air - "My mask protects you, yours protects me".  Just like they have done effectively for years in South East Asia, where everyone does it.  As well as more care on the other basic precautions, Hands and Space.

There are several mutation in the new virus variant's RNA.  The most significant produces a change on the section of the 'spike protein' of the virus, which seems to make it bind more effectively to a target cell, and thereby infect it more easily.  

This can be any cell, whether in the respiratory passages or, once in the bloodstream, any other organ with an ACE2 receptor.   It is infections of organs such as the heart, liver and brain that produce the worse types of LongCOVID, affecting people for over two months and much longer.

CAN WE PROTECT THE MOST VULNERABLE?

In the early stages of the pandemic, measures to protect the vulnerable such as those in care homes were limited, to say the least.  Matters have improved, but that still hasn't prevented hospitalisations and deaths.  There are several reasons:

• Elderly people, who are most at risk, often live in multi-generational households
• Other vulnerable people live with their families
• Those needing care are looked after by younger, fitter people

It is therefore not possible to fully shield the older and otherwise vulnerable.  If the illness is rife in the general population, the chances of vulnerable people being infected is high.

That will result in large numbers of hospitalisations.  Once hospitals are overrun, treatment will not be available for new patients with COVID-19 nor for any other reason.  Of whatever age.  It is in everyone's interest to avoid this happening.

No wonder then that protecting the NHS being overrun has been the Government's number one objective.  The basic principle of the Barrington Declaration of protecting the vulnerable is unachievable and untenable.  The unavoidable conclusion is that we must do all we can to suppress the virus.

 

THE SHADOW OF LONGCOVID

What about the survivors?  There is also the matter of LongCOVID. Studies are showing it can affect 5-10% or more of those surviving the disease, often when not hospitalised, across all age groups including children:

• Long-term lethargy that can happen after any major infection, but is no less debilitating
• Once the virus gets into the blood:
• Micro-clotting of the blood, that can cause strokes and can cause painful damage in other parts of the body
• With the variant binding more easily to ACE2 receptors in cells, it is likely it will be more powerful in attacking any cells with the ACE2 receptor, including in organs such as heart, liver, digestive system and brain
  

The more people get the new variant, the more people will suffer from the various forms of LongCOVID, and the bigger the strain in future on the health service to deal with them. So that too means the number of people catching the disease has to be minimised, of all ages. 

 

In Sweden, where there were limited restrictions, the estimate by Novus of those with LongCOVID over eight weeks by mid September was some 150,000.  15% of those catching COVID-19, compared to 6,000 deaths.  

 

In the UK, the King's College ZOE Symptoms Study has found "...it does occur across all ages. Long COVID affects around 10% of 18-49 year olds who become unwell with COVID-19"!  "...rising to 22% of over 70s."  People "...whose symptoms were not serious enough to land them in hospital yet have persisted for many weeks or months", plus serious long-term issues for people who have been hospitalised.  Overall estimating "around one in seven (14.5%) of people with symptomatic COVID-19 would be ill for at least 4 weeks, one in 20 (5.1%) for 8 weeks and one in 45 (2.2%) for 12 weeks or more. "  

 

The UK's Office for National Statistics estimate "186,000 people in private households in England were living with symptoms that had persisted for between 5 and 12 weeks, with a 95% confidence interval of 153,000 to 221,000." Substantial numbers that will put another enormous strain on the NHS as they consult their GPs and more.  We await their further research and analysis.

 

This means, again, that the level of infections must be minimised.  The Great Barrington approach of letting the disease rip through the so-called 'non-vulnerable population' is totally unsuitable.  Everyone is potentially 'vulnerable'.

WHAT CAN WE DO TO REDUCE RISK OF INFECTION?

Quickly recapping on the basics.  The virus spreads through the air, in water droplets and microdroplets in breath, and to a certain extent via touching and infecting a surface that someone later touches.

Basic precautions have some effect, to protect ourselves and each other:

• As Sir Patrick Vallance said recently "Assume you could be infectious" and that others around you are infectious
  
• Keeping meetings with other people very short, to minimise the amount of virus that can be transferred
  
• Meeting outdoors or in well-ventilated indoor places, so the breeze takes viruses away 
• Wearing a mask to catch as many droplets and microdroplets as possible, in case someone wearing the mask is infectious without knowing it - "My mask protects you, yours protects me"
• Keeping a distance from other people.  Even when masks are worn.  At least 2m but preferably 4m given the risk of clouds of microdroplets (known as 'aerosols') that don't drop quickly to the floor.
  
• Avoiding touching things other people may touch, and washing hands regularly

"Hands Face Space" plus Ventilation and Time.  The less human to human contact the better.

WHAT OTHER ACTION NEEDS TO BE TAKEN?  DO LOCKDOWNS WORK?

But what we have found is that these basic precautions are not enough to stop the spread of the virus, especially the new variant.

We should also remember there is a time delay between someone catching the disease, displaying symptoms, being tested and then being ill enough to need to be admitted to hospital.  We simply can't wait for hospitalisation and death statistics.  Action has to be taken on the earliest available information, however imperfect.  Those early indicators are not looking at all good.

So we have to reduce human to human contact even further.  Some say lockdowns don't work.  But in the absence of a vaccine so far, lockdowns compare favourably to flu with a vaccine.  As if the lockdown restrictions are 'in loco vaccines'. 

We also know from places such as Wales in late October / early November that restrictions reduce transmission, but releasing restrictions increases infections again.  This whilst England's infection graphs were on a consistent upward trend:

We also know that half-hearted restrictions are not effective.  Moving over 40% of England's population to tier 4 has been necessary to try to avoid the new variant spreading.  But the experts are suggesting this is not enough.  Schools and universities should not be allowed to go back in early January:

• At least not secondary schools, according to SAGE
• All schools involve adults, be they teachers, other members of staff, or parents of younger pupils at the school gates
• Even nurseries can be affected.  A friend of mine, his wife and 3 year old are all confirmed with COVID-19, most likely from when the young child was sent home from school where another 3yo was confirmed positive

If we are going to beat this new variant, and keep it suppressed until the vaccines ride to the rescue, restrictions have to be the toughest yet.  Fortunately most of the effect is in the first three weeks with any variant, so schools, universities and workplaces coud go back around 18 January.  As described in more detail here.  Only the absolutely vital care places and workplaces staying open for those three weeks.  Everyone else staying home.

 

 

SO WHEN WILL VACCINES ALLOW US TO GET BACK TO NORMAL?

 

Dr. Anthony Fauci, the most prominent infectious disease expert in the USA, has recently said that 'herd immunity' would need up to 90% of people to be vaccinated.  That is where enough people are immune to reduce infections to an acceptable trickle.  Certainly at least 70%.  That would likely take well into the summer.

 

With influenza vaccination, the principle in the UK has been to vaccinate the most at risk, and let other people catch the disease without too much concern.  That lets life and the economy continue.  After seeing the impact of COVID-19 on lives and livelihoods in 2020, it is tempting to think a 'flu approach' is also applicable to COVID-19

 

Accordingly some people are suggesting restrictions can be relaxed as soon as the vulnerable have been vaccinated, something that could potentially be achieved by around Easter.   That is effectively the Great Barrington approach, using vaccination to protect the vulnerable.

 

But as mentioned above, COVID-19 is far worse than flu, initially and later, as set out here.  In particular the types of debilitating LongCOVID that are not caused by other viruses such as influenza.  So the flu approach to vaccination is not appropriate to when restrictions can be lifted.  A much higher proportion of the population needs to be vaccinated.

IN CONCLUSION

Hospitals are at risk of being overrun, and LongCOVID affecting over 10% of those catching the disease, including the under 50s.  We have no alternative but to try to stamp down hard on the virus.

Whilst we all hate lockdowns, but basic precautions are not proving sufficient to get infection rates right down to let life continue.  A very tough FireBreak, the toughest yet for an initial three weeks, is the best way.  That would involve:

• Only absolutely vital organisations and workplaces remaining open, such as hospitals, care homes, utilities and food
  
• "Stay at home" being the law, minimising any physical contact with other people, such as exercise only with your 'bubble' and minimising the number of supermarket visits.  As close to self-isolation as possible for the three weeks.
  
• All schools and universities being closed until 18 January, except for kids in vital circumstances.  Importantly, so education can then be kept open for the remainder of term.
  

This 'Vital Firebreak' will need to be national to be of full effect.  Preferably the whole of Great Britain, or the whole British Isles including Ireland.

After three weeks, some relaxation should be possible.  But another Firebreak might be expected at Easter.  

By then the level of vaccination should be significant, and our understanding of LongCOVID well advanced.  This will likely mean we will have to be very careful about relaxing restrictions too quickly until a much larger proportion of the population have been vaccinated.  Hopefully by later in the summer.