COVID-19: THE KEY QUESTION. WHEN CAN RESTRICTIONS BE LIFTED?

The question everyone is asking is "When can restrictions be lifted and we get back to normal"?  The sooner the better!

The UK Government has suggested restrictions will be eased gradually as the vaccination programme progresses, before restrictions can be lifted completely.

With the newer more infectious strains, it could be 70% or more of the population being immune before 'herd immunity' is achieved.  That's when the virus has trouble finding the next person to infect, and infection rates can stay low without restrictions.  That's immune either from vaccination or from having had the disease.  Some estimates as high as 90%.  That's some time to go.

To assess which restrictions can be lifted when, a number of factors need to be considered.  It's like we have a set of weighing scales with the harms of the virus on one side balanced by the harms of restrictions on the other:

• When there are higher rates of infection, the harms of COVID-19 outweigh the harms of restrictions:
  

 

• When infection rates reduce, the harms of the virus reduce, the balance shifts, and restrictions can be eased:
  
  

What are the factors that need to be considered in assessing this balance?   How can easing of restrictions be accelerated?

 

THE FACTORS TO CONSIDER - IN FAVOUR OF EASING RESTRICTIONS

At the press conference yesterday, Matt Hancock the Health Secretary gave four factors that would allow restrictions to be eased. "We need to see...":

• "Number of deaths coming down"
• "Pressure on NHS reducing"
• "Vaccination programme working", seeing efficacy of vaccines in actuality
  
• "No new variant" or other factor
  

it is not simply a matter of saying restrictions can be substantially lifted as soon as the groups most likely to die have been vaccinated.  Hospitals are increasingly seeing younger people under 55 being admitted for treatment with latest reports at around 25%.  People of all ages, including children, are also susceptible to LongCOVID, even when not hospitalised.  That's a set of problems that not only can significantly adversely affect their health, but will also put much greater ongoing strain on the health service to treat them.

For some reason Hancock did not explicitly mention LongCOVID, though must be aware of this set of health problems.  Whilst many people affected have not needed hospital treatment, there is a new study concluding "Nearly a third of people who were discharged from hospitals in England after being treated for Covid-19 were readmitted within five months – and almost one in eight died".  That study is awaiting peer review, but in the meantime we need to be very wary of how COVID-19 is affecting people long-term, whether they have been hospitalised or not. 

The Independent SAGE group of health specialists recently wrote to the Sunday Times mentioning how dangerous it would be to relax restrictions after vaccination ony of those most vulnerable to death.  The points raised have been put into a clear animation by Vicki Martin:

• Protecting the vulnerable by vaccination does not make the virus innocuous
• Vaccine-resistant mutations can arise
• Whilst mortality may fall, pressure will still exist on critical care, as 3 in 4 patients are under 71
• Vaccination of more vulnerable groups will do little to reduce the prevalence of LongCOVID
• The risk of death does not change dramatically on turning 70

We also need to consider that with high rates of infection in the working population:

• Vaccination is not perfect, so vulnerable individuals are still at risk. A vaccine 90%-95% effective means 1 in 20 to 1 in 10 are still susceptible to catching the disease
• We don't yet know whether vaccination reduces the possibility of someone carrying the virus and transmitting it to others
  
• High rates of hospitalisation result in other treatments being suspended
  
• High numbers of people off work ill is extremely disruptive to their places of work.  That includes key workers.  Plus those self-isolating.
  
• That produces an economic hit too.

So there's a whole host of factors.  With a common theme that the lower the infection rate the better.  As close to elimination as possible.

THE FACTORS TO CONSIDER - THE HARMS OF RESTRICTIONS

On the other side of the balance, we are all aware of the harms of restrictions, including:

• Financial pressure on individuals and firms
• A significant hit to the Exchequer through a drop in taxes, plus higher public expenditure for health measures and financial support
  
• Individuals' loneliness and lack of social interaction
• Restrictions on entertainments, holidays and other enjoyable activities
• Severe disruption to education, and the impact that has on parents
  

 

SO WHEN TO EASE RESTRICTIONS?

The factors above contain significant unknowns.  It is also unclear how quickly vaccine can be produced, checked safe, and distributed.  Dates given by the Government for easing restrictions are little more than conjecture at this stage.  It will take weeks to begin easing restrictions, and more likely months to remove restrictions completely.

How can easing be accelerated?  It's all about getting infection levels right down across the country.  Infection levels would reduce significantly with a very tough three-week FireBreak, with as many people as possible self-isolating.  In combination with vaccination, that would certainly help to bring forward when restrictions can be eased.  A sensible investment?

COVID-19: DIAGNOSIS FOR MULTI-ORGAN DAMAGE IN LONGCOVID

It was great to see LongCOVID being debated in Parliament last Thursday.  The Office for National Statistics suggests "one in ten people testing positive for Covid-19 have symptoms that last longer than 12 weeks".  That is across all ages including children.  

In opening the debate, Layla Moran MP who chairs the APPG on CoronaVirus, said "It is believed that there are 300,000 people living with Long Covid already in the UK".

In part this is lethargy that follows any serious illness.  Whilst that can be serious enough, there are other serious problems, including these:

• Long-term damage to the lungs
• Damage to other organs from when the SARS-COV-2 virus that causes COVID-19 gets into the bloodstream
• It causes micro-clotting that can damage organs
• The virus can attack other organs directly
  

This latter problem is because the ACE2 'gateway' that lets the virus into cells on the respiratory system are also present in other parts of the body, including brain, heart and other essential organs.

From CoverScan MD

 

It has been difficult to assess the extent of damage.  But now a software suite driven by a single, quick MRI scan has just been approved by the UK's MRHA. The "CoverScan MD" suite from Perspectum helps identify the extent of damage in "hearts, lungs, livers, as well as other internal organs".

As the number of serious cases of LongCOVID increases, this diagnostic tool will help doctors bring relief to those people young and old who are affected.

 

 

LongCOVID highlights that COVID-19 is not just like flu.  The long-term effects on a substantial proportion of people who catch the disease will need careful consideration in how and when to relax current restrictions, and prioritise vaccines.

 

 

COVID-19: TRANSMISSION QUESTIONS

Transmission - is this all?

Whilst we hear about the possibility of tighter restrictions in England, and whether enough people are following the existing restrictions, we don't yet know how well the new 'lockdown' restrictions are working.

I have long advocated that the best thing to do was ultra-tough restrictions to drive the infection rate well down in  the shortest possible time.  Instead the existing semi-tough 'lockdown' restrictions look as if they will be dragging on.

Indeed the spread of the new variant of the virus makes me wonder, as a scientist, how well we understand its transmission.  Infection rates dropped during the November lockdown and the earlier Welsh 'firebreak', but not as much as might be hoped. And these initiatives were before the new variant, which is spreading more rapidly.

Are we missing something important?  Could it be that there are other important transmission methods?  Perhaps:

• Transmission via food?
• Via drinking water (this is a virus not bacteria)?
• Via packaging of food and other essentials? 
• Takeaways?
• Frozen food?
  
• Other mechanisms?
  

We need to keep an open mind.  We're still learning about this virus.

Update 17Jan21:  There is now news that the virus behind COVID-19 has been found in ice cream.

Also, a cold store was suspected as the source of one of the early outbreaks in New Zealand. 

Even so, organisations such as the World Health Organisation and the US's CDC say "There is no scientific evidence that eating hygienically made frozen food and ice-cream spreads the new coronavirus."  

We know that the virus survives intact and infectious for longer in colder conditions.  So we need to be testing for the virus in foodstuffs and packaging, especially those that are frozen.  We also need to investigate any cases where there is no obvious cause of transmission.

Maybe there is truth in the virus surviving in food and its packaging.  I sincerely hope not.  But at this stage we should not ignore the possibility.

Washing hands thoroughly after handling frozen foods is certainly a sensible precaution.

COVID-19: KEEPING EACH OTHER SAFE

Given that people are infectious before they display symptoms, I'm pleased that Professor Whitty and others are now endorsing the two principles I have been following for the last few months:

1. Act as if you are infectious
2. Act as if anyone you meet is infectious.  That includes children.
   

We still need to dramatically reduce the contact we have with other people, and reduce the risks when we do.  That means, primarily indoors but also outdoors:

• Stay home as much as possible, but for daily exercise
  
• As far as is possible, avoid situations which put you close to someone else for any length of time.  Anything more than a few seconds, so you don't breathe near each other more than a couple of times.
  
• Maintain at least 2m distance and preferably 4m because of viruses spread on tiny 'aerosol' droplets that float through the air rather than drop quickly to the floor
  
• Wear a mask, principally to catch virus-laden droplets in your breath to stop them from infecting other people. In the case of simple face coverings "My mask protects you, yours protects me."
• Follow other rules and guidance
  

In practice it means:

• Reducing the times visiting a supermarket.  When you do:
• Use hand sanitiser on arrival
• On getting home, wash hands before and after putting purchases away
  
• Avoiding public transport
• Indoors, increasing ventilation to disperse the 'aerosols'
  
• At work, adopting sensible precautions where not full PPE
• Outdoors the risk of transmission is much lower than indoors, but even so:
• Try to avoid passing people closely
• Wear a mask outdoors if you expect to have to pass people closely 

 

A NOTE ON VISORS

Visors are principally to protect yourself from people coughing or sneezing droplets directly at you, as might be the case in hospitals and personal care settings.  It is why hairdressers have been advised to wear both a mask (to avoid infecting their customers) and a visor.  

In normal situations a visor is of little benefit to you, as you have to breathe in air around it, with whatever water droplets are floating in it.

COVID-19: LOCKDOWN 3 COULD AND SHOULD HAVE BEEN FAR SHORTER

Schools in England are now going to be closed until at least half term at the end of February.  Children's education disrupted, especially those without the necessary technology for remote learning.  Let alone the pressure on parents when they are expected to be working.  Seven weeks before a formal reassessment.

Schools could have re-opened as soon on 18 January if, as suggested:

• A FireBreak had been started on Boxing Day, announced before Christmas when it was clear the growth in infections meant a 5-day relaxation of restrictions was not tenable. Before the graph rose further and made control harder.
  
• With everything except the absolutely vital being closed
• People self-isolating as much as possible.  Not just 'staying at home'
  

We know that if everybody was to self-isolate for a month, the virus would be eliminated.  That would also apply to the new variant.  Yet most of the effect is achieved in the first three weeks. 

Instead the new restrictions are too late and could have been tougher.  The result is now a longer drawn-out lockdown with more pain.  Face palm.