COVID-19: HOW IMPORTANT ARE CASE RATES?

This afternoon, Monday, Sajid Javid made his first statement to the House of Commons as Secretary of State for Health and Social Care.  He stated that it is still the Government’s intention to remove all Covid restrictions in England on 19 July, as previously announced.  But not before.  He also stated that confirmed cases are still rising, mostly being the Delta variant.

In answer to questions:

• It is clear that hospitalisations are the main concern, but he remarked that case rates should not be ignored
  
• He agreed with other MPs that there is a major concern about the number of children missing school because of Covid cases amongst children. 
  

So how concerned should we be about case rates?  Confirmed cases are rising rapidly.  The BBC reports the latest 7-day average as 16,612 new cases, with the latest day being substantially higher at 22,868.

There are several reasons to be concerned about rising case rates:

1. As Andrew Marr of the BBC discovered, double vaccination is no guarantee of avoiding symptomatic disease.  Vaccines are excellent but not perfect.
2. Virtually no children are vaccinated, so will continue to succumb to disease. Whilst generally not serious for under 18s, a few will be severely affected.
3. Children can pass disease to adults, whether vaccinated or especially if unvaccinated.  Some adults will be hospitalised, of which some will die.
4. Growth of illness amongst children will mean them being increasingly off school, disrupting their education and that of others at their school. Whilst 19 July is around the end of term, once they are back in September, disease will no doubt spread quickly.
5. Children off school ill cause disruption to parents and their employers, causing an adverse impact on livelihoods
6. Cases of Long Covid will continue to rise, affecting children and adults
7. Apart from the adverse impact on those individuals, there will be an increasing load on them seeking help from NHS Primary Care, already under extreme strain
8. The higher the case rate, the more chance of a variant arising that is worse than Delta, such as an enhanced version. The risk is if it bypasses the vaccines and/or be more serious
9. High case rates in England will mean foreign counties will continue restrictions on visitors from England.  Some countries quite possibly increasing restrictions

So would it be wise to remove all restrictions on 19 July?  These issues need to be balanced against the impact of delaying that date.  Both economically and for our mental health.  For the Government, also politically.

On balance it looks like the Government will go ahead on 19 July.  But if so, then what steps can be made in mitigation to try to keep infection rates low around the country? 

For example, is the Government going to remove the need for self-isolation, or keep it?  Javid spoke about replacing self-isolation for schoolchildren with some testing-based approach.  Then what about vaccinating children, at least those in secondary education?

What do you think the Government ought to do come 19 July?

COVID-19: WHAT ABOUT THE CHILDREN? ANY VACCINATION?

When restrictions in England are removed on 19 July, as is the plan, under 18s will not have been vaccinated. 

When the undoubted success of the adult vaccination programme is discussed, there is rarely any mention of children.

Fortunately schools will be breaking up around 19 July, so children will not be mixing with each other much until September.  But what are the likely consequences of removing restrictions on children and communities?

Indeed should under 18s be vaccinated? In deciding whether to do so, we need to consider:

• Risks of COVID-19 to under 18s
• Risks of infected youngsters to those around them
• Balanced against drawbacks of vaccination

Let’s explore.

RISKS OF COVID-19 TO UNDER 18s

There are three key risks for the children themselves, in addition to being mildly ill:

• Needing to be off school for several days, and thus disrupting their education.
  
• Risk of serious illness, albeit low
• Risk of Long Covid, which is serious ongoing symptoms due to infection by COVID-19.  There are now reports of over 2 million people in the UK who have had symptoms for over 3 months.  But it is not clear how many of these are children, or how seriously.  Nonetheless there are groups such as LongCovidKids to help kids with significant symptoms

The NHS A&E units are already being overrun by children with other minor symptoms, as primary care is struggling to see them.  In part because of Long Covid amongst adults seeking medical attention.  More children contracting Covid-19 would only be making matters worse.

 
RISKS OF ILL YOUNGSTERS TO THOSE AROUND THEM

• Children off school currently require other children in their bubble to self-isolate off school, thereby disrupting the education of a larger number of children.  The Guardian reports a quarter of million children were off school in one week recently.  A significant problem.
• Children can easily pass on the virus to siblings
• Children off school often require their parents to take time off work, with consequent disruption to livelihoods and employers
• Children can easily pass the illness to adults. The efficacy of vaccines for adults is very good but not perfect.  Furthermore not all adults are vaccinated. As discussed here, estimates of first jabs amongst adults will only be around 89% by 19 July, with older more vulnerable adults having peaked around 90%, as shown below. That means some 10% of adults will likely remain unvaccinated and vulnerable

Vaccine uptake by age group per PHE

DRAWBACKS OF VACCINATION

So COVID-19 is a significant problem for the children themselves, as well as parents and other adults.  Vaccination of children therefore looks highly beneficial.  That is provided the vaccines are safe for each age group within children.  

So far safety appears adequate to allow vaccination:

• In addition to formal trials, widespread use of vaccines in children in America, Israel and other European countries gives good information on safety
• The relevant authorities in each country would not allow vaccination unless they were satisfied about safety.  Approval can also be quickly withdrawn, such as we have seen for younger adults with the AstraZeneca vaccine

The other reason against vaccination is ethical.  Shouldn’t vaccines be provided to the vulnerable in foreign countries first?

• A major issue in many countries is limitations in the distribution of any vaccines supplied, even after improving logistics.  Provided as many vaccines are being used as being supplied, then there would be an excess available for use in well-vaccinated countries
• In any case it could be argued that countries that have developed and funded the vaccines should get priority, and the quantity required is a very small fraction of those being provided to other countries

As with any vaccination programme, there is the matter of cost.  Given the benefits, vaccinating children would be money well spent.

WHAT IF CHILDREN ARE NOT VACCINATED?

From the discussion above, it would appear that if children remain unvaccinated:

• COVID-19 infection will spread through children until most have been exposed to the illness, and sufficient natural immunity has developed to achieve ‘herd immunity’ amongst children
• Illness will be seriously disruptive to their education and to their parents in having to take time off work to look after them
• Some children, albeit a small proportion, will develop serious symptoms and/or Long Covid
• Illness will spread to adults, with some becoming seriously ill, requiring hospital treatment and some of these dying  
• The pressure on NHS services will get worse, both for primary care and A&E

Whilst the spread of infection will be lower over the summer, the risk is that infections will take off from when schools are back in September and into the winter.  There is then a higher risk of one or more Variants of Concern arising in children, providing more risk to both children and adults.
 

WHAT ABOUT KEEPING EXISTING RESTRICTIONS IN SCHOOLS?

Currently restrictions for children include:

• Children are in ‘bubbles’ within schools
• Children in the same bubble as an infected child are expected to stay at home
• Masks are worn by some children, both within school and on public transport

Will all these restrictions be removed on 19 July?  If so, infections will spread faster when schools are back in September than if some or all restrictions are retained.

ON BALANCE 

On balance, vaccination has major benefits, provided vaccines are considered safe for children.  This has to be considered for each age group, such as pre-school, infants, juniors and seniors.    

Indeed not to vaccinate children risks major problems for the NHS, especially once schools are back in September.  That provides time to get a lot of children vaccinated over the summer.

How about starting with 12-17 year olds? What do you think?

COVID-19: OVERCOMING VACCINE RELUCTANCE

PM Johnson announced this week that the relaxation of restrictions would be deferred from 21 June to 19 July.  The main justification was to substantially reduce deaths, and reduce pressure on the NHS through hospitalisation, by vaccinating more people for a further four weeks.

But will people be vaccinated quickly enough?  How significant is 'vaccine reluctance'?

We know from data published by Public Health England that:

• Many older and other more vulnerable people have had two jabs, typically AstraZeneca that provides around 92% protection against hospitalisation
• Younger people are being given Pfizer or Moderna.  Pfizer provides around 94% protection from only one dose.  
• It is too early for Moderna data, but protection would be hoped to be similar

Getting people to have their second AstraZeneca jab improves effectiveness against hospitalisation from a good 71% to an excellent 92%.

Getting people to get their first jab is arguably more important to reduce risks across more adults:

• Younger people.  All adults 18+ will be offered their first jab by the end of this week
• Older people who haven’t yet had their first jab need to be encouraged to do so

One of the slides displayed on Monday shows a steadily climbing rate of first jabs.  At that rate 100% could theoretically be achieved around 7 July, giving protection a couple of weeks later around that 19 July date:

But the Department of Health and Social Care are suggesting that by 19 July only around 89% of adults will have had their first vaccine.  As it is around 79% now, by 7 July it will only be around 84%.  That’s a 16% shortfall on what is potentially possible. 

As this does not appear to be because of vaccine supply problems, nor any other overall capacity constraint, there are two main issues:

• ‘Vaccine hesitancy’ where people refuse or are reluctant to get vaccinated.  This includes disliking a needle, and distrusting the vaccine
• Difficulty in getting a local jab

For the over 40s, it has typically taken some 2 months for each age group to reach vaccination rates over 80%, as published by Public Health England: 

Week number 2020/21

So how can more of the under 40s, in particular, be encouraged to get at least one jab by early July?  The more the better.

Restrictions awaiting relaxation, such as nightclubs and pubs without social distancing, typically involve younger people.  The sooner enough of them get vaccinated, the sooner such restrictions can be removed.  It is in their interest.

Let’s hope the Government gets that message and other vaccine encouragement out there.  Won’t it be great to get back to ‘normal’?

COVID-19: HOW CONFIDENT ARE WE ABOUT RELEASING ALL RESTRICTIONS ON 19 JULY?

Yesterday (Monday 14 June) the Prime Minister and his lead scientific advisors announced a delay in easing most of the final restrictions in England by four weeks until 19 July, no later.  With an interim assessment in two weeks’ time.

They spoke about a “race” between the vaccines and the virus, especially the now highly dominant Delta variant.  The idea is this race will have been won by 19 July, at least enough to shift the balance such that the benefits of fully releasing restrictions and re-opening the economy would outweigh the harms and risks of the virus.

All three presenters seemed confident of this.  But is this confidence warranted?  

To help answer the virus side of the balance, there are five key questions:

• How effective are the different vaccines against the now dominant Delta variant, that is already some 91% of cases and rising?  
• How quickly will people be vaccinated?
• How quickly are cases growing?
• What level of hospitalisations and deaths could result?
• What risk is there of a further lockdown, which the Government has promised to avoid?

This is in the context that:

• AstraZeneca has been given to most of the vulnerable and over 40s
• Pfizer is being given to adults under 40, and the most vulnerable first immunised
• Moderna is also being given to adults, mainly under 40
• There are no plans to vaccinate younger teenagers and other children, despite high prevalence rates in schools

HOW EFFECTIVE ARE THE DIFFERENT VACCINES?

It was disappointing that the effectiveness data for the Delta variant shown at the presentation was for all vaccines, and did not differentiate between them.

Presumably the Government has vaccine-specific data.  Indeed Public Health England (PHE) yesterday published a ‘pre-print’ (provisional) paper titled “Effectiveness of COVID-19 vaccines against hospital admission with the Delta variant”, containing this table:

All these figures are by comparison to unvaccinated individuals. As Delta is a new variant, and there is a time lag between cases and hospitalisation, the data is based on relatively low numbers of people, so results should only be considered indicative.  

The apparent weakness of AstraZeneca compared to Pfizer may simply reflect that in the real world AstraZeneca recipients are on average older or otherwise more vulnerable. It does not necessarily mean AstraZeneca is any less effective.  There is no data yet published for Moderna.

It was hoped to translate these numbers into the absolute chances of vaccinated people becoming ill.  Unfortunately the paper does not contain the absolute risks of symptoms and hospitalisation, either for vaccinated or unvaccinated individuals.  Nor is reliable data readily available from other public sources.

It is also not clear whether the table takes into account that the body takes 2-3 weeks to develop immunity.  We certainly shouldn’t assume people have the levels of immunity immediately on being given the vaccine.

But we can say that by comparison to unvaccinated people, the indicative effectiveness of vaccines against the Delta variant is as follows:

HOW QUICKLY WILL PEOPLE BE VACCINATED?

There are two aspects to this:

• When will people be offered their first or second dose?
• How quickly will people take up the offer?

The BBC reports from the Department of Health and Social Care that by 19 July, five weeks away:

• 89% of adults should have received their first vaccine, compared to 79% now.  Today it has been announced that all 18+ will be offered the vaccine by the end of this week
• 76% should have received their first vaccine, compared to 57% now.

If we assume 2-3 weeks for a vaccine to provide immunity, and linear administration of doses, the number with vaccine-induced immunity by 19 July should be around the midpoint:

• 84% from first dose
• 66% from second dose

This seems optimistic.  Though at current rates of first dose vaccination, 100% could theoretically be reached by 9 July.  The issue is the rate of uptake.

The PHE recently published this graph of how quickly the over-40s have been vaccinated, which is it has taken around 2 months to get to high levels of take-up.  Will the under 40s be any quicker?  That is the challenge. 

Week number 2020/21

So conversely this means that by 19 July:

• At least 16% of all adults, mainly the younger, plus all children, will not have the protection of a first vaccine
• At least 34% of all adults will not have protection of a second vaccine

HOW QUICKLY ARE CASES GROWING?

Cases of the Delta variant are currently low but growing exponentially.  The doubling time under current restrictions is little more than a week.  Release the remaining restrictions and cases will grow even faster.

We now from previous experience that such doubling rates can produce very high levels of cases very quickly.  This time mainly amongst younger adults and children who are mainly unvaccinated.  The virus can then pass to older and more vulnerable adults, especially if unvaccinated. 

We need to be aware that cases are growing rapidly despite it being the summer.  Growth in the colder months of the coming autumn and winter would be expected to be much higher.

WHAT LEVEL OF HOSPITALISATIONS AND DEATHS COULD RESULT?

The need for hospitalisation is the sum of the effect of the Delta variant on:

• Those having AstraZeneca
• Those having Pfizer
• Those having Moderna
• Adults remaining unvaccinated
• Under 18s, for whom there are no plans for vaccination

Estimating the total number and phasing of hospitalisations and deaths requires a sophisticated model.  What follows is simply indicative.

The Delta variant is spreading rapidly, with cases doubling in a matter of days.  This presumably means a high proportion of people will be exposed to it in the coming weeks.

For AstraZeneca, as noted above, many over 40s and the vulnerable have already had two shots of the vaccine.  With 92% effectiveness, few should need to go to hospital.

Most people in their 30s have had their first dose of Pfizer, and so relatively few will need hospital.  Hopefully other younger people will get the vaccine, and so few should need hospital.

It is hoped that Moderna will be similar to Pfizer, using similar mRNA technology, though effectiveness is dependent on formulation.

The risk for hospitalisation and potentially death is therefore primarily about who will not be vaccinated at all by the beginning of July, adults and children.  Presumably the Government has models that predict numbers and phasing that will be politically ‘acceptable’ by comparison to the benefits of releasing all restrictions on 19 July.

WHAT RISK IS THERE OF A FURTHER LOCKDOWN?

The Prime Minister has said that any easing of restrictions should not be reversible.  For businesses, the need to close, wait and re-open again would be disastrous.  It’s costly, especially if that were to involve businesses currently open.

Putting aside the possibility of a more dangerous variant, is the effectiveness and pace of vaccinations against Delta enough to prevent the re-introduction of restrictions?  Especially as autumn and winter are only weeks away.

Let’s hope so.  But it’s worth being cautious.  The delay to 19 July is well justified.

OTHER ASPECTS OF HIGH CASE RATES

As ever the Government concentrates on hospitalisations and deaths whilst ignoring two other aspects of high case rates:

• High levels of Long COVID, in both adults and children.  This is not only a sometimes serious problem for the individuals affected, but will put additional strain on NHS primary care and the need for specialist services
• Higher risk of new ‘variants of concern’ developing here in the UK, potentially more dangerous.  This is what the Government fears

Whilst it is important to re-open the economy, letting case rates rise high carries these risks.  Arguably a higher proportion of people should be vaccinated before all restrictions are released.  

IN SUMMARY

Both the Pfizer and AstraZeneca vaccines are highly effective against hospitalisation. The key question is whether enough people will have been vaccinated by 19 July to justify releasing all restrictions.

It would be great for that to happen.  But sadly this does seem optimistic.  There are four key risks of releasing restrictions on 19 July:

• Hospitalisations and deaths could rise too high, especially amongst the unvaccinated
• LongCOVID rates, especially amongst younger people, could rise too high
• A new more dangerous variant could arise
• A further lockdown could be needed later in the year, perhaps tighter than we have now. 
  

We will see how the data develops over the next few weeks.  Maybe it would be better if:

• Some restrictions are released on 19 July
• Other restrictions remain in place a little longer until a higher proportion of people have been vaccinated.  If only 'light restrictions' such as continuing to wear masks in shops and on public transport.
  

COVID-19: HOW ABOUT EASING ALL RESTRICTIONS ON 21 JUNE?

Hospitalisations rising

The Government is about to announce whether some or all restrictions will be eased on 21 June in England.  Great if at least some could be eased.  But what would likely happen if all went ahead as originally hoped?  

The fly in the ointment is the Delta variant first identified in India.  We now know:

• It is some 60% more transmissible than the Alpha (Kent) variant, and has become the dominant variant
• The vaccines are less effective according to Public Heath England:
• The AstraZeneca is only 60% effective against symptomatic disease, after 2 weeks of second dose.  As that is the type given to most of the vulnerable and over 40s, that means that 1 in 3 of these people are susceptible to the disease
• The Pfizer vaccine being given to many of the under 40s is better, at 88% effective, but that still means 1 in 8 are susceptible even 2 weeks after the second dose.  For the under 30s adults, including university students, that's a couple of months away at least.
• Furthermore very few schoolchildren and adults under 30 have been vaccinated at all as yet
• As a result, cases are increasing exponentially in many parts of the country, especially in younger age groups.  Small numbers so far, but that can quickly turn into large numbers if left unchecked.
  

What’s not so clear is whether we need be concerned.  There's a time lag between cases and hospitalisations, and another lag before deaths.  It is rather too early to say for sure, but indications from North West England (above), Scotland (below) and elsewhere are that:

• The vaccines appear to be effective at reducing serious symptoms
• But without vaccination, the disease can be more serious
• Nevertheless, hospitalisations are still happening, but at a lower rate than in previous waves, and tend to be for younger people 

Per BBC, from Gov.uk dashboard

WHAT WOULD BE THE CONSEQUENCES OF EASING ALL RESTRICTIONS ON 21 JUNE?

If all restrictions were to be eased, it would be reasonable to expect:

• The disease would rip through schoolchildren and under 30s, who could be more ill than with previous variants
  
• The disease would be passed on to many of the vulnerable and older adults

Would this result in NHS hospitals being overrun?  Difficult to tell.  It’s certainly a risk.  But whilst that has been the Government’s main concern, that’s not the only consequence:

• A proportion of those catching the disease will then suffer from LongCOVID.  This could be tens of thousands more people, young and old.   Bad for them and a major threat to NHS Primary Care to look after them.  Layla Moran MP, Chair of the APPG on Coronavirus calls this “a ticking time bomb for our NHS”
• Schools increasingly closing year groups in the final month of the school year, with a further detrimental affect on education
• The higher the case rate, the higher the risk of potentially more serious variants.   Then we would really be in trouble

Can we take those risks, which are significant?  That’s for the Government to decide.  PM Johnson has indicated they will be cautious.  A 4-week delay has been indicated, which would defer a further decision until schools have broken up for the summer, more younger adults will have been vaccinated, and the data will be clearer.

Indeed are the risks such as to need a tighter lockdown now?  Let’s hope not.  Maybe there’s scope to ease some restrictions, such as the number of guests at wedding receptions.  Wouldn't it be great to be back to normal?

We will find out the Government’s decision shortly.

COVID-19: WHAT CAN BE EASED ON 21 JUNE?

Recent cases in Oxford

It’s just a few days to go until the Government needs to announce whether the remaining restrictions in England can be eased from 21 June.

As discussed in the previous blogpost, it’s fundamentally a decision between:

• Easing all restrictions, but risking a further lockdown
• Delay some or all easings until more people are vaccinated

WHAT'S SUGGESTING DELAY?

The problem is that the ‘Delta’ variant is now the dominant variant in new cases, which are growing dramatically.  Today the official estimate is some 91% of all cases.

Here in Oxford, the estimate of new cases is rising sharply, with some other areas of the country in a far worse state.  According to the Kings College ZOE study, the 2-week average shows a rapid rise in recent days:

The vaccine roll-out has reduced hospitalisations, but these are also rising across the country.  The issue is that the existing vaccines are not as effective against the Delta variant as against the earlier Alpha (Kent) variant.  According to Public Health England’s study published in late May:

• Both AstraZeneca and Pfizer vaccines are only 33% effective against symptomatic disease for Delta three weeks after one dose, compared to 50% for Alpha

• Two weeks after two doses:

• AstraZeneca down from 66% for Alpha to 60% for Delta
• Pfizer down from 93% to 88%

These statistics were based on observations in April and early May.  The Government will now have access to more recent data, which may improve the picture.  The good news is that early indications are that the vaccines prevent serious disease, and therefore reduce the level of hospitalisations compared to previous waves.  But as hospitalisation and deaths lag new cases by a couple of weeks, it is still rather too early to get a reliable view of potential levels.

But assuming these statistics are broadly correct:

• Even fully vaccinated people, mostly with AstraZeneca, will have far lower protection than previously expected.  1 in 3 double-dosed could still catch the disease
  
• Younger adults 25-29 are only just starting to be vaccinated.  By 21 June they will have little protection. Very few younger adults and teenagers will have any protection.

That creates three problems:

• Younger people can easily transmit the virus to more vulnerable people
• The more people who catch the disease, the more are likely to suffer LongCOVID.  As Delta is more transmissible, it is potentially more likely that the virus will spread around the body and cause LongCOVID problems in other organs such as heart and brain. This would not only affect tens of thousands of individuals, but also then put enormous strain on NHS primary care and specialist services
• High case rates provide greater opportunity for the virus to mutate into more troublesome variants
  

A third wave has clearly started.  Easing restrictions further will only tend to accelerate it.  Until many more people are vaccinated, that will likely mean:

• More hospitalisations, and more deaths
• Significant increases in people suffering from LongCOVID
• Higher risk of troublesome variants
  

Against this needs to be balanced the economy, mental health and other drawbacks of continuing lockdown.

But risking going back to lockdown, especially if tighter than currently, is not desirable.  Indeed people are increasingly saying it will be better to delay some or all easings until after 21 June to minimise that risk.  That includes some businesses, as it can cost a business a lot to have to close and reopen again.

WHAT CAN BE EASED ON 21 JUNE? 

Much of the additional easings would be for gatherings, often involving younger people. Nightclubs for example.  Much of these would probably be too risky given that few participants will have been vaccinated, and easings should be delayed.

Conversely, many venues are saying they can keep people socially distanced at up to say 50% of capacity.  That would allow events such as many wedding receptions to be larger than the current limit of 30.

Other remaining restrictions will need individual consideration, in conjunction with practicality of testing people on or before entrance.  It is probably appropriate to place remaining easings into three phases:

• On or shortly after 21 June
• Two or three weeks after at least say 80% of each age group has been vaccinated once
• Two or three weeks after at least say 80% of each age group has been vaccinated twice

The Government have been right to wait to see the latest data, which could be more positive than set out above.  Hopefully that means some easings on 21 June, but it looks too risky to ease all restrictions.  We’ll find out the decisions by next Monday 14th.

COVID-19: 21 JUNE OR NOT?

We’re looking forward to restrictions being eased fully in England on 21 June.  But would it be wise?

The Government has a difficult decision.  The Delta ‘Variant of Concern’ first identified in India is transmitting more easily than earlier variants, and threatening a third wave of infections.  The risk is that lockdown restrictions would need to be re-imposed later in the year, perhaps tighter than we have currently.  Whereas delaying some or all the June easings would minimise that risk.

The roadmap out of lockdown published in February had originally said “not before 21 June”.  As discussed previously, that is to allow enough time from the last easings on 17 May to see the data, given:

• Lag between infection and people getting tested of at least a week
  
• A similar lag between infection and admittance to hospital, and then deaths
• A final decision a week before 21 June, as a minimum one week notice

So far, the data is mixed.  Overall low cases, hospitalisations and deaths.  But discerning data about the Indian variant, with local surges in various parts of England. Still too early to be sure that low numbers will continue, or that some level of restrictions would continue to be necessary. 

The vaccines are working, but:

• Around 1 in 20 vaccinated people can catch the disease, at around 95% effective
  
• It takes around three weeks for vaccines to be effective to that level.  Now, in early June, most younger adults have not had their first vaccination yet.  The second booster for many more won’t be until well after 21 June.  

The problem is that younger adults can spread the disease to older and more vulnerable people, and also risk LongCOVID.  Not only their own lives being blighted, but also an increasing workload for the NHS to deal with them all.  Potentially tens of thousands.  Not something that can be ignored.

Better to wait until all adults have been vaccinated?  In an ideal world.

Yet many businesses are desperate to re-open fully, and people want to hold their wedding and other personal parties.  They all want to know for sure, now.

But we must wait another couple of weeks to see how the data develops.  That’s to ensure the Indian variant is sufficiently under control without risk of further avoidable lockdowns, and no other Variant of Concern emerges.  Fingers crossed!