COVID-19: WHAT RISKS REMAIN IF YOU ARE DOUBLE-VAXED?

From PHE study

The vaccination programme against COVID-19 in England has been an outstanding success.  Hospitalisations and deaths in this wave dramatically reduced compared to previous waves when people weren’t vaccinated. 

But what does it mean to you as an individual to be double-vaxed, whilst infection rates are high?  Unfortunately the vaccines are not perfect so there are residual risks.  How big are they?  Do they matter compared to the benefits of an activity?:

• Chances of catching COVID-19
• Chances of passing it on to family, colleagues and other contacts, 'transmission'
• Chances of hospitalisation and death
• Chances of being left with long-term symptoms, ‘Long Covid’

Let’s look at each of these risks in turn, in the context of the now highly dominant Delta variant.  As was shown at the press conference on 19 July the extra ease with which Delta spreads means cases have been rising as quickly as in past waves, despite many people being vaccinated:

Until this wave of infections is over, and infection rates are back down to a very low level, there are still significant residual risks as follow.

CHANCE OF CATCHING COVID-19

Andrew Marr

We've recently seen 'breakthrough cases' of double-vaxed people suffering COVID-19.  Sajid Javid, the Health Minister, recently contracted COVID-19 despite being double-vaxed.  As did the BBC’s Andrew Marr, who said he had felt “pretty much invulnerable” before contracting the disease.  Certainly not.  He then felt seriously ill for several days.  A nastier, more disruptive disease than flu.

A study by Public Health England highlighted initial risks with the Delta variant compared to being unvaccinated:

• 1 in 3 for AstraZeneca
• 1 in 8 for Pfizer

The difference is not necessarily a measure of the relative effectiveness of the two vaccines.  AstraZeneca has been given mainly to older and otherwise more vulnerable people, Pfizer to younger. It will be good to see an assessment analysed by age, sex and other key factors.

In any case we’re talking risks comparable to 6-barrel Russian roulette.  Not many people would take that risk.  Worth being careful.  Especially the Clinically Extremely Vulnerable, whether or not they have been double-vaxed.
 

CHANCES OF TRANSMISSION

As noted above, Delta is more transmissible than earlier variants.  That means once you’ve caught COVID-19, even if you are yet to show symptoms, you can more easily pass on the virus to other people.  As above, they can then develop it even if they are double-vaxed.

Indeed there is now evidence that people who have had COVID before can catch it again, especially now there is a different more powerful variant in circulation.  Hence PM Johnson and other members of the Government self-isolating who had been in contact with Javid.

As you can be infectious before developing symptoms, it’s worth continuing to wear a mask in crowded situations.  Just in case, to protect those around you.
 

CHANCES OF HOSPITALISATION AND DEATH

As noted above, the chances of hospitalisation compared to not being vaccinated are for better, on average:

• 1 in 12 for AstraZeneca
• 1 in 20 for Pfizer

Whilst symptoms can thankfully be easier to treat if double-vaxed, death can still occur.  Nasty.

CHANCES OF LONG COVID

Everyone who catches COVID-19 has a chance of developing symptoms that last for over three months, and sometimes over a year. 

Symptoms are many and various, and can be painful and totally debilitating. Some people not being able to return to work, or struggle to work.  

Children affected too.

 

The symptoms are in four groups:

• Continuation of basic COVID-19 symptoms such as lung problems
  
• Post-viral fatigue, as can happen after any severe viral infection
• Pain and discomfort, or loss or impairment of bodily function, when the virus spreads around body and attacks other organs.  Symptoms such as heart palpitations.  Possibly the cause of brain fade too, which is commonly reported.
  
• Resulting mental health issues, such as depression and anxiety

We don’t yet know if the Delta variant cause more or less problems than earlier variants.  Indeed it could be worse, due to the variant’s increased power to infect.  But if we assume Long Covid rates are comparable, then the Kings College ZOE study from last year gives a good indication for those who have symptoms.  Around 1 in 50 suffering for longer than 12 weeks.  1 in 7 for at least 4 weeks.  Maybe higher with Delta.

Further details on Long Covid are here.  Given the huge numbers of people impacted, somewhere in the region of 1 to 2 million, it is disappointing that SAGE is only just including it in their deliberations.

IN SUMMARY

On average for people double-vaxed, it is far better than being unvaccinated, so worth being vaccinated.  But there are a number of residual risks, so it is not a matter of being 'invulnerable':

• Around 1 in 5 will still get infected by Delta compared to being unvaccinated, depending on vaccine, age, sex and other factors
• Each of these people can pass on the virus to other people, even when not displaying symptoms.  So wearing masks is still worthwhile in crowded places to protect others
  
• The chance of hospitalisation and death is far better when double-vaxed, but is not zero
• The chances of Long Covid for those catching Delta are probably at least 1 in 7 with symptoms lasting beyond four weeks.  Then 1 in 50 for more than three months.  The symptoms can be painful and debilitating, and stop people returning to work. 

Depending on your activity, you may regard these risks as acceptable.  But as a double-vaccinated individual, it's well worth you maintaining basic precautions.   'Hands Face Space'.  Avoiding crowds, especially indoors, and continuing to wear a mask to help protect others.
 

COVID-19: STRAP IN FOR HIGH CASE RATES

Sir Patrick

In the press conference this evening, Monday 19 July, a presentation was made by the UK’s Chief Scientific Adviser, Sir Patrick Vallance.

In this presentation (starting 7min55s) he set out five issues with the high case rates. These are already some 50,000 confirmed cases per day, almost as many as the peak in March.  Expected to rise further to 100,000 a day or more, which means, as he said in speech marks:

• “Translates into hospitalisations and deaths”, albeit at lower levels than before the vaccination programme.  But with hospitalisations expected to reach some “1000 a day or quite a bit higher”. 

• “Increased risk of long-term complications, so-called Long Covid”.  The first time this set of often serious conditions has been acknowledged in such a pre-prepared presentation?  Albeit without details or projected numbers.
  

• Risk of new variants.  But not mentioning the risk highlighted by international scientists of an ‘escape variant' that reduces the effectiveness of the vaccines.

• “High number of people off work”.  See discussion below.

• “Testing becomes very stretched”

In the Q&A session, there were several further issues highlighted:

• Transmissibility.  The Delta variant, which is now most prevalent, is more transmissible than the Alpha variant that was most prevalent in the previous wave.  Delta spreading as if vaccines hadn't been used, such that a graphic showed cases rising at the same rate as in January-March:

• Vaccines are not fully effective.  So now "60% of people hospitalised are un-vaccinated" (not "60% double-vaccinated", as he corrected later). Meaning 40% were vaccinated once or twice.
  

• Transmission.  Can still catch and pass on virus if double-vaccinated, as we’ve seen with Chancellor Sajid Javid and the BBC’s Andrew Marr

• The unvaccinated.  Younger adults are less keen to be vaccinated, with some "3 million" not yet having their first vaccine.  Young adults are those most likely to take advantage of the latest easings, such as attending night clubs.  Which makes super-spreader events likely, as has been found in Holland and elsewhere.  

• Tracing.  Sir Patrick (34min15s) admitted that the ‘Trace’ aspect of Test and Trace works well at low infection rates, but becomes “increasingly difficult” as rates rise 

This means for you and your family: 

• Hospitals overrun?  There is no guarantee that hospitals won’t be over-run without re-establishing restrictions.  Indeed hospitalisations could reach “scary numbers” according to Prof Chris Whitty recently.

• NHS increasingly stretched.  Hospitalisations and Long Covid patients will stretch various parts of the NHS, and make it more difficult to treat and catch up on your other health issues. 

• Education disrupted.  The peak of cases is modelled as being in mid or late August.  So it would still be high when schools go back in early September, closely followed by universities and colleges which would provide “added pressure” on case rates.  Education from September would therefore get disrupted, by students being off ill.  Even with ‘bubbles’ no longer in place.

Today it was announced that those youngsters approaching 18 can be vaccinated over the summer, ready for younger A level students to be ready for higher education.  But only a relatively few school-children will be vaccinated, providing the vast majority with no protection from catching and spreading infection once they are back at school.

• Millions worried.  The 3.8 million people who are 'Clinically Extremely Vulnerable' (CEV) are going to have to self-isolate again.  Plus millions also concerned about spending any time indoors with strangers, be that in shops, hospitality venues or entertainment venues.  Undermining any economic bounce-back, as witnessed by the drop in stock markets.

• Another lockdown.  There is a risk of restrictions needing to be re-imposed in the autumn, if not earlier.
  

HIGH NUMBER OF PEOPLE OFF WORK

Currently there is concern that the NHS Covid app is ’pinging’ an increasing number of people, asking them to self-isolate.

The Government is sticking to double-vaccinated adults having to self-isolate, until 16 August when there will be regular testing instead. In the meantime, today it was announced that certain critical workers will be able to adopt the approach immediately, but only to go to work.

But pings are only part of the problem.  High case rates mean:

• A large number of people off ill or self-isolating after a positive test
• Plus their families and other close contacts.

Some businesses are already having to close, such as some Iceland shops and Greene King pubs.  As are small family businesses.  This problem will only get worse, app or not.  Reducing any improvement in the economy, and impacting livelihoods of many of those affected.

Update:  Twelve members of the Oxford United first team squad have tested positive or are self-isolating.   Imagine every organisation being prone to such disruption, sooner or later!

THE INTERNATIONAL PERSPECTIVE

High case rates also means that other countries will increasingly bar visitors from Britain, be they tourists or business people.  

Indeed the international community is looking at England and the UK in horror.  

They will never forgive this country should an ‘escape variant’ arise that bypasses vaccines.  High case rates in a highly-vaccinated population provides just the right conditions to allow an escape variant to arise.  That will inevitably spread to put the whole world back to square one.

IS THE GOVERNMENT RIGHT TO LET INFECTION RATES RISE SO HIGH?

The disruption to employers, livelihoods and education is bad news.  Let alone the increase in long-term illness and deaths.

On top of which is creating the conditions for an ‘escape variant’ to arise.  This is unacceptable.

So no, allowing such high case rates is not right.  Indeed reckless.  For the economy and the world’s health.

COVID-19: WHEN CAN WE STOP WEARING MASKS?

Professor Trish Greenhalgh of Oxford University has published a thread about why it is important to continue wearing masks.  Here are the most salient points.

Trish asks 6 questions:

• Do masks work?
• Why do some people claim they don’t work?
• Do they cause harm?
• What kinds of masks should we wear?
• How does masking need to change now we know that Covid is airborne?
• When can we stop wearing them?
  

Let’s focus on what Trish says about masks for the general public, starting with what problem are masks aiming to solve?

HOW DOES THE VIRUS SPREAD?

Covid-19 is caused by a virus called SARS-CoV-2.

There are two issues:

• It is estimated 40-50% of all people who catch Covid-19 get it from someone who has no symptoms at the time
• There is now a huge body of evidence that the SARS-CoV-2 virus is airborne.  That is that it spreads via ‘aerosols’. Tiny droplets of water bearing even tinier viruses, in our normal breath.  

So not just coughs and sneezes.  Indeed people with such symptoms stay at home.  Transmission is simply by anyone infected breathing and talking, and especially laughing and singing such that people nearby breath in the virus-laden aerosols.


HOW CAN MASKS HELP REDUCE TRANSMISSION?

There are two ways masks and other face coverings can in theory help reduce transmission:

• Catching droplets and aerosols breathed out by people not realising they are infected and infectious.  Termed ‘Source Control’
• Reducing the amount of virus breathed in by a mask wearer

But do masks and other face coverings work in one or both ways?

The materials used for masks and face coverings have tiny holes to let air in and out, and let you breathe.  The advice is that there should be at least three layers, as commonly found in the typically light blue ‘medical masks’.  That increases the chance of catching aerosols and larger droplets, both breathed out and breathed in.

Mathematically, only a small reduction in transmission makes a massive difference in the transmission over time.  Currently UK Covid-19 rates are doubling every 9 days. If they increased by 1.9 every 9 days, only 5% down:

• After 180 days (six months) daily cases would be down by 60%.  
• After three months down by 33%.

If face coverings are more effective, the decrease in case rates is more dramatic.  The fewer people are infected the better.  It reduces strain on the NHS, reduces incidence of Long Covid, and of course reduces deaths.

Countries that introduced mandated masking within 30 days of the first case, mostly Asian, had dramatically fewer Covid-19 deaths than those that delayed beyond 100 days, mostly Western, according to this study: 

SO WHY SHOULDN’T WE USE MASKS?

There is no evidence from Asia that anyone has come to harm from wearing masks.

For drugs and vaccines, it’s important to carry out RCTs (Random Controlled Trials) to assess effectiveness and safety.  With masks, this is very difficult to do, and in short periods can lead to misleading results.  

Better to use the precautionary principle, let’s all wear masks, just in case.  Provided there are no serious problems.

Some people have been concerned about two key issues:

• Self-infection from touching one’s own mask.  But then if you are infected, it’s unlikely to make much difference.  If anything people touch their face less, and therefore are less likely to spread the virus by touch
• If you wear a mask, you’ll feel protected and take more risks.  ‘Risk compensation’.  But as yet there is no evidence of this.

So without serious problems, it makes sense to use masks and other face coverings.


WHAT KINDS OF MASKS SHOULD WE WEAR?

Masks are most effective in crowded, indoor settings where ventilation is poor.  
There are three factors as to how effective a mask or face covering is:

• How well it filters
• How well it fits
• Whether you actually wear it, which in turn depends on how comfortable it is

As noted above, medical masks have three layers, and that should be the minimum.  Then making sure it is tight, by bending the metal strip over the nose and knotting the ear loops to make them tighter.

Double-masking, with another cloth covering on top, helps too.  

Provided you can breathe easily and are comfortable.  This is especially important for public facing people, such as shop staff and hairdressers, who will need to wear a mask for long periods.

Note that face visors, which have large gaps around them, are intended to stop large droplets such as someone coughing, and are ineffective for the aerosol issue in general life.

WHEN CAN WE STOP WEARING THEM?

As we’ve seen above, masks and face coverings work in two ways:

• ‘Source control’, reducing the amount of viruses from an infected person
• Protecting the wearer

Masks are most effective if everyone wears one, not knowing who is infected and infectious.  That’s primarily in indoor settings, especially where crowded.  Including public transport, shops, theatres, workplaces and schools.

Conversely, one infected person without a mask can create a super-spreader event.  Continuing regulation is needed, not leaving wearing to individual discretion.

People who are Clinically Extremely Vulnerable cannot take the risk of being near someone infectious without a mask, and so are being confined to home.  Those at medium risk will also not be inclined to mix with strangers as much as they can now.

As Trish says “When, then, will it be safe for the public to stop wearing masks in indoor spaces? The answer is when there is no longer uncontrolled spread in the community.”

COVID-19: VACCINE EFFECTIVENESS FOR INDIVIDUALS

The PM’s press conference this afternoon (Monday 12 July) included a look at the effectiveness of vaccines.  This is in the context that it was announced that over 98% of confirmed infections are the newer Delta variant.  See graphic to the right.

These are average figures, across all types of vaccines.  So let’s look at the vaccine effectiveness for people in four groups, taking into account the specific vaccines that have been in use:

• The clinically vulnerable, and others deemed high risk
• Adults at medium risk
• Adults at low risk, including many younger adults
• Children

The figures shown are broadly consistent with the figures published by PHE (Public Health England) that separate out Pfizer and AstraZeneca for Delta:

These percentages mean:

• Older adults, typically double-vaccinated with AstraZeneca, still have a notable risk of serious infection, albeit substantially reduced.  There is also a 1 in 3 risk (33%) of catching the disease and passing it on, compared to being unvaccinated
• Younger adults, typically single-vaccinated so far with Pfizer, also have a similar risk of serious infection. But have double the risk, 2 in 3 (64%), of catching the disease and passing it on, compared to being unvaccinated
• Unvaccinated adults have no direct extra protection
• Likewise children, who have not been vaccinated

No wonder then that cases of the highly transmissible Delta variant are rising rapidly, and are expected to continue to rise to a peak of some 100,000 new cases a day.

IMPLICATIONS OF HIGH COVID RATES FOR LONG COVID

Whilst it is too early to assess the impact of the Delta variant on longer-term symptoms, Long Covid, research by Kings College ZOE for earlier variants suggests:
“around one in seven who had symptoms lasting for at least 4 weeks, with around one in twenty staying ill for 8 weeks and one in fifty suffering for longer than 12 weeks”

This impacts all ages, including younger adults and children.  More women than men.  The ONS recently reported that already some 178,000 people have had their ability to undertake their day-to-day activities "limited a lot".  Clearly this number will rise substantially with the rise in new cases.

BBC's Panorama broadcast a new programme tonight, Monday 12 July, which will give you an insight into the scale, severity and potential causes of Long Covid.

It was good to hear Sajid Javid acknowledge the problem in Westminster today.  Yet there was no mention of Long Covid by the speakers at the PM’s press conference.  Indeed SAGE mysteriously does not include Long Covid in its modelling, nor hitherto in formal advice to Government. 

There is one small mention in the latest SAGE meeting minutes for 7 July, as a noted consequence of high case rates.

WHAT DO HIGH CASE RATES MEAN TO THOSE AT HIGH RISK?

All the figures above are averages across age, gender and other factors.  One such factor is risk level, especially those at high risk:

• Inherently more likely to catch the disease
• So more likely to need hospitalisation, and then potentially die
• More likely to suffer from Long Covid

With so many people in the community catching the disease and becoming infectious once restrictions are removed, the risk to the clinically vulnerable and others at high risk is significant.  Some 3.8 milion people are regarded as "Extremely Clinically Vulnerable" (CEV).

Rather than “Freedom Day” om 19 July, high case rates will mean these many people will again need to self-isolate for extensive periods.  Yet even that is not effective for those with children in their households.

WHAT DO HIGH CASE RATES MEAN TO THOSE AT MEDIUM RISK?

The same applies to those advised by their GPs to be at medium risk.  Whilst complete self-isolation may not be necessary, the wise will avoid places where face-coverings will no longer be required, such as public transport and shops.  That is a significant restriction on their freedoms.

The problem is that it only takes one person to be unknowingly (or knowingly) infectious, and not wear a mask, for those around them to catch the disease.  Why mask wearing should remain compulsory in such situations.

WHAT DO HIGH CASE RATES MEAN TO THOSE AT LOW RISK?

Low risk does not mean ‘no risk’.   In particular it is too early to assess the risk of serious Long Covid symptoms.  

The extra transmissibility of the Delta variant could well mean it spreads around the body via the bloodstream more easily to cause organ damage.  Heart, brain and other organs are all at risk, given they have the same ACE2 receptor on cells which the virus uses to attack the lungs.

Young people should consider this risk seriously, especially whilst only single-vaccinated.  

WHAT DO HIGH CASE RATES MEAN TO CHILDREN?

Hospitalisation and death of children is very low, certainly by comparison to other causes of death.

But they too can suffer from Long Covid, as the Long Covid Kids group testifies.  There is also a child in the Panorama programme mentioned above.

It is also acknowledged that children can pass on the infection to adults, even if the child is not displaying symptoms.  

The risk is likely to be reduced during the summer holidays, But once the schools are back in September, with many mitigations in schools withdrawn, infections in children are likely to rise substantially.  With an impact on their families and the wider community.

THE IMPLICATIONS

Individuals should therefore seriously consider what activities they are prepared to undertake, whoever they are.  19 July for many will not be ‘Freedom Day’.  Quite the opposite for many.

The PM and scientific advisors stressed the need to relax restrictions slowly.  Yet that is being rushed.  The impact on individuals and their mental health can be devastating.  Let alone the impact on the NHS for consultations, testing and treatments for Long Covid, as well as hospitalisations.

Specifically on face coverings, people who are not using one are likely to be taking other risks too, and so more likely to be infectious.  There only needs to be one such person in a shop, venue or public transport for there to be a super-spreader event.  Just like speed limits to protect the public, it is appropriate to keep face coverings and some other compulsory restrictions in place for some time longer.  

COVID-19: HOW HIGH CASE RATES CAN BACKFIRE

Any Government is responsible for both the economy and public health.  In deciding how to relax the existing restrictions in England, the UK Government is having to balance conflicting objectives.  Many prominent scientists are strongly recommending caution, whereas members of the Conservative Party want to see restrictions removed as soon as possible.  But would the latter backfire?

Some say ‘Health is Wealth’, a principle that serves us well, both personally and as a population.  Yet the Government is prepared to see COVID-19 cases rise to some 100,000 per day.  That will be amongst four groups:

• Double-vaccinated adults, mainly older and more vulnerable people with AstraZeneca
• Single-vaccinated adults, mainly younger people with Pfizer
• Unvaccinated adults
• Unvaccinated children

We know from PHE (Public Health England) research on the now-dominant Delta variant that vaccines are good, but still leave significant scope for illness and transmission for vaccinated people.  Compared to being unvaccinated, 1 in 20 or more will still need hospitalisation, some of whom will die:

THE ECONOMIC IMPACT

The high case rates predicted mean, for the economy:

• We are already seeing serious disruption for businesses and the NHS, where the numbers of staff off ill or self-isolating is rising dramatically.
• An increasing number of family businesses will need to close to self-isolate, probably repeatedly when their customers are tested positive for the virus
• Many people will prefer to avoid indoor spaces, such as shops, theatres and public transport.  Staying at home, as imprisonment rather than freedom

There are calls to remove the need for people to self-isolate if double-vaccinated.  But this ignores the chances for "symptoms" above.

Walking through a formerly popular area of the City on Friday evening around 10.30pm, there were far fewer people on the street, and the front section of one usually busy pub was empty.  Whether that was people ill or self-isolating, or simply avoiding mixing with strangers, is unclear.  When infection rates rise further, this problem can only get worse.

That disruption hardly helps the economy, even if more businesses can open.

The Government appears to be betting on the third wave and this disruption being short-lived.  Banking on the population reaching ‘hybrid immunity’ through a combination of vaccines and infection in a matter of weeks.  The latter being the only possibility for children, who can pass infection to adults in their household.

In terms of disruption, we may also find that foreign countries will be less inclined to accept visitors from the UK, even where travellers are double-vaccinated.  That impacts business travellers as well as tourists, and would of course impact travel companies.

FROM A HEALTHCARE PERSPECTIVE

From a personal perspective, high case rates increase the possibility of illness, even for the vaccinated.  Anyone falling ill will find:

• A very unpleasant initial illness, as double-vaccinated Andrew Marr of the BBC has found
• Possibility of long, disruptive and unpleasant hospital treatment
• Risk of Long Covid. The Kings College ZOE study suggests of those people developing symptoms, “around one in seven had symptoms lasting for at least 4 weeks, with around one in 20 staying ill for 8 weeks and one in fifty suffering for longer than 12 weeks”.  The ONS (Office for National Statistics) estimates that already some 178,000 people have had their ability to undertake their day-to-day activities "limited a lot"
• Oh, and the possibility of death.  And the risk of hospitals being overwhelmed.
  

Furthermore, scientists say that letting infection ‘let rip’ in a highly vaccinated population increases the risk of a new variant that escapes the vaccine.  That is hardly the gift the UK wants to give the world, let alone the impact on our own population.

BALANCING PUBLIC HEALTH AND THE ECONOMY

So allowing high case rates is bad news both in terms of public health and the economy.  It would be foolish to allow case rates to rise unchecked by completely removing all restrictions and mitigations, such as face coverings, on 19 July.  That's what the government has indicated.  That would backfire on the economy, as well as being a public health disaster.

We all want to get back to 'normal'.  But at a sensible pace.  With an announcement due on Monday 12 July, we’ll soon see if the Government has seen sense and modified its approach.

COVID-19: WHY DOES SAGE IGNORE LONG COVID?

Some members of SAGE

Hospitalisations and deaths are obviously important factors in considering how to respond to Covid-19.  That has been the focus of SAGE, the Scientific Advisory Group for Emergencies.

In the early weeks of the pandemic, we hadn’t even heard about Long Covid.  Yet we now know that many people are seriously affected by ongoing symptoms.   Shouldn’t SAGE now take Long Covid into account?

Plus, what will the high infection rates forecast mean to us personally?
 

THE EXTENT OF THE LONG COVID PROBLEM

The latest ONS (Office for National Statistics) report suggests that in early June around a million people were experiencing self-reported 'long COVID'. That is "symptoms persisting for more than four weeks after the first suspected coronavirus (COVID-19) infection that were not explained by something else”.

Quoting from the report in terms of longer duration:

• 856,000 (89.0%) first had (or suspected they had) COVID-19 at least 12 weeks previously
• 385,000 (40.0%) at least one year previously

The resulting impact being:

• 178,000 (18.5%) reporting that their ability to undertake their day-to-day activities had been "limited a lot"
• Symptoms adversely affected the day-to-day activities of 634,000 people (65.9%)

These figures are significantly higher than the number of deaths.  Long Covid affects young and old including children.  Even if the numbers above are somewhat over-estimated, Long Covid is clearly a significant problem.

THE SAGE APPROACH

Yet SAGE (Scientific Advisory Group for Emergencies), the main scientific group advising the UK Government, does not formally take Long Covid into account:

• Not part of SAGE's forecast modelling
• Not recorded in the published minutes, although these do not record the discussions.  Such as the last meeting on 9 June which made clear a 4-week delay to step 4 would be worthwhile, which the Government adopted for England.  SAGE clearly has an impact on Government policy.
  

But why does SAGE ignore Long Covid?  Professor Chris Whitty who co-chairs SAGE said on Monday, in answer to a question on Long Covid, that it isn’t well understood.  But we know more than nothing.  Surely the high numbers cannot be ignored?
 

THE LINK BETWEEN CASES AND LONG COVID

The ZOE study

We don’t yet know if the Delta variant cause more or less problems than earlier variants.  Indeed it could be worse, due to the variant’s increased power to infect, if the virus spreads around the body.  

But if we assume Long Covid rates are comparable, then the Kings College ZOE study from last year gives a good indication for those who have symptoms :

• around one in fifty suffering for longer than 12 weeks
• around one in 20 staying ill for 8 weeks
• around one in seven had symptoms lasting for at least 4 weeks

The latest daily confirmed cases are running at 28,773 in the UK, with a doubling time around 9 days. Sajid Javid, the Health Secretary, is talking of soon reaching 100,000 a day.  That would mean around:

• 2,000 extra people a day suffering for longer than 12 weeks
• 5,000 extra people a day staying ill more than 8 weeks
• 14,000 extra people a day with symptoms lasting for at least 4 weeks

After a month or so of high infection rates we would expect to be talking hundreds of thousands more people with prolonged symptoms.  Many of whom will have their lives seriously blighted.

On this scale, imagine the disruption to people’s lives, their livelihoods and their employers.  So why isn’t Long Covid at least being considered by SAGE? 

THE PERSONAL IMPACT

Early data for the Delta variant from Public Health England suggests high vaccine effectiveness against serious disease, as highlighted in yellow:

But as Long Covid is more based on having symptoms, this research suggests results would be expected to be, on average:

• Older adults mainly double-vaccinated with Astra Zeneca would still have around a 1 in 3 chance (33%) of Long Covid compared to being unvaccinated
• Young adults so far single-vaccinated with Pfizer would have around a 2 in 3 chance (64%)
  
• Unvaccinated adults and children have no protection against Long Covid

Of coruse, those who are more susceptible to Covid-19 will have a higher risk of Long Covid.

So as individuals, we still need to take care against contracting COVID-19, whether we are vaccinated or not.
 

IN CONCLUSION

High rates of Covid-19 will inevitably mean a high number of cases of Long Covid.  Vaccination provides limited protection.  Unvaccinated children and adults will continue to be at risk.

We want to get back to normal as quickly as possible.  But surely SAGE and the Government should be more concerned about Long Covid than they are?  To avoid high case rates, and therefore be more careful how quickly to relax all restrictions?

COVID-19: HOW MUCH IS 'LONG COVID' BEING CONSIDERED?

At a Long Covid clinic

Today it was good to hear mention of Long Covid today, both during PM Johnson’s presentation and by the Health Secretary, Sajid Javid, in the Commons.  That has been rare.  Yet Long Covid, as a collection of ongoing symptoms, is a major problem.  How much is the Government taking it into account?

As we saw in an earlier post, the ONS (Office of National Statistics) recently estimates hundreds of thousands of people experience long-term symptoms.  For example, some 178,000 people have had their ability to undertake their day-to-day activities "limited a lot", and 634,000 have their day-to-day activities adversely affected by symptoms.  A major problem.

The last SAGE meeting on 9 June considered three reports from modelling groups:

• Warwick University
• LSHTM (London School of Hygiene and Tropical Medicine)
• Imperial College London

The combined picture was behind the delay in removing restrictions from 21 June to 19 July.  To allow more adults to be vaccinated, and to collect more data on the newer, dominant Delta variant.

The models primarily address case rates, hospitalisations and deaths.  But not a single mention of Long Covid.  Whilst that would have been understandable early in the pandemic, it is a glaring omission now.

Case rates are rising rapidly, amongst three groups:

• Vaccinated adults, given that the vaccine is not totally effective, especially for those who have not yet had two jabs.  As vaccines take around 2 weeks to be effective, they would have had to be done by now to be ready for 19 July
• Unvaccinated adults
• Unvaccinated children

In total there are still millions of people who will catch the virus.  The ZOE symptoms study last year for King’s College London estimated for those who had had Covid-19 "around one in seven had symptoms lasting for at least 4 weeks, with around one in 20 staying ill for 8 weeks and one in fifty suffering for longer than 12 weeks".  It is as yet unclear how the Delta variant will act in causing Long Covid, and the extent vaccination will reduce the severity of symptoms.  Maybe lower proportions.  Could be higher, or similar.  We don’t yet know.

With rising case rates, potentially many more thousands of people of all ages will suffer, including children. Many seriously as the ONS has discovered. The sheer numbers potentially becoming a bigger problem for society than hospitalisation and deaths.  Not only for the individuals, but also their livelihoods and employers.  Plus extra strain on GPs and specialist NHS services.  That has a knock-on impact on ability of the NHS to provide a service for other health conditions.

So is the Government taking the risk of Long Covid into account?  Informally if not formally in the modelling?  Surely Long Covid can’t be ignored?

COVID-19: THE IMPACT OF LONG COVID

When the UK Government talks about Covid-19, the main concerns are deaths and avoiding overwhelming NHS hospitals.  Little if any mention of Long Covid.  

Yet Long Covid is a major problem, with the ONS (Office for National Statistics) estimating hundreds of thousands of people suffering from ongoing symptoms after COVID-19.  How concerned should we be, with restrictions planned to be removed on 19 July?

Given high numbers of people impacted, the NHS has set up more than 60 specialist clinics across England.  These assessment centres “are taking referrals from GPs for people experiencing brain fog, anxiety, depression, breathlessness, fatigue and other debilitating symptoms”.

So what is Long Covid?  How does it arise?  How many people does it affect?  How concerned should we be with restrictions planned to be removed in England on 19 July?

WHAT IS LONG COVID?

There is no universal definition for Long Covid, but two definitions are in common use in the UK:

• Symptoms of COVID-19, or attributed to it, lasting more than 4 weeks.  The ONS estimates nearly a million people are currently suffering, with another million previously affected.
• Lasting more than 12 weeks (or 3 months), which is also called Post-COVID Syndrome. Some 856,000 people per ONS.

‘Long haulers’ is another term in use.  Some sufferers have been impacted for over a year.  ONS estimates some 385,000 people, who would have caught the disease at the start of the pandemic last spring.

HOW DOES LONG COVID ARISE?

ACE2 binds to virus spike proteins

The SARS-COV-2 virus that causes COVID-19 usually enters the body via the respiratory tract, including the lungs where major breathing problems become commonly evident.  The virus attacks and enters cells via the ACE2 receptors in cell surfaces.  

“ACE2 is also present in many cell types and tissues including the lungs, heart, blood vessels, kidneys, liver and gastrointestinal tract”.  And the brain.

If the virus gets into the blood stream, such as when lung cells explode after infection, the virus can permeate around the body.  It then attacks and damages cells in other organs that have the ACE2 receptor.

Furthermore the virus causes micro-clotting in the blood.  This can block small blood vessels, such as in the lungs.  As the blood flows around the body , microclots and larger clots can cause additional damage to organs.  Microclots can cause rashes to appear on skin, and be a key factor in severe disease.

As a result COVID-19 can cause five groups of long-term problems for people recovering from infection: 

• Continuation of basic COVID-19 symptoms such as loss of taste and smell
• Post-viral fatigue, as can happen after any severe viral infection
• Pain and discomfort
• Loss or impairment of bodily function, such as heart palpitations
• Mental health issues, such as depression and anxiety

The NHS has published a long list of symptoms for Long Covid.
 

HOW MANY PEOPLE DOES IT AFFECT?

As indicated above, millions of people have been and will be affected by Long Covid. Many of those recovering have symptoms lasting more than twelve weeks, and a significant number more than a year.

The ONS estimates from their recent sample that in the UK:

• 535,000 people are impacted by fatigue
• 397,000 by shortness of breath
• 309,000 by muscle ache
• 295,000 difficulty concentrating

As a result:

• Some 178,000 people have had their ability to undertake their day-to-day activities "limited a lot".  This is more than the number of deaths so far in the UK
• 634,000 have their day-to-day activities adversely affected by symptoms.  An even bigger problem

The ZOE symptoms study for King’s College London estimated "around one in seven had symptoms lasting for at least 4 weeks, with around one in 20 staying ill for 8 weeks and one in fifty suffering for longer than 12 weeks"

The ONS reports that the problem is more acute in females and over 35s, plus some other groups.  Long Covid can impact all ages, including children, for which there are now support groups in UK and North America

It is too early to know what impact vaccinations will have on Long Covid numbers.   People can suffer from it even when they have not been hospitalised. As vaccines are not totally effective to prevent severe disease, they would not be expected to be totally effective against Long Covid either.  Without vaccination, children will continue bearing the same risk as now.

HOW CONCERNED SHOULD WE BE?

Long Covid is clearly a serious problem, badly affecting many more people than have been hospitalised or died.  Adults and children.  For many, a living death.

The numbers are going to be in some way proportional to cases.  With case rates continuing to rise, despite vaccination, the number of new Long Covid sufferers will continue to rise too.  Especially if all remaining restrictions are removed and case numbers allowed to rise unchecked.

The Government always talks about not allowing the NHS to be overrun, with the focus on hospitals.  But as the specialist Covid centres require a referral from a GP, it is no wonder GPs are struggling to provide the service for other health conditions.  Added to which is increasing strain on specialist NHS services involved.  An increasing workload will only make matters worse across many parts of the NHS, reducing availability for people with other health conditions.

The Government has indicated that in removing legal restrictions on 19 July, simple mitigations such as masks on public transport will no longer be required. That will allow case rates to continue to rise until ‘herd immunity’ is reached across two groups, whether that is by vaccination or infection:

• Adults, of which many are yet unvaccinated
• Children, who are unvaccinated

This is asking for trouble, with Long Covid numbers continuing to rise for some time.  Putting additional strain on GPs and other NHS services, in addition to adversely affecting the lives of thousands more people, their families and employers.

The new Health Secretary Sajid Javid is right to indicate that restrictions need to be balanced against the other health and economic factors which would improve from removing restrictions.  But Long Covid needs to be taken into account in striking the right balance.

A 3-ply medical mask

Does that mean removing simple and cheap mitigations such as masks and social distancing, where practical?  

Given the numbers and risks involved with Long Covid, we ought to be concerned, and act accordingly.

What do you think?