Christina Pagel, Director of the Clinical Operation Research Unit at UCL and member of Independent SAGE, lays out her reasoning for cautious optimism about the trajectory of the pandemic as the UK eases out of lockdown.
With students returning to schools and the promises of “one-way” restriction-lifting last week, there is an overall feeling of optimism among many in England with regards to COVID-19. However, given the UK’s porous border policy and the threat of vaccine-resistant variants, I am veering pessimistic about the pandemic’s trajectory in the medium-term. But with a few small policy shifts on the part of the government, I could be swayed into optimism – I lay out these shifts below.
Let’s start with the positives. The vaccine roll out is going amazingly well. Over 40% of the adult population in England has now been vaccinated, and we are on track to offer everyone a first dose by June – perhaps even earlier. Overall uptake has also been much higher than anticipated.
Not just that, but the vaccines work better than expected. They are not only very effective at preventing illness, hospitalisation, and death but are also effective at reducing transmission. This means those who have been vaccinated are much less likely to spread COVID to others — a factor that could make a huge difference for how we can behave socially once most people have been fully vaccinated.
After a brief plateau a few weeks ago, cases have been dropping faster again. This is likely the result of vaccines starting to combine with lockdown restrictions, especially as care home and healthcare workers are now several weeks out from their first dose and starting to receive their second. On top of this, lockdown has also worked better than expected. I, and others, were worried that the restrictions and support for isolation and workplaces wouldn’t be enough to bring cases down quickly with the new more transmissible strain.
According to the roadmap, indoor spaces such as gyms, hairdressers, and shops are not opening until 12 April at the earliest (except for schools – more on that later), with indoor household mixing and pubs potentially 5 weeks later.
If we can keep R down to 0.85-0.9 as we open (higher than lockdown levels to allow for a natural increase in transmission as restrictions lift), we could be at 500-1,000 confirmed cases a day by mid-May, and could keep cases reducing over the summer. As more adults become vaccinated, we could reach even lower, effectively elimination, levels and stay there with minimal restrictions.
That’s the optimistic scenario.
So what are the potential problems? Why am I hesitant to be optimistic?
The above optimistic scenario relies on four things all going right.
a) Vaccines doing almost all the heavy lifting of keeping cases down as we open up;
b) Being able to open schools up AND keep cases reducing (R<1);
c) No new variants popping up that resist the vaccines; and
d) Cases getting low everywhere
Vaccines can, and will do, a lot of heavy lifting. But even in Israel (which has same variant as us) where a high percentage of all adults have been vaccinated, cases are still relatively high and pockets of high transmission remain. A Lancet Covid-19 commission released this week also highlighted that relying on vaccines to do all the work of keeping cases low is a dangerous strategy.
The government’s scientific advisors on SAGE believe that opening schools all at once on 8 March is likely to push the R rate over 1, increasing case transmission. Other UK nations are instead taking a phased approach to opening. Schools being open is the biggest difference between this lockdown and that last November. Cases rose in the London and the South East last November where schools were open and most school staff and parents still haven’t been vaccinated.
That said, Scotland is doing well three weeks after primary schools opened although there are slight rises in cases in children, and France has successfully kept its schools open the whole time. But both are doing more mitigation than England – including a massive testing programme and stricter COVID-safe policies. Last week saw an uptick in reported cases in England. While it is likely that this is an artefact of the mass testing of schoolchildren, the next few weeks will be crucial in learning more about the impact of schools on transmission. However, there is still a lot more the government could be doing to support safer schools which would maximise the chance that children can stay in school with minimal disruption. Ultimately, we will also need to vaccinate kids.
3. New variants
If we tolerate cases at current(ish) levels, then we do risk new vaccine-resistant variants emerging here, especially while vaccines are still rolled out and millions have only received their first dose. We are also at a high risk of importing new variants – our border policies are still nowhere near strict enough as recent importations of the Brazilian “P1” strain have shown.
A year ago, over 1,000 separate seeding events launched the pandemic in England. Last summer, travel re-seeded COVID in places that were near maximum suppression, like Ireland and Scotland. Selection pressure on COVID is increasing rapidly. Our border policy is basically a big fat gamble.
A new vaccine-resistant variant risks a whole new wave, new lockdowns, waiting for updated vaccines and re-delivering them to people already vaccinated. It risks more stress for the NHS, more deaths, more people living with long COVID and another very difficult winter.
With our current policies, minimal foreign travel is the best bet for 2021, despite countries declaring their borders open to UK tourists even before international travel is permitted. I’m not calling for borders to be shut forever, but if we can prevent a third wave this year, we’ll be in a much better place in 2022 with a fully-vaccinated population and greater knowledge of emergent variants. Even if vaccine-resistant variants emerge elsewhere (as many experts think is likely), if we can keep them from spreading here until next year, we should be able to pre-emptively vaccinate our population against them – a much better position to be in. I am certainly planning to stay in the UK this year.
4. Keeping cases low everywhere
Last year we saw areas with stubbornly high cases, and we’re seeing it again now. Not only are more deprived communities more likely to get COVID, and more likely to need hospital once they have COVID, they are also less likely to get vaccinated. The inequalities that this pandemic has so blatantly exposed risk COVID becoming a disease of poverty, like TB before it. We must address issues of deprivation in tandem with tackling COVID spread.
These potential pitfalls are all solvable things, with a few significant but not impossible changes: supporting the vaccination programme with tried and tested public health measures such as excellent test-and-trace (particularly supported isolation, both financially and practically), safer workspaces, safer schools, tackling poverty, addressing vaccine hesitancy, and a stricter border policy this year.
Vaccination makes many of these things easier, but not less important. Tackling poverty and inequality are, obviously, much harder, but this underlies the fundamentals of better public health, for COVID and everything else.
So my pessimism comes from the fact that the current government strategy is relying almost entirely on vaccination. Basically, it’s leaving a route out of the pandemic this year to a lot of chance. The government is crossing its fingers and hoping it’ll get away with it.
What is especially frustrating is that, with a minimal amount of extra effort, a true one-way route out of the pandemic this year is so, so much more likely.
I hope we’ll be lucky, but I wish with all my heart that we weren’t relying so much on luck.
Note: The views expressed in this post are those of the author, and not of the UCL European Institute, nor of UCL.