To Plan B, or not to Plan B?

To Plan B, or not to Plan B; as Covid-19 cases hit a new high recently, that is the question that’s hogged the headlines this week, such as this clip from BBC Radio 4:

Labour has made a stinging attack on the government's COVID strategy and suggested that Sajid Javid is the most complacent health secretary in the history of the NHS. Speaking in the Commons, the Shadow Health Secretary, Jonathan Ashworth, highlighted the pressures facing the health service as infection rates rise and said the vaccination program was stalling. The doctors' union, the BMA, has accused ministers of being willfully negligent by not introducing some coronavirus restrictions in England.

Some, like Bath University mathematician Kit Yates, think that as half term comes to an end, restrictions need to be reintroduced across the board sooner rather than later, as Chris Smith found out...

Kit - I'm worried that when schools do go back that we will see cases rising again and of course that will lead to rises and hospitalisations. Unfortunately that will lead to rises in deaths. At the moment we're averaging a rate of death equivalent to about 50,000 a year, which I think is unacceptably high.

Chris - What would you like to see done as a reaction to the present trends?

Kit - What we could be doing is taking relatively light touch mitigations, things like asking people to wear masks in enclosed public spaces, things like putting mitigations in schools to try to make sure we can mitigate the spread in schools like ventilation and filtering. I think there are small things we can be doing like asking people to work from home, which could all have a big impact on transmission. Cases are not growing that quickly at the moment as the reproduction number is just above one, which means it's growing quite slowly and small things we could do now would help us to bring cases down as we head into winter.

Nevertheless, with R just above 1, meaning the outbreak is growing only very slowly - despite the fact that we’re all out and about - and cases are actually now appearing to fall, others are more sanguine, like UEA Professor of Medicine, Paul Hunter, who favours the status quo, arguing that the answer lies in vaccines and boosters, rather than restrictions; more restrictions, he says, might in fact prolong the pain long term, not lessen it…

Paul - Well, at the moment, it's looking substantially more promising than even a week or so ago. Case numbers have started to decline but we are also beginning to see, I think, hospitalisations now starting to plateau.

Chris - This to my mind, listening to you sounds like you're taking fairly optimistic viewpoint.

Paul - Absolutely. We're in a situation where the vast majority of adults and particularly vulnerable adults have already had one course of vaccine. But, vaccination effectiveness is declining and has continued to decline. On the other hand, recent evidence on the booster vaccine is that it actually is looking substantially more effective at both stopping infections and more importantly, stopping severe disease than many of us were expecting.

Chris - Nevertheless, some people are saying that the current case load translates into tens of thousands of mortalities per year, which some say is unacceptable. How do you read it?

Paul - What we saw last year was a substantial number of excess deaths driven by large numbers of coronavirus deaths. What we're seeing in the last few months is that yes, we are still seeing excess mortality. Only a minority of those excess deaths are in people who have recently tested positive for COVID. It's difficult to know what's driving that. It's plausible that problems around what's called non-pharmaceutical interventions that are actually delaying people getting treatment for heart attacks, or maybe people not actually exercising enough, becoming more sedentary and that's speeding up cardiovascular disease.

Chris - Some people, including letters penned by significant numbers of members of the medical profession (open letters and so on), are calling for the government to put more measures in place to try and head off the surge at the pass as it were. Do you think that's a good idea or do you think actually that we should go steady as she goes, which is apparently the government's present policy? They say they have no plans to escalate things.

Paul - Actually at the moment the indications are that they're going to review this in a week or so's time. And I think that's the right thing to do. You know, nobody can be absolutely certain what's going to be happening but the thing about non-pharmaceutical interventions, like restrictions, is they never prevent infections and we've known this long before COVID.

Chris - When you say 'never protect' you mean they don't ever prevent them but what they do do is kick the can down the road. They're going to happen anyway, they are just going to take longer.

Paul - Absolutely, yes. As Fauci said the other day, people who have been vaccinated will get infected. Even those of us who have been infected will almost certainly get repeat infected. Those of us who've been vaccinated will almost certainly get breakthrough infections and that's because this is a coronavirus. Immunity to infection from coronaviruses are generally quite short-lived. The other coronaviruses typically cause infections every three to six years. What that means is if we implement these restrictions now we might actually suppress the curve a little bit more than it might be otherwise. Ultimately those people still have to have their infection if they've not been boosted. So these restrictions don't ultimately prevent transmission, they just delay it. Sometimes delaying it is all you need. Once we have a vaccine, as we do at the moment, delaying it, paradoxically, could make things worse. A longer time between infections, these endemic infections, causes you to initially lose your immunity to mild infections then ultimately you lose your immunity to severe infections unless you've had a booster from a vaccine or an infection in the meantime. So increasing the gap between infections can actually increase mortality.