Living with Covid: looking ahead
Do you remember that scene in Groundhog Day, where Bill Murray’s character eventually resorts to taking a bath with his toaster in an attempt to put an end to the interminable repetitive nightmare that his life has become?
Although I’ve not reached my toaster moment quite yet, I suspect that, with the much muted Christmas many of us enjoyed again, and another potential lockdown looming in some places, I’m not alone in wondering where and when this Covid-19 nightmare will end, and hoping the answer is "soon".
The reason we’re in this pickle is owing to omicron. Before this new variant emerged, we were beginning to manoeuvre our mindsets towards one of living with Covid. Even formerly “zero Covid” countries, like Australia and New Zealand, were coming around to the idea. Yes, in the UK we were seeing hefty numbers of daily cases of what was then the dominant “delta” variant, but they were not translating into consequences – meaning people in hospital, or worse – with anything like the frequency we had seen previously.
Back in January of 2021, in what we’ll dub the pre-vaccine era, we were seeing 1500 people losing their lives each day and over half of the beds across the entire NHS were occupied by Covid casualties. But thanks to one of the most impressive vaccination campaigns ever recorded in history, with well over 90% of adults vaccinated in some age groups, within months the link between cases and consequences was severed. Normality was returning. On the Covid-19 snakes and ladders board, it looked like we were getting close to square 100 and winning the game. But then along came omicron and down the long snake we seem to be sliding, back to the square labelled “lockdown”.
This variant spooked doctors, politicians and policymakers because of its super-charged transmissibility. It can dodge existing immunity conferred by vaccination or a previous brush with Covid, and, according to researchers in Hong Kong, it grows much faster in the upper airways than other viral variants. The result has been case numbers that were doubling every two or three days with omicron rapidly becoming the most common form of Covid in the country. Thankfully it’s now slowed down a bit, but this accumulating head of steam, were it to turn into cases with the same consequences and severity as other existing variants, would result in thousands of daily hospitalisations again, a significant death toll, and paralysis for the NHS.
On the other hand, if omicron turns out to be more trivial, which initial data now suggest is the case, then we’ve much less to fear. And results from South Africa are painting a reassuring picture: there, cases have peaked, rates of hospitalisation are coming down, and the reported risk of severe illness with omicron is about 80% lower than with delta. These results have since been echoed by researchers in Edinburgh, where based on an admittedly small number of cases, researchers found a two thirds reduction in rates of hospitalisation with omicron compared with an equivalent delta infection. Danish, UKHSA and Israeli data also seem to be singing from the same song sheet.
But this presented the government with the type of Christmas gift no one wants to receive – the decision whether to augment existing restrictions, based on reasoning that, despite being a milder illness on average, the transmissibility of omicron means it still has the potential to make sufficient numbers of people severely ill and overwhelm healthcare’s ability to cope, or to carry on as we were. The problem is, it takes a few weeks for the full force of an outbreak to hit the health service, because people don’t catch Covid and instantly toddle off to hospital. So if we wait until we have clear signs of a crisis, it’ll be too late to intervene. Jump too soon, on the other hand, and we see lost livelihoods and unpopular restrictions that erode public support.
The result is that opinion is split between those favouring a light touch approach versus those who want imposed restraints and laws to back them up. Nevertheless, most people agree that periodically pummelling our pubs and entertainment venues, paralysing the economy, denting education and destabilising the nation’s mental health to control outbreaks of variants with uncertain characteristics is just not a sustainable long-term proposition. As Oxford University’s Carl Henegan told the BBC Radio 4 “Today” programme recently, calling for more personal responsibility and agency, “this is as good as it gets.” Because omicron isn’t the first and it won’t be the last variant: Covid-19 has plenty more rolls of the genetic dice where that came from. This means that we need a robust plan for a future living with Covid-19, not allowing it to rule our lives with lockdowns. If we follow that path, piece by piece we will eventually dismantle society and bankrupt the country. Under those circumstances, the pill will most certainly be worse than the ill. As one elderly care home resident put it to me, “This is not living. So what am I living for?”
The one certainty is that this virus is not going away. It is becoming endemic, meaning it will continue to circulate, probably indefinitely, producing seasonal surges like the one we are seeing right now. So what can we do to safeguard our future?
Optimistically, there are some bright lights on the horizon, and we’ve learned a lot over the last two years. In the near term, we’re seeing initial data suggesting that, although the vaccines might not be perfect at halting omicron and variants like it, they seem nevertheless still to be effective at preventing severe disease, which is what, at the end of the day, really matters. As Boris Johnson said to Kate Bingham when she was appointed to set up and lead the UK’s vaccine taskforce, “we need to stop people dying.” Indeed, it’s consequences, not cases, we need to focus on.
We also know who is at greatest risk from Covid-19, meaning we know where to concentrate our firepower. And that now includes a suite of new drugs that, for the first time, can be used to stop people who catch the virus from falling seriously ill. Pfizer’s new agent, Paxlovid, which has just received regulatory approval, is the first dedicated anti-coronavirus agent. Given as a short course when a person first develops the infection, it blocks the ability of the virus to assemble new viral particles inside our cells, knocking down rates of serious disease by as much as 90%. Merck have also re-purposed a flu drug, molnupiravir, which they were working on pre-pandemic. This throws a spanner in the mechanism used by the virus to copy its genetic code. In initial trials it cut rates of severe disease by 50%.
There are also antibody preparations that can be used to “top up” a patient’s own immunity, helping their immune systems to get a head start fighting off the virus should the fall ill. This week these preparations began to be offered in some parts of the country to at risk individuals.
Behind the scenes, vaccine manufacturers are also working on “Covid vaccine 2.0”, including updates to our existing vaccines to better reflect the new variants, and broader spectrum vaccines that will work against variants that don’t even exist yet.
Together, we can use these therapies and preventative measures in a targeted way to protect the vulnerable from Covid-19 while also protecting the freedoms of those for whom Covid is otherwise a mild infection. Essentially the aim is to convert what is a lethal infection for some into a trivial infection for everyone. As such, we can manage Covid-19 much as we do the flu. We protect the vulnerable via annual vaccination, which we periodically update to stay in step with what the virus is doing, and we have drugs to reduce the impact of flu in those unlucky enough to catch it.
But, to my mind, there’s one other major priority that we ignore at our peril. Boris Johnson has urged us to “build back better”. So let’s start with the NHS and specifically one aspect of healthcare that seems to be persistently overlooked: infection control. One of the reasons why our hospitals are in a permanent state of crisis is because we are routinely operating them at near full capacity. While that might sound attractive from an efficiency point of view, quite the opposite is true in practice. With no room to manoeuvre, when an infectious outbreak occurs there are too few places to isolate infected individuals and cases quickly amplify as patients infect each other. The ensuing ward closures and cancelled surgeries mean that even a handful of cases can capsize the service.
What we really need to help us to live with Covid-19 are large numbers of dedicated single occupancy isolation facilities in every hospital, with testing facilities nearby, so any new admissions can be safely screened before they go anywhere near a ward. My prediction is that the number of beds we’ll save by not closing wards or losing staff members to sickness will more than compensate for the capital outlay. Perhaps then we’ll climb a few ladders rather than sliding down snakes every winter...