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The Prime Minister laid out England’s roadmap out of the current lockdown in the Commons this afternoon.
Dr Julian Tang, Honorary Associate Professor/Clinical Virologist, University of Leicester, said:
“The proposed roadmap seems reasonable – will be great to be able to go to the cinema again. The most important aspect of this proposed plan is the 5-week intervals between each step to assess the impact of each relaxation step on the virus spread.
“Now that the elderly and vulnerable are mostly protected, we won’t see any of the previous dramatic increases in hospitalisation and deaths that prompted the previous two national lockdowns.
“What interests me most now, as a clinical virologist, is the possible gradual emergence of younger cases of COVID-19 in the as yet unvaccinated population, who may not need hospitalisation but who may still develop long COVID complications. This may shift the COVID-19 healthcare burden to outpatient settings like GPs and specialist ‘chronic fatigue’-like hospital clinics – and the extent of this burden will affect how we manage this virus in the longer-term as the virus becomes more seasonal.
“This will also impact on how we assess the cost-benefit of updating future COVID-19 vaccines – both to prevent severe diseases and death in the elderly and vulnerable – but also for the younger working population who may be at more risk of long COVID-19 complications.
“However, I would add a cautious note of optimism looking into the future. As we have seen with flu, the first years of a pandemic are usually the worst as the new host population is non-immune and the virus can spread relatively uninhibited through this naive population.
“But over years of seasonal vaccination and/or natural exposure to different, evolving strains of the virus, we will build up a barrier (though leaky) of cross-reactive immunity that can mitigate the more severe complications from the infection – such as this study showed during the 2009 A(H1N1) influenza pandemic: https://pubmed.ncbi.nlm.nih.gov/19745214/ So hopefully we will see the severity of COVID-19 and any related complications gradually diminish over time, with increasing population level experience with this virus.”
Dr Stephen Griffin, Associate Professor in the School of Medicine, University of Leeds, said:
“The cautionary note in the Prime Minister’s announcements is well received, yet would have been more welcome back in Spring 2020. However, one dramatic difference since then, as rightly pointed out, is the success of the vaccination programme. The PM followed by saying that we should no longer – nor in my opinion ever should have – rely upon multiple lockdowns to keep SARS-CoV2 under control. Importantly, the news that vaccines are able to mainly prevent infection is a welcome boost to an already impressive roll out that has already provided over a quarter of the country with its first immunisation. Whilst there were perhaps more dates than hoped, the message that these were the earliest times at which certain restrictions would be lifted was clear, as were the criteria by which they were to be judged, although case numbers were conspicuous by their absence.
“Nonetheless, this positive message felt completely at odds with the defeatist attitude concerning the notion of having to “live with the virus”, as we do seasonal influenza. The two viruses are clearly not comparable, with ~130K deaths in the UK and over half a million in the US that we know of, as well as many more suffering from the debilitating effects of long COVID. Whilst vaccines will clearly dramatically limit the severe consequences of SARS-CoV2 infection, allowing continued circulation of this virus poses a very real risk that more serious variants might emerge that better-evade the responses elicited by our vaccines. For example, the more transmissible B1.1.7 variant arose in the southern UK whilst prevalence was comparatively low towards the end of summer, and we are seeing the emergence of similar antibody-evading mutations across multiple geographical locations. Whilst certainly not yet cause to panic, these changes serve as a warning that this virus is still adapting to its newfound host – the human race. We have yet to severely test SARS-CoV2 by restricting its reservoir of hosts via vaccination, and this situation has never before been applied to a pathogenic human coronavirus. To allow SARS-CoV2 to maintain significant prevalence and diversity in this scenario therefore seems unwise at best.
“However, we are indeed fortunate to possess an accumulation of factors and weaponry with which the possibility of declawing SARS-CoV2 is very real. Lockdown has regained control of the second wave and we are starting to alleviate some of the burden placed upon our formidable NHS. Vaccines are being rapidly deployed, appear to prevent both infection and severe disease, plus are thought to now be emulating Israel in affecting the likelihood that older and more vulnerable patients will succumb to COVID. We have an aware and vigilant population now accustomed to the rigmarole of COVID restrictions, and with the improving weather our behaviour will further limit the spread of the virus. The main pieces missing from the puzzle are requisite improvements to the contact tracing system and a sensible, effective quarantine protocol – the two of which should work in tandem to rapidly quell any future imported outbreaks.
“The terms elimination and eradication, along with hashtags such as zero COVID are often banded around social media, whereas endemic, seasonality and the opposite extremes to zero COVID also resonate. Yet these can all mean different things depending on context. Analogies to viruses past and present are often used to explain concepts of how the future might look in relation to when COVID is hopefully behind us, and these can indeed be tremendously useful illustrations. However, perhaps we ought not to, in my view, attempt to label SARS-CoV2 with such models. Nobody alive has ever witnessed such devastation caused by an infectious disease, and the virus continues to surprise us on a daily basis.
“Nevertheless, we retain the means to ensure that SARS-CoV2 never again achieves so much as a foothold within the UK. Moreover, once the situation here is stable, we can help extend that good fortune elsewhere around the globe. I for one do not wish to see even shallow echoes of 2020/21 return year upon year, and for the sake of a relatively short period extra effort – albeit from a population battered by three dreadful lockdowns – I am genuinely optimistic that this could be realised as it has in other countries around the world.”
Dr Peter English, Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice Magazine, Immediate past Chair of the BMA Public Health Medicine Committee, said:
“The Prime Minister’s announcement in the House of Commons, and the underlying paper both emphasise that the steps are contingent upon four “tests” being met. Yet the reporting consistently reported the earliest possible dates on which the “steps” the prime minister announced could possibly happen – subject to meeting the tests described – as if they were the dates on which these steps would actually be taken.
“The tests proposed were as follows (page 25 of the report1):
The tests
1.The vaccine deployment programme continues successfully.
2.Evidence shows vaccines are sufficiently effective in reducing hospitalisations and deaths in those vaccinated.
3.Infection rates do not risk a surge in hospitalisations which would put unsustainable pressure on the NHS.
4.Our assessment of the risks is not fundamentally changed by new Variants of Concern.
“These tests are all rather vague – no detail on how they will define “successfully”, “sufficiently effective” and so on. This seems unusual – one would expect there to be background papers giving details; but perhaps they were deliberately left vague, to allow “wiggle-room” as new information (and new ideas) become available. The tests need to be refined with more precision, and I would be surprised if further tests – in particular, the current new case rate – were not added to the tests.
“The prime minister described four “steps” – each a progressive easing of current restrictions. Dates were given on which the steps might be taken, but these dates were clearly described, both by the PM in his statement to Parliament, and in the paper as the earliest possible dates on which the “steps” could be taken. Despite this, much of the immediate reporting gave the dates as if they were set in stone, rather than being contingent upon the tests having been met. The dates provided strike me as highly optimistic – perhaps to raise morale, for better PR, or to passify critics in the Conservative party who are keen to reduce restrictions faster than the government’s scientific and medical advisors think wise.
“Opening all schools to all pupils on 08 March, for example, will definitely increase the R number. It will increase transmission, and the number of new cases – at least compared to keeping schools “closed”. (Of course, they are not really closed: teachers are providing online learning for many pupils; and the children of key workers, vulnerable children, and those without access to online learning are currently attending already.)
“Other expert bodies including Independent Sage, the BMA, and the Association of Directors of Public Health, have all provided clearer proposals for safer ways to exit from lockdown2-5.
“Returning to schools – as an example (similar proposals could be made for other sectors), it seems reckless to have all pupils attending from 08 March, regardless of whether case rates in the local populations remain high. The consensus from other experts is that it would safer not to fully open schools while the number of new cases remains above 10 per 100,000 population per week (based on the 7-day rolling average). Schools could open for “blended learning” if rates are higher. Perhaps with half the students attending (e.g. they attend alternate weeks) if rates are not low enough for full reopening (perhaps 10 – ≤20 /100k/wk); and only 1 in 5 pupils attending (e.g. they come in once per week) if levels are higher (perhaps 20 – ≤50 /100k/wk). And, in my opinion, carbon dioxide meters (an excellent proxy for the accumulation of aerosols of potentially infectious respiratory droplets) should be installed in all classrooms, designed to set off an (amber) alarm if levels exceed a threshold, indicating that doors and windows should be opened; and a red alarm if carbon dioxide levels remain at this threshold for 10 minutes or more, or if they exceed a higher threshold6,7.”
Prof Linda Bauld, Professor of Public Health, University of Edinburgh, said:
“This gradual easing is welcome but there are some important questions remaining on travel within the UK and internationally. If the government is concerned about variants and managing infection rates across the country, then what will the approach to domestic and international travel be? It looks like people in England will be free to travel around the country for non-essential purposes from the end of March or mid April. What happens when there are high or low infection levels in one area compared with another, and between England and the devolved nations? In addition, how can foreign travel be back on the cards from May when the importation of cases will pose a significant threat to any progress we make within the country, and the current UK level system for quarantine is full of holes. The UK is committed to an international response to vaccine roll out, but that will be slow in many parts of the world. Many have said that we are not safe until everyone is safe. The government should prioritise the planned report from the successor to the global travel task force, and also set out how travel within the UK and the common travel area (the Republic of Ireland etc.) will be managed.”
Prof Lawrence Young, Professor of Molecular Oncology, Warwick Medical School, said:
“Re ‘heavy lifting’ with vaccines: Great news today confirming the effectiveness of vaccination in the real world. The data from England and Scotland confirm the ability of both the Pfizer/BioNTech and AstraZeneca/Oxford vaccines to protect from severe disease and hospitalisations. The study from Scotland presents data on both vaccines after a single dose and shows that these had their peak efficacy at 28-34 days post-vaccination (85% for Pfizer/BioNTech vaccine and 94% for AstraZeneca/Oxford vaccine). Data from both the PHE’s SIREN study and from Israel independently confirm that the Pfizer/BioNTech vaccine is able to significantly reduce infections even in asymptomatic individuals after two doses – up to 85% from the SIREN study. This suggests that this vaccine is very likely to block virus transmission as you can’t spread the virus if you are not infected. It is very likely that the AstraZeneca/Oxford jab will do the same but we need to see the data.”
Prof Martin Hibberd, Professor of Emerging Infectious Disease, London School of Hygiene & Tropical Medicine, said:
“Looking at the modelling (released by SAGE today), I have a worry that September this year will be very similar to September last year. With some luck, I think we may escape the predicted huge increase in cases in June and July (thanks to the vaccines being better than we thought), but if we do, we will end up too relaxed and then be wide open for new vaccine escape variants to arrive and drive up the cases for September.
“Just as last year, we need to be planning to get test and trace to work (preferably by returning it to PHE, NHS and local government) during the (hopefully) quiet summer months, so that any new upturn in cases can be quickly spotted and averted (without the need for lock downs again next Winter).
“Where is the planning to make us resilient to future outbreaks? If we don’t do it now, it will certainly be forgotten by the time we need it.”
Dr Michael Head, Senior Research Fellow in Global Health, University of Southampton, said:
“In the short-term, we will soon see the return of children to schools in England. Children do desperately need to be back in school, but the trade-off is that there will an increase in the R number as a result. My personal view is that a more cautious approach with a phased return would be better. However, the flip side is that other indoor spaces are being kept closed and so there are few other areas where multiple households can mix, so hopefully this will still allow community transmission to come under control. We know that indoor settings are where most transmission takes places, and so the key to keeping new daily cases as low as possible is to restrict mixing of households within those indoor environments. Overall, this roadmap looks broadly sensible. With the vaccine roll-out going so well, this will allow for a safer environment for staff and users when indoor workplaces like pubs, restaurants and office spaces do open again.
“The Prime Minister did start off his announcement with the declaration that “we will be driven by data, not dates”, but then went on to provide a whole series of dates. One aspect that looks a little curious are the four tests that will be used to allow the next stage of intervention to be lifted. There is not yet any suggestion as to how these tests could be met. It is important that there is clarity here as to what measures will indicate a successful ‘pass’ onto the next phase of reopening, and that there is also flexibility in the timeframe the Prime Minister has mentioned.”
The following comments were sent out on Monday morning in response to media reports suggesting what the Prime Minister was set to announce, before the detail was published:
Dr Julian Tang, Honorary Associate Professor/Clinical Virologist, University of Leicester, said:
“The proposed cautious approach to lift this third (and hopefully final) lockdown by the PM’s team is a wise move – we don’t want a repeat of the two previous national lockdown/virus resurgence that we have seen previously in the UK.
“However, this needs to be approached carefully so that a return to much tougher restrictions need not be imposed – even if we see case numbers rising slightly after each relaxation step – which they may.
“This will also depend on how much further the COVID-19 vaccination programme has reached these younger populations involved in the initial steps of the lockdown relaxations – so school teachers, parents picking up/dropping off school children, taxi drivers, even outdoor sports coaches, where needed, etc.
“It will also be critical that we roll out these lockdown relaxations cautiously so that the most badly affected hospitality industry can plan, stock supplies for an eventual re-opening perhaps later in April/May – if the case numbers/vaccine rates are all favourable for this – to avoid wasting all that costly stock again.
“There are still likely over half of the UK population (including U18s – a common reservoir for seasonal respiratory viruses) that are still susceptible to the virus – and this lack of herd immunity is what drives virus pandemics.
“So the proposed 4-5 weekly review of these figures before the next relaxation step is important.
“With over 4 million cases and 120,00 deaths, I hope we have learned that this virus (with its various variants) needs to be treated with respect and caution – and we should have anticipated and responded in this way a year ago.”
Prof Paul Hunter, Professor in Medicine, The Norwich School of Medicine, University of East Anglia, said:
“If we believe the reporting over the past couple of days then schools in England are set to open from the 8th March and at that time limited socialisation would be allowed in a public space with one other person outside the household/bubble. From 29th March socialising out of doors would allowed with up to six people or two households. Outdoor hospitality such as beer gardens or open air restaurants may also open sometime in April as may non-essential retail. After then the timetable becomes less clear.
“Allowing increased social interaction out of doors is likely to have little impact on R as we know that transmission of COVID outside is much less efficient than indoors1 and as pointed out by Professor Woolhouse there have been no obvious outbreaks associated with crowded beaches anywhere in the world.
“The main concern will be around opening schools on the 8th March. Although some scientists have argued that schools play little role in the spread of the epidemic, I think the consensus is that having schools open does increase transmission in the community, although why that should be is still not totally clear.2,3 The main risk seems to be around secondary school aged children.4 Non-essential retail also seems to have a relatively small impact on R.2,3
“So the balance of evidence is that allowing more social interactions out of doors as is being suggested would carry little extra risk and should be welcomed. On balance, the evidence would also support opening schools up to year 6. However, opening secondary schools does carry the risk of increasing R above 1.0 but this is not inevitable. Personally I would have waited till after the Easter holiday for secondary schools, but I understand the vital importance of getting our children back into education.
“The breaking news from Scotland about the effectiveness of both the Pfizer and AstraZeneca vaccines at preventing hospitalization is very good news, but there is still uncertainty about how effective vaccines will be at reducing spread. These vaccines will undoubtedly reduce R, especially as more people in the under 60s are vaccinated, but as we and other groups have pointed out vaccination by itself is unlikely to be sufficient to reduce R to below 1 by itself.5,6 So at least until more of the vulnerable population (people over 50 years and those with a pre-existing disease) are protected from severe disease by vaccination we need to be careful about allowing indoor environments, whether they be work places or entertainment venues, to become crowded. Nevertheless, I do look forward to a more relaxed and free summer in 2021 than we had in 2020 and once vaccine has been given to all people on the current priority list we should be able to relax restrictions further.
“But we must be cautious. Although there has been a lot of reporting that the UK R value has fallen to its lowest level, recent data on case numbers from the DHSC dashboard and the ZOE app suggest that the decline in the epidemic may be already slowing and so the R value already starting to rise. If this trend continues we may have less room to manoeuvre during the next couple of months.”
Prof Russell Viner, Professor of Adolescent Health, UCL, said:
“When considering reopening schools, it is essential we balance the risks of not reopening schools with the potential for schools to increase infection rates. To focus only on infection risks, as many do, ignores the clear evidence of major harms to mental and physical health that school closures brings to children and young people right now – and the reduced life expectancy and poorer health that this loss of education will bring to the next generation.
“Schools undoubtedly play a role in transmission of this pandemic, particularly secondary schools. Yet the evidence suggests that transmission can be very much reduced when effective control measures are used in schools.
“Our modelling (https://www.medrxiv.org/content/10.1101/2021.02.07.21251287v1) suggests it is plausible that schools can be reopened on 8 March whilst keeping the pandemic under control, if – and this is important – if we maintain lockdown for other parts of society and continue the rapid vaccine roll-out. Reopening secondaries fully brings the greatest risk for increasing infections, but may bring the greatest benefits for the mental health and life-chances of our children.
“Schools should be the first part of society to reopen after lockdown. The risks of not reopening schools are high.
“The plans for school reopening whilst very largely maintaining other elements of lockdown as reported over the weekend appear to offer a pragmatic and plausible approach to balancing the risks to different parts of our population. It will however require very careful support for schools and families, scientifically appropriate use of rapid testing and an efficient test and trace system linking schools with local public health.”
For a detailed systematic review of the harms incurred by school closures see our paper https://www.medrxiv.org/content/10.1101/2021.02.10.21251526v1
For modelling see https://www.medrxiv.org/content/10.1101/2021.02.07.21251287v1
For a systematic review of the impacts of school closures on community infection see our paper https://www.medrxiv.org/content/10.1101/2021.01.02.21249146v1
Note that all the above are preprints and under submission to journals.
Dr Michael Head, Senior Research Fellow in Global Health, University of Southampton, said:
“The key will be the return of children to schools. Children do desperately need to be back in school, but the trade-off is that there will an increase in the R number as a result. My personal view is that a more cautious approach with a phased return would be better. However, the flip side is that other indoor spaces are being kept closed and so there are few other areas where multiple households can mix, so hopefully this will still allow community transmission to come under control. We know that indoor settings are where most transmission takes places, and so the key to keeping new daily cases as low as possible is to restrict mixing of households within those indoor environments. Therefore, on the whole, this roadmap looks broadly sensible. With the vaccine roll-out going so well, this will eventually allow for a safer environment for staff and users when indoor workplaces like pubs, restaurants and office spaces do open again.”
Prof Lawrence Young, Professor of Molecular Oncology, Warwick Medical School, said:
“The government will use four tests to decide on the stepwise easing of lockdown. The current proposal to start lifting restrictions will proceed from the 8th March when the top four priority groups for vaccination will be three weeks after their first jab – the time it takes to reach a reasonable level of protective immunity. The four tests make sense in terms of ensuring that the vaccination programme continues at the current pace, that vaccinations are reducing the levels of hospitalisations and deaths thereby taking pressure off the NHS, and that the virus variants are not impacting the levels of infection and sickness. But there remain a number of significant unknowns. We don’t know for how long vaccines will afford protection and to what extent virus variants are or will become resistant to vaccines. We expect the Prime Minister to provide some initial detail on the impact of the current vaccination programme on the transmission of infection. Unpublished data from Israel shows that the Pfizer vaccine is 89.4% effective at preventing infections, whether symptomatic or not. This provides the first real-world indication that vaccination will block virus transmission. It is very likely that the AstraZeneca/Oxford jab will do the same but we need to see the data.”
‘COVID-19 Response – Spring 2021’: https://www.gov.uk/government/publications/covid-19-response-spring-2021
All our previous output on this subject can be seen at this weblink:
www.sciencemediacentre.org/tag/covid-19
Declared interests
Dr Peter English: “No interests to declare.”
Prof Lawrence Young: “No conflicts.”
None others received.