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Speaking to MPs this afternoon, the Health Secretary Sajid Javid confirmed the government’s planned easing of almost all remaining legal restrictions put in place during the pandemic will go ahead on July 19th.
Prof Mark Woolhouse, Professor of Infectious Disease Epidemiology, University of Edinburgh, said:
“The most difficult question to answer at this stage of the Covid-19 pandemic in the UK is: if we don’t lift restrictions now when should we do so? The government has taken the view – for England – that the benefits of lifting restrictions now outweigh the risks. The government recognises that there are risks, but we all need to understand that there will be risks whenever restrictions are lifted. The choice is not between taking a risk now and Covid-19 no longer posing any kind of threat if we were to wait a few more weeks or months – Covid-19 will continue to pose a threat for the foreseeable future; that is what ‘living with virus’ implies. We do not know precisely what will happen over the next few weeks – the government’s models have had difficulty predicting the complex interplay between relaxing restrictions, continuing vaccine roll-out, and a new variant – so it is vital that the course of the UK epidemic is monitored closely and that the public health response remains flexible.”
Prof Adam Finn, Professor of Paediatrics, University of Bristol, said:
“If you get any expert who tells you confidently what will happen next and what should be done you should probably ignore them as the truth is we are all in a state of considerable uncertainty and looking at the different scientific opinions around this there certainly isn’t a clear consensus one way or another.
“I sympathise with the political message that this can’t go on forever but on the other hand we really don’t want to get to a situation where things get so bad that we have to re-impose restrictions and it’s a very delicate balancing act to get that right. The more you let the genie out of the bottle the harder it is to put it back in.
“I think it’s right that people are being asked to continue to be cautious and there are things that we can do to reduce the spread of the virus that have no or limited impact on businesses, such as wearing masks, regularly testing yourself with a lateral flow test and working from home if possible.
“The most important message that should not be lost is that the vaccine program is key here. If people start to feel that the pandemic is all over and they no longer need to get vaccinated or their second jab then that would be a disaster as all the modelling relies on continued good uptake of vaccines.
“We need to get the message across that this is not a completely innocent infection in young people, it’s less of a problem than in the elderly or vulnerable of course but young people also come into contact with the old and vulnerable so they do pose a risk to others as well as having some risk themselves. Young people need to be vaccinated to get back to the normality than we all want – we need to work hard to get that message across over the next few weeks.
“There is some truth in the suggestion that it’s better to open up now than closer to winter as there is the risk of simultaneous epidemics of different diseases in winter. But in paediatrics we are actually seeing epidemics of viral infections breaking out now when we don’t normally see them as there is more mixing among children and adults after very little due to restrictions and so now we are seeing diseases breaking out even in the summer.
“Just how this all plays out is a hard thing to predict and I would urge people on an individual basis to continue to be cautious and not just throw all caution to the wind.”
Prof Azra Ghani, Chair in Infectious Disease Epidemiology, Imperial College London, said:
“The announcement today to lift a large number of restrictions in one go remains concerning at a time when transmission of COVID-19 is increasing rapidly accompanied by an increase in hospitalisations and intensive care units around the country.
“As reflected in the documents released by SAGE/SPI-M, there is a high level of uncertainty that remains about the evolution of COVID-19 in the UK in coming weeks. Whilst we have a much better understanding of the delta virus than just a few weeks ago, it is not clear how the public will react to this final phase of unlocking and hence what the likely impact will be on transmission.
“However, what is clear from all of the scenarios is that it is highly likely that rises in hospitalisations and deaths will accompany the recent rise in cases. Furthermore, in many of the scenarios considered, this could place a significant demand on health services that, whilst lower than the previous wave, is still going to reduce the capacity of the NHS to deal with other urgent care.
“The decision to fully lift seems to be driven by an ‘if not now, then when’ approach under the assumption that the only option available is to remove all restrictions at once. As illustrated in the SPI-M modelling (see for example page 7 of the report with graphs from Warwick University1 ), a rapid increase in contacts is expected to result in the worst possible scenario with higher peak levels of hospitalisations and more deaths than under scenarios where the change in contacts occurs more gradually. The latter could have been achieved through a gradual easing of the remaining restrictions and careful monitoring. Importantly, by taking a more gradual approach we could have kept transmission at low levels until all adults had the opportunity to receive both vaccine doses, thereby unnecessary exposure to a large segment of the population and the risks that this poses to their long-term health.”
Dr Peter English, Retired Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice, Immediate past Chair of the BMA Public Health Medicine Committee, said:
“I commented on anticipated announcements for Science Media Centre last week, and those comments stand.1
“We know that vaccination reduces the likelihood of being infected (although not as much as it reduces the risk of severe disease); but it does not eliminate it. And, while vaccination might reduce viral load and infectiousness in people who become infected, we cannot rely on this. Indeed, vaccination may induce, in people who are infected despite vaccination, a less severe, “attenuated” form of disease, in which they feel less unwell, and therefore continue normal activities, meeting and infecting more people.
“The more-infectious Delta variant is predominating now, and vaccine efficacy is relatively poor after a single dose, although from about 2 weeks after the second dose it rises to become comparable, at least in terms of prevention of severe illness (requiring hospital admission) to prevention with previous strains. Nevertheless, even according to this morning’s Downing Street press release, full vaccination is roughly 95% effective against hospitalisation. “…Pfizer-BioNTech vaccine is 96% effective and the Oxford-AstraZeneca vaccine is 92% effective against hospitalisation after two doses.”3 Even if this isn’t overoptimistic, about 5% of people who would previously have been hospitalised still will be. Case numbers are rocketing, rising faster than exponentially (doubling times are reducing) according to last week’s REACT-1 report.4 As Dr Duncan has reported, compared to the previous week, last week case numbers were 38% higher, and hospitalisations 58% higher, than the previous week; and intensive care and HDU bed occupancy had doubled in the previous 22 days.
The road map
“The NHS was already at breaking point before the pandemic, and by now it is broken.5
“Downing Street has referred to the government’s “four tests” for easing Covid restrictions.
“The four tests, all of which must apparently be met, are:
“Vaccine uptake rates are available at the government’s dashboard.6 Uptake rates are not too bad; but a significant proportion of the population is as yet incompletely vaccinated; and note my previous comments about the delta variant. The programme is continuing to be deployed successfully, so this first test is met.
“However, with respect to test 2, a single dose of vaccine is less effective than it was before the delta variant arrived. Regarding test 3, with the sort of case numbers predicted, even if only 5% of the cases who would previously have required hospitalisation do so once fully vaccinated, even with full, complete vaccination, hospitals and ICUs will rapidly be overwhelmed. So in my opinion it is clear that tests 2 and 3 have NOT been met.
“And of course, the delta variant has changed everything since it started to predominate, so test 4 has not been met either.
“Given that three of the government’s four tests have clearly not been met, we should not be moving to the next step on the “roadmap”.
When should we relax restrictions?
“Ministers have asked “if not now, when?”
“This seems to imply that it’s now or never; and it’s everything all at once… This is a false binary, of course. The truth is, the answer to the question “should we relax all restrictions” is not “Yes, straight away” or “No, not for the foreseeable future”. Other, more sensible answers are “Not yet” and “Maybe some of the restrictions can be relaxed, but others must be kept for longer”.7
“It has been suggested that if we don’t relax restrictions yet, it will mean doing so in winter, when transmission will be more likely. That is a very strange idea, given how quickly case numbers are rising now! If we “let it rip” now, we will likely be starting winter with a much higher number of cases than if we wait a few more weeks, until a much higher proportion of the population has been vaccinated. And ideally we should have vaccinated young people. Many of the infections are now in adolescents and young adults who, by their nature, tend to have a great deal of contact with other people, and thus to be a much stronger driver of transmission. Only once we have fully vaccinated a significant proportion of these young people will vaccination, alone, be able to reduce the daily new case numbers.
“It has been suggested that the link between cases and hospital admissions has been broken. As I explain above, it has been weakened; but there will still be large numbers of hospital admissions and deaths; and this number will be very much greater if restrictions are relaxed. And many of the commentators suggesting such a relaxed approach forget that Long Covid affects 30-50% of people, including children and young people; and a proportion will have lung, brain, or other organ damage that is likely to affect them for the rest of their lives. We should still be taking steps to protect others – including young people – until case rates can be brought under control; until the daily incidence is much lower, and rates are falling.
Are then any restrictions we could relax now?
“This is not to say that all restrictions must be kept on until case rates have fallen. The USA has, for some time, permitted gatherings without restrictions, when everybody attending the gathering is fully vaccinated. This approach may be reasonable (although I have some concerns about the delta variant).
“And, as I described in my previous response,1 we know a lot more about the virus and how it transmits than we did previously, meaning that we could review the guidance, and, for example, permit more contact in well-ventilated places, with regulation to ensure adequate vaccination before masks can be dropped.8
“We should still, however, legally mandate (and rigorously enforce) mask-wearing in enclosed public spaces, especially where people have little choice in whether they enter them. Good compliance with mask-wearing can be implemented – other countries have shown us the way.8
“For people who are reasonably concerned about their safety (people who are immune-suppressed, unable to be vaccinated, etc.), “freedom day” will be bitterly ironic. They will be less safe in public spaces, and be unable, for example, safely to go to work if they have no control over whether other, potentially infectious individuals will wear a mask. Rather than being freed, they will become more confined.
What will happen if restrictions are lifted on 19 July?
“Case rates, hospitalisations, and critical care admissions are rising dramatically at present. Deaths are “baked in”, and will certainly follow.
“Now is the time to tighten restrictions – perhaps not to add new restrictions, but at the very least, to more rigorously enforce the existing ones.
“It is possible that many people will follow government guidance, and continue to socially distance, to wear masks in indoor public spaces, and to limit their contacts with other people. But the message sent by relaxing restrictions – especially when some ministers say they will refuse to follow advice that isn’t legally required, as they have done – suggests that a significant and dangerous minority will ignore the advice, adding further impetus to the already high and rising case numbers.
“This will lead to many more cases, pressure on the NHS, cancelled urgent operations, people with long-term impairments from Long Covid and organ damage, and deaths. If restrictions are all lifted. Many of these could be avoided by maintaining and rigorously enforcing the restrictions until many more people have been vaccinated – every week’s delay in relaxing restrictions will make a huge difference.
“The harms that relaxing restrictions will cause can, and have, been confidently predicted. When they arise, the blame for these harms can be squarely laid at the feet of the ministers responsible.
References
Prof James Naismith, Director of the Rosalind Franklin Institute, and University of Oxford, said:
“With the government predicting up to 100,000 cases a day by August, I support the Prime Minister’s call for caution today after 19th July. The 4 week delay to date has saved lives as more people have been vaccinated.
“The more infections the more hospital admissions, the differences is it takes a lot more infections to create one hospital patient than it did (due to vaccines). The summer months and some hints from Scottish data might suggest, that we might not hit 100, 000 a day. We do not know enough to be certain. We have to hope but experience suggests and SAGE predict that we will see a large rise when final restrictions are lifted. I would plan for the pessimistic.
“We do know the cases will mainly be in the young, who are at much lower risk of serious disease (but not at zero risk). We know the vaccines are highly effective and safe. I would urge everyone to get vaccinated as soon as they can.
“Should we reach 100, 000 cases a day, then the consequences are likely to include
– 1000’s of new sufferers of long covid19
– Spill over into the vulnerable who are either unvaccinated or do not have effective response to vaccine; these people may wish to shield
– Difficulty for the health service as admissions climb to 1000 a day
– tracking and tracing could become counter productive but will inevitably stop / break.
“Our testing system and genetic analysis pipelines are world class. I have no doubt they will hold up under any conceivable wave. People who test positive must be supported to isolate as quickly as possible.
“Vaccination and social restrictions are the only measures proven to work in the UK and bring down cases. Once 80 % of those who can spread the virus are immune (by vaccination or infection), the virus will be unlikely to gain or sustain a foothold. The consequence of a large wave is to achieve this target by infection not vaccination.
“There is a lot of debate around masking. I will be wearing mine at work, on the train and indoor spaces. I do this to protect others, as a doubly vaccinated man in my 50’s, the mask offers me no benefit. I see this as tiny inconvenience that benefits wider society.
“Masks are not a panacea, they help but as part of package of measures. That package includes avoiding < 1 m contact indoors, improving ventilation, being outside where possible, testing twice a week and avoiding very crowded places.
“By focussing on the emotive issue of masks, we have lost sight of much bigger issues. Crowded gatherings which are indoors and poorly ventilated offer the virus the best opportunity, for example pubs or nightclubs or parties or crowded trains. It is to be regretted that we have not had a campaign to improve ventilation and have expended so much hot air on masking. Should virus friendly activities resume at scale, then I would expect a significant wave irrespective of masking. This wave would be relatively short but very intense.”
Prof Paul Hunter, Professor in Medicine, The Norwich School of Medicine, University of East Anglia, said:
“Much of the debate in recent days has been around whether or not it is safe to lift the remaining restrictions now. To my mind this is the wrong question. We should instead be asking ourselves when is the best time to lift restrictions.
“Looking at the four criteria:
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
“So I consider that we have met the criteria for initiating step 4 out of lock down. That does not mean that relaxing restrictions has no risk. But I would argue leaving step 4 till the autumn carries a far greater risk.
“The remaining restrictions should be lifted when the benefits to society from controlling the epidemic outweigh the harms of not lifting them and we are clearly getting to that point. But there is an additional issue that if we do not lift restrictions now when do we lift restrictions, especially as there is a real possibility that lifting those restrictions in the autumn would be more damaging to the epidemic and the NHS than lifting them now in the summer.
“Unfortunately a very small proportion of individuals in particular at risk age groups do not appear to have taken up the offer of vaccine for whatever reason and if they have not already recovered from a natural infection they should consider themselves to be at just as much risk are they ever have during the pandemic and need to continue with other forms of self-protection.”
Prof John Drury, Professor of Social Psychology, University of Sussex, said:
“What’s worrying about the new messaging is the way it individualises. The successes up till now in the UK response to the pandemic have been based on the public seeing themselves as interdependent. Some of the most effective government communications stressed the need to distance, wear masks etc. for others around us. The new announcement implies both individual self-interest and sufficient knowledge about risks (‘personal judgment’). But the government’s own advisory group SPI-B recommended only recently that personal judgement would only work if combined with support in the form of education so that people understand risks (e.g. indoors vs outdoors). By emphasizing individual responsibility, the government seems to be reneging on its responsibility to protect its citizens.”
Dr Stephen Griffin, Associate Professor in the School of Medicine, University of Leeds, said:
“It is understandable that the British public are frustrated and damaged by the repeated failure of the Government to make good on the sacrifices made during three consecutive lockdowns. However, as set out in a recent joint letter to the Lancet that has since received more than a thousand signatories from scientists, healthcare professionals and others, the planned relaxations on “freedom day” amount to a dangerous, irresponsible and experimental gamble that poses a very real threat of unnecessary harm to the British public. I am dumbfounded by the notion that public health can be left to individual choice when, in the case of infectious disease it is, in fact, the epitome of collective responsibility. Government messaging on restrictions currently amounts to an outright oxymoron by urging caution whilst simultaneously allowing all guidance to be lifted. How, exactly, are the British public supposed to “stay alert” to an unseen threat?
“In my view, there can be no logical measure by which the four tests required to move on to the next stage of unlocking are met, unless one takes an entirely static view of the current UK situation. First and foremost, the roadmap was designed to deal with the Alpha variant and yet we are now faced with Delta – the increased transmissibility and inadequacy of single vaccine doses must surely cause the Government to pause and reassess risk? Our incredible vaccines have weakened, but by no means severed the link between infections and hospitalisation, and although predominantly in younger people, there are now demonstrable and troubling increases in severe disease with an expected lag behind infection rates. This is already impacting upon NHS healthcare provision and will only continue to get worse as the NHS attempts to redress the current backlog. Delta is growing exponentially across all parts of the UK and freedom day will literally add more fuel to that fire – to ignore case numbers is to ignore the logical consequences of infection with a potentially dangerous virus.
“It is critical that we afford our incredible vaccination programme the opportunity to achieve its objective. By far the most important factors are to offer enough of the population a vaccine so as to approach population immunity (i.e. including adolescents), and to afford the programme enough time in which to achieve this goal. The mantra of data, not dates should not be forgotten or ignored, nor should the UK consider itself exceptional in being able to pursue impatient unlocking without profound consequences. This path is contrary to all guidance from WHO and any rational plan put in place by other countries, including those with similarly high vaccination rates.”
All our previous output on this subject can be seen at this weblink:
www.sciencemediacentre.org/tag/covid-19
Declared interests
Dr Stephen Griffin: “No conflicts.”
None others received.