With 19 July 2021 designated “Freedom Day” in England as all COVID-19 restrictions were lifted, the reality is that COVID-19 is still very much with us. We have not unlocked because case numbers are low, in fact they were rising rapidly to the levels seen in the previous waves on 19 July. (1)
We have unlocked for two reasons; one is the vaccination programme and the hope that it will protect against serious illness and deaths from COVID-19. The other reason is a case of “If not now, when?” as the summer months and school holidays provide the best opportunity this year to ease restrictions. (2)
Doctors are worried about the coming autumn and winter months. Cases of flu and other respiratory illnesses were dramatically lower last winter compared with those of previous years as the lockdown prevented them from spreading in the usual way. (3)
This was good in many ways, not least because an already over-burdened NHS may not have coped with a huge influx of flu patients. However, the downside is that some of the natural immunity built up in the population each winter did not happen either. Already this summer A&E departments are reporting seeing people presenting with illnesses usually seen only in the winter. (4)
The fear is that three viruses in particular will come together to create another potential breaking point for the NHS. The three? COVID-19, Influenza (flu) and the Respiratory Syncytial Virus (RSV) which predominantly affects babies and young children under the age of two. (See Appendix for more information on RSV.)
Society has never experienced the prolonged lockdowns of the pandemic before so it is hard to predict exactly what will happen over the latter part of 2021. With this in mind, Sir Patrick Vallance, the Chief Scientific Adviser to the UK Government, asked the Academy of Medical Sciences to assess what they thought might happen this winter. (5)
29 researchers came together along with 57 patient representatives to try and model possible scenarios. Their projections for a “reasonable” worst case scenario are that we will see twice as many hospital admissions for flu and RSV alongside continuing COVID-19 infection.
In a typical winter there are between 10,000 and 30,000 deaths from flu and around 20,000 infants are admitted to hospital each year with RSV.
Current projections are that this winter we will see up to 60,000 deaths from flu and 40,000 children admitted with RSV. (6)
The Academy also warned that the NHS, with a shortage of around 84,000 staff, is already heavily depleted and, with one in four NHS workers saying they are likely to leave their jobs as a direct result of the pandemic pressures they have been working under, further staff shortages could occur. (7) (8)
Professor Sir Stephen Holgate, the chair of the research group said: “Despite a highly successful COVID-19 vaccine campaign, the pandemic is not over yet. The message from our report is clear – COVID-19 is still with us and remains a threat to our health both directly and indirectly. All parts of society need to take action to head off the serious health risks we are facing now, and in the future.”
Professor Azra Ghani, also in the research group, said: “It is very difficult to predict the course of the pandemic this winter. We do not know how people will react to relaxing restrictions and the impact this will have on transmission, how long the COVID-19 vaccines will provide immunity for, or what new disease variants may emerge.” (6)
Vaccination Problems
Vulnerable people and all those aged 50 and over will be offered a double vaccine - flu and a COVID-19 booster - in the autumn. However, there are concerns over the growing number of younger people who are choosing not to be vaccinated. The UK has now offered a COVID-19 vaccine to every adult aged 18 and over but the initial long queues of young adults waiting to be vaccinated have dropped off.
London vaccination centres are reporting that they are operating at just 30% capacity. They are fully staffed and have more than enough vaccine but people simply aren’t coming forward.
Pippa Nightingale is the chief nursing officer of the Chelsea and Westminster Foundation Trust and has noted that: “Growing numbers of young people believed they “don’t need the vaccine.” I think this is the population that needs to really think, the ones that are sitting on the fence thinking they’re invincible, that actually they need to know this might be their last chance to come forward. We have done a lot of promotion about protecting grandparents, protect your parents, protect your communities.” (9)
Alongside this, researchers at Imperial College, London have found that vaccination rates among retail and hospitality staff are 20% lower than the national average. It is not clear why this is though there is speculation that working so-called zero hours contracts makes it harder for staff to book vaccination appointments as they do not know if and when they are free to attend. (10)
Triple tests
The Academy has also called for rapid tests for flu and RSV to be developed similar to those already in use for COVID-19. These viruses produce very similar symptoms to each other so testing for all three at once would help distinguish between them.
We already have the ability to test for flu and RSV as well as COVID-19 but, at the time of writing, testing for all three requires three separate tests in the UK. A single swab test that can look for all three viruses at once would speed up diagnosis considerably.
As Dr Alexander Edwards, University of Reading, says: “The triple tests have great appeal but the logistics could be a challenge. Whether there will be enough instruments and testing capacity available for this to be available widely in primary care remains to be seen." (11)
In the USA there is now a test in use that screens for COVID-19 and flu at the same time. (12)
And several US based firms are developing a triple test for COVID-19, flu and RSV. (13) (14)
Is there any room for optimism?
Yes, there is - if you search for it.
This is what Academy president Professor Anne Johnson had to say about its predictions: “Our modelling suggests a summer peak of COVID-19 infections with subsequent local outbreaks over winter – though we can’t completely rule out another winter wave. Whilst we expect the peak in deaths to be considerably lower than last winter, under some scenarios we could see hospital admission rise to similar levels. Furthermore, with a high level of virus circulating in the community there is a risk that the number of people living with long COVID could double....We’re not saying we’re about to have the worst winter ever, we’re saying we have got a bunch of uncertain things that could hit us in the winter that we need to think about mitigating now.” (15)
In other words, whilst we have to plan for a worst case scenario that does not mean it will inevitably happen. Trying to predict exactly what will happen and when with any disease involves the use of the words “could” and “might” a lot of the time. In the meantime there are a lot of extreme views circulating, from advocating a full lockdown again until COVID-19 is eradicated to claiming the pandemic is a hoax and does not even exist.
Absence of evidence does not deter scare store stories from being continually spread both in the mainstream media and on social media. What is needed is reasonableness and level headedness.
For example, every year we order vast quantities of flu vaccine without knowing how severe that winter’s flu will be or how effective the vaccine will be. This is not because of shoddy science or poor governmental policies, it is because diseases are unpredictable, they always have been and always will be.
Every winter we face uncertainty about how much flu, RSV and other respiratory viruses will circulate, this winter we have an extra uncertainty – COVID-19. We need to plan for it.
The UK’s current daily case numbers are exhibiting a pattern that is the opposite of the worst predictions.
The week before the UK ended lockdown the chief medical officer, Professor Chris Whitty, warned that the escalation of cases of infection in the UK was surpassing early predictions with close to 50,000 new cases a day being reported ahead of the ending of lockdown on 19 July.
Professor Whitty said: "Currently this epidemic is doubling. It's doubling in cases. It is also doubling in people going to hospital, and it's doubling in deaths. We've still got over 2000 people in hospital, and that number is increasing. If we double from 2000 to 4000, from 4000 to 8000, to 8000 and so on, it doesn't take many doubling times till you're into very, very large numbers indeed. I don't think we should underestimate the fact that we could get into trouble again, surprisingly fast."
The fear was some level of restrictions would have to be re-imposed within weeks of 19 July’s unlocking. (16)
Worldwide, scientists accused the UK government of acting "recklessly, unethically and unscientifically" by sticking with the 19 July date accusing the UK of providing the virus with “fertile ground”.
Professor Michael Baker, a professor of public health at the University of Otago and a member of the New Zealand ministry of health’s COVID-19 technical advisory group said: “In New Zealand we have always looked to the UK for leadership when it comes to scientific expertise, which is why it’s so remarkable that it is not following even basic public health principles.”
Professor José Martin-Moreno from the University of Valencia in Spain and a senior adviser to the World Health Organization (WHO), said: “We cannot understand why this is happening in spite of the scientific knowledge that you have.”
And Dr William Haseltine, a former Harvard Medical School researcher, said: “I am extremely dismayed to see the very rapid rate of increasing infections in a population that is vaccinated pretty much like we are.” (17)
However, I would take issue with some of these statements. The claim that the UK had not followed “even basic public health principles” does not stand up to scrutiny. One of the core tenets of public health is the prevention of disease which has vaccination at its heart. (18)
The UK’s COVID-19 vaccination programme has been rolled out more rapidly than virtually anywhere else in the world. 88.2% of all adults have received a first dose of vaccine in the UK and 70.8% have received a second.
In New Zealand just 8% of the population are fully vaccinated. (19)
In the US, as of 26 July, a total of 163,173,366 Americans had been fully vaccinated which is 49.1% percent of the country's population. (20)
Despite the claims above the UK is in a very different position vaccination-wise to many other places.
The UK’s decision to lift all remaining restrictions was based on the hope that the rapid roll out of vaccines would keep the number of people becoming seriously ill with COVID-19 down. It is based on the known science about vaccines and how they work so it is a little unfair to accuse the UK of ignoring scientific knowledge.
At the time of writing (27 July 2021) the daily number of COVID-19 cases recorded in the UK has fallen for seven days in a row.
It now stands at 23,511 having been 54,205 on 17 July 2021.
Epidemiologist Professor Neil Ferguson who had previously said 100,000 COVID-19 cases a day was "almost inevitable" after England's unlocking on 19 July reflected on the current case numbers saying: “ It is too early to tell if cases would now reach 100,000 a day, but I am happy to be wrong - if it's wrong in the right direction. We're not completely out of the woods, but the equation has fundamentally changed."
Without doubt, the UK is still walking on a tightrope where COVID-19 is concerned. Cases may be dropping but they are still high and could easily climb again. It is still a very fine balance between the virus and the vaccine that can easily be tipped in favour of one or the other but there is light now at the end of what has been a very long tunnel.
COVID-19 could be back with a vengeance next week....or next month....or next year. Or it might never cause problems again. Whatever happens it is always shrewd to plan for the worst whilst hoping for the best.
Appendix
RSV (Respiratory Syncytial Virus)
COVID-19 and flu need no further explanation but many may be less familiar with RSV.
RSV causes a condition called bronchiolitis which is a lung infection seen almost exclusively in very young children and babies, usually under the age of two. The infant has a marked cough and can be short of breath with a high temperature and runny nose. The breathing can become rapid and/or noisy.
More serious cases need hospitalisation primarily to administer oxygen to support the child’s breathing.
By the age of 2, almost all children have been infected with RSV although only around half will have had associated bronchiolitis. Of that half 2 to 3 % require hospital admission.
Very rarely RSV can cause permanent lung damage and be fatal but for the vast majority of cases full recovery in two to three weeks is the norm.
