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Persistent high case numbers in the UK but does the Government’s ‘carry on as normal’ approach make sense?

https://coronavirus.data.gov.uk/details/cases

New cases of Covid-19 are now around  50,000 per day, with deaths and hospitalisations seemingly rising.  Yet the government response is to focus on the successful roll out of their vaccine programme, and not to be unduly concerned. This ‘passive’ response is being widely criticised in the media and by some experts.  In this post I consider how far the available data justify this ‘ vaccine only’ strategy.  (For the non-UK readers, I hope that many of the issues I raise are relevant to other countries with population-wide vaccine programmes)

What is the UK government narrative?

It may not have been enunciated as such, but this is my take on their view!

  • Covid-19 is now endemic within the population (rather than epidemic*), ie has moved from being an unusual one-off event to being a permanent state – at least for as long as anyone can forecast) – and its eradication is not likely  
  • Vaccines have been phenomenally successful at protecting against the adverse health consequences from being  infected 
  • Booster vaccines extend this protection
  • If the most vulnerable are vaccinated to the highest reasonable extent, ie by boosters at appropriate intervals, then the risk to individuals is as low as it can be and the burden on the health care system is acceptable
  • Whilst the overall number of cases was important as a measure of public health success at controlling the epidemic in March 2020, it is less relevant today – because of the success of vaccines 
  • We  accept that vaccines cannot eliminate transmission; but the recent overall rise in cases is predominantly explained by cases amongst the unvaccinated, especially teenage children 
  • This rise was entirely expected following the relaxation of mitigation measures in July and the return to schools and colleges last month 
  • Although not stated as such, the narrative above could also be summarised as “the new normal is that this flu-like illness will be around at some level continuously – but  given that this ‘flu’ has a successful vaccine to prevent the overwhelming majority of sufferers becoming seriously ill, no further public health interventions are needed.“

*What’s in a word? Pandemic is used when an infection covers several countries and populations, so the world has a pandemic whilst our individual countries suffer an epidemic  

What is the alternative narrative?

  • Cases are soaring out of control and are much higher than in other Western European countries who were more cautious in relaxing mitigation regulations 
  • With increasing number of cases, even if the percentage risk of a bad infection is the same, there will be numerically more deaths and those with serious complications
  • The reliance on vaccines may be over-optimistic if immunity is waning
  • The higher the number of people infected, the greater the chance that more vaccine-resistant mutations could become established
  • Public health measures should not only focus on preventing serious consequences but also stopping people getting ill at all; and even trying to stop transmission.

What are the facts?

1. Covid-19 is probably endemic

  • Even very high vaccination rates in some countries such as Singapore, they  are still seeing significant number of new cases
  • Indeed several national examples of infection rates disappearing almost to nothing then to reappear
  • Most experts accepted that Covid-19 was going to move to becoming endemic although this can only be proven in the future!

2. It is unvaccinated teenagers contributing the majority of the new cases

  • The UK government is correct that most cases are amongst the non-vaccinated, with teenagers being the group at greatest risk
  • The data from last week illustrate this clearly 
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/22october2021#percentage-of-people-who-had-covid-19-in-england-wales-northern-ireland-and-scotland
  • Most of the teenagers being infected had not been vaccinated: of 220,000 total cases in those under 18 in the most recent data; around 190,000 had had no vaccine

3. The vaccines are doing their job

  • It is well known that being double vaccinated gives excellent protection, greatly both reducing hospitalisations and deaths 
  • Some recent data last month published in the British Medical Journal* showed that
    • 97% of the 40,000 people admitted to hospital in 2021 (to the end of July) had not been double vaccinated
    • 99.5% of the 52,000 people who died within 28 days of  a positive test in the same time period had not been double vaccinated

*https://www.bmj.com/content/374/bmj.n2306

  • But these results can be easily misinterpreted, as double vaccination took some time to roll out
    •  ie the fact that there were only 3% of hospitalisations and 0.5% of deaths in people who had been double vaccinated reflects in part the low numbers that received their second dose by July
  • There is no dispute that vaccines are very protective, but that is not the main question we have as individuals.  Put crudely, “I am not interested that my risk is lower than if I had not been vaccinated, I want to know what my absolute risk is from getting really ill if I become infected
  • We now have these data from linking vaccine, testing and hospital datasets in the UK
  • The chart below shows the rate per 100,00 of ending up being admitted to hospital if you test positive (the black bars) 
  • As an example, this shows that this month even in the over 80s, less than 60/100,000 people who have been double vaccinated and who become infected are admitted, ie less than 1/1000
  • For the risk of dying following an infection the figures are equally reassuring 
  • Thus even in the 70-79 age group, less than 1/5000 double vaccinated, but infected, people will die (within 28 days of a positive test)
  • At first sight the data would support the government narrative that relying on vaccines at both an individual and societal level would appear to make sense

4. How much does vaccine immunity wanes

  • The above data assume that vaccines continue to be as effective over time – but we know that immunity wanes  
  • How much this waning protects against the most severe forms of infection is still not clear but rather than wait, UK and other countries have started a booster programme
  • The national data from Israel, and the recent clinical trial data from Pfizer,  would suggest that with a booster the protection against severe infection is maintained 
  • ‘We can only know what we know’ and cannot predict beyond the data we have; but a booster can restore or even raise the level of protection

5. Does it matter that the numbers are increasing?

  • It is mathematically obvious that as the number of cases increases, then transmission will increase
  • This is not necessarily linear and at any point the number of cases could soar
  • Thus, with increasing number of cases, the chances of any of us being in close contact with an infected person rise: so even if the percent protection from our vaccine against contracting  infection is the same, we are at greater risk of catching the infection (this is blindingly obvious but not often stated!)
  • So as a vaccinated person, as the number of cases rises, then my individual chance of contracting Covid-19 will rise and hence my individual risk of getting a severe outcome will also rise
  • But given the data above, even if my risk of catching Covid-19 infection increases 10-fold from the current rates – which is highly unlikely – then my absolute risk, as a double vaccinated person, of dying or getting a severe infection is still very small 

. Finally, what about mutations?

  • It is true that the higher the number of cases, the greater the risk of new mutations 
  • There are thus new mutations emerging all the time, with the most recent being a Delta-related variant: although these cause much excitement in the media they do not at the moment raise specific risks for vaccine success (so called ‘escape variants’)

Conclusion

  • It would be an act of folly to totally ignore the rising number of cases of Covid-19 in the UK
  • Given the relaxation by both government and the population of their vigilance and acts of mitigation, such as enforced mask wearing, it was obvious that transmission would increase and the numbers of cases grow
  • Thus far though, the data would support the success of the vaccine programme  as dramatically reducing the impact of the virus on individually affected people
  • The continuing emphasis on the vaccine programme, including boosters, should prevent any looming catastrophe from the current increased number of cases
  • Of course, there is a compelling case that say encouraging mask wearing might be a no-brainer at one level, to reduce transmission as far as possible and avoid even mild infection with the potential for longer-term symptoms

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7 replies on “Persistent high case numbers in the UK but does the Government’s ‘carry on as normal’ approach make sense?”

This article sets out to consider the Government’s claims and does so. But by limiting the scope to this aspect is disingenuous, I think. To be clear it is the issues the government avoids that should be integral to this article. There are questions relating to hospital overload: cancer patients not getting treatment and ill people being advised to go private if affordable for them( I would argue this is one of the Government’s intention in promoting private health care at the expense of the NHS) the vulnerability of immunosuppressed people with infections so high; the risk to some children. In fact to me it reads as a political piece. I fully support vaccination.

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Apologies for late reply, somehow I missed this comment. It was not my intention to be political and indeed I have several substantial criticisms of the current government in relation to their handling of the pandemic. Since I wrote this piece there have however been other independent experts from SAGE and other advisory bodies who have reached a similar conclusion: that both a successful teenage and a vulnerable persons booster programme could prove the most efficient use of govt resources at this stage in the pandemic. One can also question the population health benefit of the £20bn test and trace programme compared to the same investment into other aspects of the health and care system. As you say the harm to cancer and other services for people with none life threatening health problems is incalculable.

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Alan, this is tremendously helpful, because otherwise it is so difficult to get any type of balanced and informed view of the current situation. All of your postings have been of great use but this one puts the position in context and is devoid of the partiality of so much coverage of the pandemic. We live in Scotland and the retention of masks in many situations is not resented by anyone that we know, if fact, quite the reverse. Thanks for all the trouble that you take.

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This is very helpful and I appreciate it, but it leaves some things out in calculating risk. What is the risk of a case that causes harm, but is not deemed worthy of hospitalization? What if you will be ill for several weeks but never hospitalized? What will be the cost, financially and otherwise, to the individual and to society, from this happening on a large scale?

And even worse, what is the risk of Long Covid and permanent damage to an organ or multiple organs? For me, even losing my sense of taste or smell would diminish my life. It is starting to look as though Covid may turn out to be endemic the way polio and TB were endemic for centuries, causing suffering to millions of people over time.

Also even if one is in a low risk category, what is the risk of passing Covid on to someone in one’s household who is in a higher risk category?

I also notice something interesting in your numbers: for people over 80, the risk of death seems to be higher than the risk of hospitalization. How many people are dying without being hospitalized? Why? Is this by their choice? Are they getting some kind of supportive care?

Overall, if a condition that kills some people, makes others ill for long periods, and completely disables some unknown number, has now become endemic, should we not look at it as something to work towards eradicating as much as possible as soon as possible rather than just accepting it?

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The questions you raise about cases of Covid that are less serious are pertinent but almost impossible to put numbers on. The challenge is how to achieve a balance. In the Uk the test and trace system and the millions of tests done have been at the cost of £20billion to the public purse. Health economists rightly ask what would be the total benefit of using those monies to address other causes of ill health.

The risk of passing on Covid to someone in your own household is high and seems to be independent of your vaccine status, but this is now well known. Vaccines have some, but only some, impact on transmission

The question you raise about deaths and hospitalisation in the over 80’s is an observant one! Several things could be at play here including a reluctance to admit people over 80, the issue that the deaths record ‘dying with Covid’ and not necessarily ‘dying from Covid’

Eradication would be a worthy objective, I do not think with a reservoir of 1 million people in the UK currently infected that we have the tools to achieve this without a Chinese style lockdown!

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