Thoughts on where we are in the UK right now with cases, and the new variant, and what this likely means for the future. And the focus of government solely on vaccination of vulnerable individuals- rather than mitigating transmission. This is short-sighted, and dangerous. Thread

Let's review where we are first. We have ~58K daily cases in the UK (7 day average) at the moment, and numbers are still rising. Hospitalisations are now 50% higher than the April peak, with deaths at ~600/day. We are now in a national lockdown with schools moving remote.

The govts plan for the lockdown appears to be roll-out of vaccines to ~13 million vulnerable people in the top 4 priority categories. The idea appears to be to vaccinate rapidly to reduce symptomatic and severe disease in these groups- reducing hospitalisations & deaths.

No plan has been articulated beyond this point, and vaccination of these groups has been presented as some sort of silver bullet after which life gets back to normal. This is not only completely unrealistic, but dangerous as it does not focus on transmission in the community.

Why is this short-sighted? First, vaccination of these vulnerable groups alone, will lead to a *reduction* in deaths, but we will still continue to see a large number of deaths if we allow the virus to spread.

To illustrate, considering an attack rate of 90%, we would still expect to see almost 200,000 deaths in other age groups if the virus was allowed to spread across the population (and this is assuming 100% vaccine uptake & efficacy for those vaccinated, which is very unlikely)

Second, this plan does not focus on transmission at all. Let's look at case numbers, and how these might change with restrictions. Let's first recall that cases with this variant were rising with an R of 1.45, even during the last lockdown (when schools were open).

Despite much of England being in Tier 4 until recently & schools being closed over Christmas, cases have still been rising rapidly as per the last ONS survey (some of this is likely due to socialising over & around christmas).

The next few weeks will be crucial to seeing the impact of further restrictions, but there is no doubt that as the variant is now dominant, and still increasing in frequency across much of the UK, bringing R below 1 will be very challenging even under current lockdown.

Lockdown measure in March brought R down to 0.6-0.7, but that lockdown was stricter, compliance was higher, and we didn't have the new variant to contend with. I think it is likely that we will at best achieve an R of just below 1 even with all these measures in place.

If we assume 60,000 daily cases currently based on current testing (almost definitely an underestimate- ONS figures put current cases at >110K), and an R of 0.9, we can expect daily cases to be ~32K, ~19K and 10K in 1, 2 and 3 months respectively.

This means that we will still likely have high case numbers, even in several months *if* we are able to bring R down to 0.9, starting with a baseline case number of 60K, which is in itself an underestimate.
One might ask - but what about the impact of vaccination?

We don't currently know the impact of vaccination on reducing transmission- we only know that it prevents symptomatic disease. Also, vaccinating 20% of the population (with unknown effect on transmission) isn't going to have a huge impact on spread.

Given these considerations, we can once again expect to see cases surging again once restrictions are eased *unless* we do something to break this cycle. If we want to break this cycle we need a long-term plan to prevent a surge after restrictions are eased.

Why would a surge of cases post-vaccination of these groups be harmful? Many reasons:
1. As I said before, there are many other vulnerable groups, and up to 200K people could still die if the virus spread unmitigated.
2. Long COVID- at least 10% of people have symptoms >12 wks

3. Risk of new viral mutations emerging high when transmission is high- these could be adaptations that change virus behaviour, but also more likely to see escape from vaccines, given a sub-population has been vaccinated.

4. We don't fully understand the impact of COVID-19 yet- it's been associated with long-term dysregulation of our immune systems, development of auto-antibodies, involvement of multiple organs, and virus persistence observed for months in the gut and brain in studies so far.

Are we happy for millions of people to be infected when we simply don't understand what this means?

This is why its deeply concerning that while the govt appears to be focused on bringing down deaths (which is key of course), there is no attention being paid to a long-term plan.

Allowing unmitigated transmission at population level is dangerous - and will have a significant impact on public health. Much of this impact will likely only be understood months or years later, but it doesn't make it any less important.

What should the govt do?
In parallel with vaccination, the govt should focus on elimination efforts- bringing transmission and cases down as quickly as possible. During this period, we need to reform our broken test, trace, isolate & *support* system.

This will help keep case numbers down, and prevent surges so outbreaks are contained as they happen, and before they give rise to onward community transmission so we don't see exponential growth like we've seen many times now. This will crucially mean better support for isolation

We urgently need to revisit our policies around social distancing & mask wearing, as it's likely that much higher compliance, and stricter distancing policies may be needed in light of the higher transmissibility of the new variant- this has also been suggested by NERVTAG.

Another surprisingly overlooked area has been planning for mitigatory measures in schools during this period. It's clear that schools have contributed significantly to transmission in the last many months, so it's astonishing that we are seeing no plans for making schools safer.

Unless we do this, we will continue to see surges in transmission as we open up, including transmission relating to schools. Another area that needs much more attention is travel & quarantine. The govt last year changed quarantine periods from 14 to 10 days without evidence.

It further discussed reducing quarantine by testing people 5 days apart. None of these strategies eliminate the risk of importing infection, which may also include new variants of virus identified in different parts of the world.

The govts current strategy of focusing solely on vaccination with vaccine roll-out being the only end-point & lack of long-term measures to contain transmission - seems suspiciously like the idea of 'focused protection' that was promoted by the Great Barrington Declaration.

We've been here 3 times now, but it doesn't seem like the govt has learned its lessons. There's no reason to think things will be different after easing lockdown if there are no measures to contain transmission. Deaths may be lower due to vaccination, but spread will happen.

The only way to protect our health is to focus on elimination with a long-term strategy that targets not just reducing severe disease among the vulnerable but also protects our whole society from the very real risk of transmission. Anything less than this is deeply negligent.

Just want to clarify for those who've raised questions about the 200K figure & how it was derived. It's based on the infection fatality rates (Verity) by age, used to calculate fatalities under 70 yrs based on UK demographics. Assumes an attack rate of 90% (due to higher R0)

It's illustrative in that it doesn't account for continuing vaccination for younger priority groups. I only included the top 4 priority groups because this seems to be the end-point with respect to easing lockdown.

It's likely that easing lockdown will lead to a surge in cases, unless we work pro-actively to put in place measures now to prevent this later. And surges could easily outstrip vaccination rates as we are seeing now.

Of course in reality, vaccination will continue down priority groups which will mitigate deaths depending on speed of roll-out vs transmission. The calculation also doesn't account for benefits from new treatments (including steroids etc.) & assumes 100% efficacy of vaccination.

So, essentially for illustrative purposes, to show the extent of risk to the population at large - but not a sophisticated model that accounts for all factors, including vaccine efficacy, and continuing roll-out etc. And it shouldn't be assumed to be predictive.