There is media bias around discussing an elimination strategy- which is considered 'unrealistic' or not possible in the UK- where the rhetoric from govt & its advisors has been 'acceptable deaths' or 'living with it'. And this is hugely impacting conversations around UK strategy

These ideas are prominently platformed and discussed on the media, and discussions around elimination tend to be shut down. This is despite world-leading scientists, including @IndependentSage having repeatedly advocated for this approach, and this approach being tried & tested.

So let's have the discussion I was hoping to have yesterday on long-term strategy for COVID-19 in the UK. As I see it, there are two routes (not mutually exclusive).
1. Elimination through multi-pronged measures
2. Immunity through vaccination - accept 'tolerable' cases & deaths

Let's look at each of these. Let's look at 1. first - this strategy would require restrictions to be in place to bring cases down to very low levels (<10/100K) before easing restrictions. During this period, we would need to reform our broken Test, trace, isolate & support system

Duration of restrictions? From current levels, at an R=0.8, it would take 2-3 mnths to reach this target. If we improve current measures (better support for isolation, improved masking policies, mitigation in schools), this period could be reduced significantly, by reducing R.

What do we need to do during this period? Need to fix our test, trace, isolate system (put it in the hands of the NHS where its performance for complex cases has been excellent). Support with isolation. Improve safety measures in schools. Managed quarantine for 14 days at borders

Once we come out of lockdown, our test, trace & isolate system will need to rapidly identify any cases that arise, and take urgent measures to trace contacts, isolate, and stop spread into the community.

Additional protections e.g. mask use, distancing in some settings will continue until we have no outbreaks for a period of time, when life can return to normal. We will continue vaccinating people so they are protected in case community transmission occurs.

We will need continued border quarantine restrictions, like NZ & Australia which have been quite effective in preventing re-introduction of infection. When this does occur, it will need a quick & aggressive response.

This approach is associated with generally lower uncertainty because:
1. We've seen this be achieved in other countries.
2. It will require a defined duration of measures, but life will return to near-normal.
3. Less uncertainty around vaccine strategy

e.g. we wouldn't have to consider deviations from vaccine protocol, as vaccines are a pre-emptive measure, rather than carrying out vaccine roll-out in the midst of an overwhelmed health system.
4. Less uncertainty around evolution of new variants, and impact on vaccine efficacy

Let's look at 2. now - trying to achieve herd immunity or at least less severe illness in the majority of the population through vaccination.

While vaccines are central to any pandemic strategy, there are many unknowns with an approach that focuses solely or mostly on vaccines.

1. While vaccines confer protection against severe disease, & symptomatic infection, we don't know the extent to which they reduce transmission.
2. Even with full uptake of vaccines in eligible (not trialled in children yet), no guarantee of reaching the herd immunity threshold

3. The virus may be a moving target with the rapid evolution we are seeing at the moment, with mutations that make vaccines less effective, at least in preventing symptomatic infection. This means we may never reach elimination with vaccines.

4. Even without escape mutations, just with more transmissible strains, the herd immunity threshold (the proportion of the population that needs to be vaccinated to bring R below 1) will be higher. More transmissible new variants could push this even further.

5. We don't know the duration of immunity conferred by vaccination, which may mean frequent boosters are needed to top this up, or against new variants - we will need a high uptake of these across the population
6. We don't know the impact of vaccination in preventing long COVID

7. There is significant vaccine hesitancy in groups who are most at risk for many legitimate reasons, including structural discrimination which is not just historic but has continued throughout the pandemic. While uptake has been high in vulnerable groups, this may not generalise

Worth remembering Manaus where the majority of the population was exposed to virus, but we are still seeing surges of cases that are overwhelming healthcare capacity, with R well above 1. This could be the impact of a new variant escaping immune responses to previous variants

Or it could mean a higher herd immunity threshold than we anticipated, or that the duration of immunity conferred by infection is lower than we previously thought. Either way, it's clear that achieving elimination through this approach may not be as straightforward as we think.

Even if we could achieve herd immunity through vaccination, what is the cost of transmission after easing lockdown going to be, while only part of the population (albeit some of the most vulnerable) are vaccinated?

While it may seem counterintuitive, the cost is still huge.

A SAGE/Imperial model which examined release of restrictions gradually from March alongside vaccine roll out showed that even in the most optimistic scenario, this could lead to between 82,000 and 150,000 deaths. Model here:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/958913/S1024_SPI-M_vaccination_ask_Imperial_College.pdf

How is this possible?
Many reasons.
1. A single dose of vaccines in the over 70s will not provide absolute protection even for them.
2. Many deaths occur in people under 70 yrs
3. Roll-out and immunity post-roll out take time to develop

Exponential rises in cases can rapidly lead to high numbers of deaths even while vaccine roll-out continues.

While the model focuses on deaths, the impact on long COVID numbers would also be large - given case numbers & transmission would be high.

Further, high levels of transmission continuing alongside vaccination mean greater potential for virus adaptation. Escape mutations have arisen in the UK, even when population-wide immunity wasn't at high levels. With more selection pressure we should expect more adaptation.

We currently have at least three different variants with the E484K escape mutation circulating within the UK. We've been told that these are not likely to become dominant any time soon- but if these escape vaccines better than the original B117, they may become more frequent.

While we may be able to update vaccines, this will take time, and as we've seen from the data, high levels of transmission even over short periods of time with a partially protected population can have huge consequences.

And there are no guarantees will we be able to keep up with virus evolution. It's possible by the time we have vaccines against these variants, more may have evolved, if we allow adaptation to continue (by allowing high levels of transmission to continue).

So what about the 'downsides' of elimination that we keep hearing about?

'But we will need to have travel restrictions indefinitely'

Response: But we have travel restrictions in place now - and will likely need them to be in place for a long time because of new variants.

Not least because we have new variants within the UK, that many countries across the world are worried about importing.

It is likely we will need strict managed quarantines, but we will likely need these even in scenario 2.

And we're an island, so in some ways easier

'We can't do this - the UK is a travel hub- we can't have restrictions for so long'
Response: We've been in restrictions and in an out of lockdowns for almost a year. This will be much shorter, and the long-term impact on the economy much lower - with greater long-term certainty.

'But population density!'
Many countries across the world with greater population density than ours have achieved this - Taiwan, Vietnam.

'But we're culturally different'
Australia, New Zealand?

'But it would never work'
Why? It's clearly worked in other parts of the world

I think we need an honest, transparent, and factual discussion about this in the UK. These options aren't mutually exclusive, but one provides much more certainty, is tried & tested & has many advantages.

We should at the very least consider it & not silence discussions on it.