The UK COVID response — Things we could do better

It’s been a while since I’ve written about Covid, partly because it’s felt like not much has changed during these long gloomy weeks of lockdown, and partly because I’ve been hanging out on Twitter a lot observing the discourse and mulling it over. But I guess it’s fair to say that we’re moving into a new phase of the pandemic now, and that over the past few weeks my thoughts about it all have percolated into a few persistent messages. Note that scientific and opinions and predictions as to what will or should happen next are pretty broad at the moment, so this is definitely more of a “these are how I view things from my personal professional perspective” article than it is an explainer article. On that note, here are my thoughts on what we need to improve on at the moment:

THE DOOM AND GLOOM

It’s been a long, hard winter of long and difficult weeks. The death rates have been appalling, the scenes from the NHS wards heart-rending, and the news of new variants frightening. It’s easy to open the news headlines or scroll through your news feed and feel like of this is ever going to end, and that we will be stuck in this awful, terrible pit forever. But there are reasons to be cheerful. Really, there are. Let’s outline a couple:

Case numbers are dropping — When the new variant B.1.1.7. (aka the “Kent variant”) arrived on the scene, there was real concern that this version of the virus was so transmissible that even lockdown would not contain it. Scientists postulated that potentially even the toughest of restrictions would not be sufficient to get R under 1, and the most we could do would be to slow the increase of cases but not turn them around — with potentially catastrophic effects for the NHS. As it turned out, those fears were unfounded. All across the UK, case numbers, hospitalisations and deaths are dropping steadily. We’re still far from out of the danger zone, wards are still too full, and too many people are still losing our lives, but we shouldn’t forget amongst all of this that the curves are all heading in the right direction, which is something to be very thankful for. Cases dropping brings hope.

Spring is on the horizon — Lockdown3 has been really hard to deal with, in large part because of the greyness, the cold, and the general bleakness of the world contributing to the sense of being under siege in our homes. But the days are getting longer, the Earth is about to blossom again. This is good for multiple reasons — firstly, being outdoors in nature is really good for our mental health and wellbeing; secondly, the risk of transmitting Covid outdoors is remarkably small so is a much safer place for social interactions (and my goodness we are all craving those); and thirdly, spring marks the end of “respiratory viruses season” and we can anticipate that transmission of SARS-CoV2 (the virus that causes Covid) may drop off naturally in the same way that many respiratory viruses tend to. Spring brings hope.

The vaccination programme is nothing short of incredible — it’s been barely a year since Covid arrived uninvited into our lives, and here we are with not one, not two, but several highly effective vaccines that are licensed and being rolled out across the world. That is a staggeringly phenomenal achievement (for more info on how we got there, see my earlier article — reference in the comments). In the UK the vaccine roll-out is going so well that we have exceeded expectations on of jabs administered, and early data are suggesting that the decision to gamble on a one-dose-for-more-people strategy has proved the right one. With vaccination continuing apace, severe Covid and an overwhelmed health service should soon be a thing of the past. There are also early signals that as well as reducing severe illness, the vaccines also reduce viral transmission — something that wasn’t tested for during the clinical trials, but which is really good news. Vaccines bring hope in abundance.

These past few months were always going to be the hard. It’s no exaggeration that I used to lie awake at night in July last year dreading what we would see over the winter. But we are coming out of the worst of it now. There is still a need for vigilance — to not ease restrictions too early (numbers are still far too high and relaxing prematurely could make them shoot up again); to not facilitate the spread of transmissible variants that could threaten to outpace the pace at which we vaccinate; and to protect a greater proportion of the population through vaccination, to prevent both severe illness but also hopefully long Covid as well. We’ll also have to be vigilant with virological surveillance and the potential need to tweak vaccines to make sure that new variants don’t escape the current vaccines available — which is a standard part of the ongoing dance that vaccinologists engage in with the pathogens they are tasked to prevent.

But amidst all this vigilance there is, most definitely, a lot of good reason for hope.

BLAMING, SHAMING, AND CHASING FALSE NARRATIVES

Over the past months there has been a lot of outrage from media, the public and politicians at “Covidiots” and selfish people breaking the rules, as if these people are numerous and are solely responsible for the spread of the virus. This isn’t really the case, however. Most people have understood the need for control measures and have followed them wherever they can. Compliance is pretty high — and in fact, drawing attention to rule-breakers actually has a negative effect overall because it can convince people that “other people are breaking the rules, so why shouldn’t I?”

Another focus for fear and outrage has been around people meeting or exercising outdoors, with joggers being particularly stigmatized for running round breathing heavily. But this is largely a red herring: the risk of Covid transmission outdoors is pretty tiny, and negligible if passing someone momentarily in the street. Far from being discouraged, exercising in the pandemic is a great way to maintain physical and mental health during the challenges of lockdown and should be encouraged.

Indeed, blaming, shaming and stigmatization have never been very effective ways of improving health and welfare. It’s best to look to the evidence to see what are the actual reasons behind the distribution of disease in a population, and having identified those, to facilitate and support people to adopt healthier behaviours that are feasible within the context of their lives. With Covid, the reasons for spread are much less to do with willful disregard of the restrictions, and more to do with people not being able to comply with them for structural reasons outside of their control, such as social and/or racialized inequality (more on that later). These things might be less visible than a jogger in the street — but they are what we should be directing our focus towards.

CONSIDERING CHILDREN

One of the strangest and most wonderful things about Covid is how it affects children. For reasons still poorly understood, children — particularly primary school age — are less susceptible to infection with SARS-CoV2, very possibly less likely to transmit the infection further when they do become infected, and highly unlikely to experience severe disease. This might seem counterintuitive, given that kids are not famed for being the most hygienic of beasts, but as an age group they are not big drivers of transmission. What is less well understood, however, is the role of schools in driving transmission in the community. Schools are a context where a lot of households mix; so you can imagine that even if it’s unusual for a child to infect someone else, if that child comes into contact with lots of people (in a way that adults don’t really get an opportunity to these days), the likelihood of that child passing on the virus to someone else might increase.

Prior to the new variants arriving on the scene, the consensus view held by WHO and ECDC on assessment of the available evidence was that community transmission drove outbreaks in schools, rather than the other way round — i.e. it was people bringing virus into the school that caused school outbreaks, rather than superspreading in schools seeding outbreaks in the community — and that primary schools had lower rates of transmission than secondary schools. However, the Kent variant (which is now dominant in the UK) is across-the-board more transmissible in all age groups including children (although not disproportionately more so in children), and this may well have moved the goalposts in terms of how risky schools are as an environment for transmission.

Whether schools are driving community transmission or community transmission is driving outbreaks in schools is hotly contested by scientists. There’s also some discussion of to what degree Long Covid might affect children — ONS published some worrying data that 12% of kids might be showing symptoms of Long Covid, but this did not have a control or comparator group — so there is no way of knowing whether these symptoms are being seen amongst kids who’ve had Covid in particular, or amongst kids in general.

What is not contested, however, is the mounting evidence that (1) children are at very low risk of severe illness from Covid; (2) teachers do not seem to be at increased risk of more severe illness compared to the general population, and (3) prolonged school closure is causing huge harms to children, in terms of their mental health, social development, learning loss, and embedding inequalities (NB — more to come on why inequality comes back to bite us all). Children need children. Shutting them away from each other for months on end is harmful — for them, and ultimately for all of us given these little people are the adults we’ll be relying on to underpin the very fabric of our society when we’re older. Taking all this evidence together, the message is pretty clear: for most children, the risk that school closure poses to them far, far outweighs any risk that Covid poses.

So what to do? In my view, we need to get children back in school for in-person learning as quickly as we possibly can. My own interpretation of the evidence is also that the risks that schools pose for Covid transmission is probably being overstated. But that doesn’t mean we should just open them back up and carry on as before — low risk doesn’t mean no risk, after all. It makes sense to lower any transmission risk in schools to the lowest level possible — this in itself will help prevent further disruption to children’s lives as it would mean fewer classes being sent home to isolate whenever cases are identified. In an ideal world, we’d see a funded plan from government, co-produced with schools who understand their environments, to reduce class sizes, increase space available for teaching, improve ventilation, provide better handwashing facilities, etc. There will always be logistical challenges, but other countries have found ways round these things to keep their schools open — for example through part-time attendance mixed with remote learning. I have no idea why this doesn’t seem to be forthcoming (leaks seem to suggest the bold move of reopening all schools for full-time in-person learning in one big thunderclap on March 8th, which seems quite a gamble) — but perhaps I’ll be pleasantly surprised.

However — the absolute best thing we can do to bring down any risk in schools and their wider communities is to prevent spread happening between adults. Adults are the super-spreaders when it comes to Covid. We grown-ups need to take the hit. And there are ways and means of doing that which we haven’t even tried yet — more on that later (spoiler alert: a lot of the solution lies in Covid infection not actually causing so much of “a hit”). I very much hope that when we do re-open, we don’t see a repeat of the complaints last autumn going round on social media along the lines of “Why can’t I have my friends round for dinner given my child is back at school?”. The reason why is precisely *because* your child is back at school. If we add pressure to the system in one place (schools reopening), we have to release it elsewhere (limits on adults mixing). We will need to make some sacrifices for the nation’s children — goodness knows they’ve made enough sacrifices for us.

ADDRESSING INEQUALITIES

There’s no magic bullet to solve the Covid pandemic, but if there was one thing that could help solve a lot of our problems, it would be responding to social and racial inequalities as part of our response.

If you’re in a lower income or BAME group, you’re more likely to have severe Covid or to die from Covid. This is not a coincidence. Less privileged societal groups tend to have worse pre-existing health, due to living conditions and to the “inverse care law” (the principle that the availability of good medical or social care tends to vary inversely with the need of the population served).

If you’re in a lower income or BAME group, you’re more likely to contract Covid. This is not a coincidence. Lockdown policies privilege people who can work from home, and shift risk onto those who can’t. People who are on low incomes and/or are from a BAME group are more likely to be in a job that requires contact with the public, and to have to use public transport to get there. They’re also more likely to be in a position where they can’t self-isolate if needed, perhaps because they can’t afford the time off work, or because they live in a crowded household and are going to expose the people you live with.

If you’re in a lower income or BAME group, you’re less likely to get vaccinated. This is not a coincidence. If you are working all hours to make ends meet, it can be hard to find the time to get to an appointment — and why would you trust the medical establishment if all your life you’ve suffered from the inverse care law?

Taken together, this is the perfect storm. Our response at present is heavily discriminatory, privileges the affluent, and exacerbates inequalities that already existed. This is evidently unjust — which should be enough in itself to mean that we should do more about it — but moreover, it affects every single one of us, no matter how much privilege we’ve been born into. Social inequalities drive up Covid rates and hospitalisations, and high Covid rates mean persisting restrictions for everyone. I believe that we would get a lot further, faster if we focussed not so much on “tough” restrictions and more on “supportive” ones — for example, easy access to financial support to isolate for people on low incomes, or provision of hotel quarantine for people who live in crowded homes. Right now even our level of statutory sick pay is barely enough to live on. These kinds of policies would do a lot to bring down transmission amongst adults, and in doing so would pay for themselves pretty quickly. It’s never too late to implement them, so if you’re going to be demanding anything different about the Covid response, this is where I recommend you lay your focus. That extends internationally, by the way — if we want to protect ourselves from new more transmissible variants, the best way to do so is to reduce Covid prevalence across the world by making sure Low and Middle Income Countries also achieve high levels of vaccine coverage, rather than rich countries gobbling up all the vaccines for ourselves.

So — in summary, we’re not quite out of the woods yet, and there’s much that still could be improved. But, to bring us back to the first point — now more than any point in the pandemic: there is very good reason for hope.

A few references/further reading:

Vaccine development: https://georgialadbury.medium.com/to-vaccinate-or-not-to-vaccinate-that-is-the-question-306a9ba1da00

Compliance with restrictions: https://blogs.bmj.com/bmj/2021/01/07/pandemic-fatigue-how-adherence-to-covid-19-regulations-has-been-misrepresented-and-why-it-matters/

Risks of outdoor transmission: https://threadreaderapp.com/thread/1348771251758784517.html

Schools and Covid: https://www.youtube.com/watch?v=OOpH9mbiGnQ

Social inequalities and Covid: https://www.bmj.com/content/372/bmj.n224.full

https://georgialadbury.medium.com/covid-control-the-critical-factor-thats-missing-from-the-uk-response-45d6e73c5e89

I’m an infectious disease epidemiologist with special interest in zoonoses, new & emerging infectious, One Health, and interdisciplinary public health research