The Covid discussion is all about the high case rates in England, the phenomenally high rates in children and whether we should do anything about it. Last week the British Medical Association, the NHS Confederation, trade unions and the Labour Party all called for the government to move to its winter “Plan B,” which would mean reinstating mask mandates in indoor public spaces, recommending home working where possible and potentially introducing vaccine passports. Meanwhile, there were rumours that Plan B would come this week, “not today,” after COP26 in November or not at all as cases are set to plummet. Reported cases have fallen in the past few days, but so have tests (with the start of half term) and the proportion of people testing positive remains high. So what is going on?
There is little doubt that we are entering winter in a much worse position than our western European neighbours. Cases, hospital admissions and deaths are all considerably lower in Spain, Portugal, France, Germany and Italy, to name a few. This is largely due to England being the first among those to remove almost all restrictions. Other countries have pursued a “vaccine-plus” strategy, where high vaccination rates are combined with some or all of continued mask mandates, restrictions on the highest-risk venues (such as nightclubs), vaccine passports and efforts to improve ventilation, all of which seemed to help keep Delta under control as vaccinations progressed (85 per cent of Portugal’s entire population is vaccinated, compared to 67 per cent in England).
While the 100,000 daily cases Health Secretary Sajid Javid warned about in July did not materialise, cases remained high all summer. Again unlike our European neighbours, we failed to vaccinate as many teenagers as we needed over those months and failed to put in place proper mitigations in schools, leading to rapid increases in cases among children over the first half of term. By the end of last week, we had 15,000 newly reported cases in children under 15 every day and almost 10 per cent of all 11-15 year olds had Covid. High cases in children have spread to not just their parents’ generation but also their grandparents’. The same number of people in England have tested positive for the first time since 1st June as did from 1st September 2020 to 31st March 2021—3.5m.
These high case numbers have consequences: over 75,000 hospital admissions, 11,000 deaths and thousands more cases of Long Covid. We have also seen a new subtype of Delta emerge, called AY.4.2, that appears to be a little more transmissible than its parent. Its advantage is small enough that it is unlikely to change the game in the way that Delta did, but it will be enough to make things harder than they should have been. We are now heading into the months when people move indoors to socialise and Covid-19 thrives.
“By the end of last week, almost 10 per cent of all 11-15 year olds had Covid”
As well as the deliberate policy decisions to tolerate high case numbers, particularly in young people, England has also been a little unlucky. The greater vaccine resistance of Delta compared to previously dominant variants has meant that any waning of immunity after vaccination is more of a problem. Waning is gradual, but becomes a noticeable issue about four to five months after the second dose. While effectiveness in preventing severe illness and death has remained high, waning is more pronounced in older people or those with underlying conditions. We also used far more AstraZeneca than our European neighbours for over-40s which, while an excellent vaccine, is less effective than Pfizer against Delta. That means many of our most vulnerable people, now six months or more from their second dose, are at increasing risk of catching Covid and then developing more severe illness.
So where is there cause for optimism? Firstly, vaccines in people under 30 are extremely effective in preventing both infection and severe illness. After a dismally slow beginning, the teen vaccination programme in England is hopefully about to take off, with parents being able to access vaccines for 12-15-year-olds outside of school settings. If we can get doses into teens rapidly over the next two weeks, this will have a significant braking effect on transmission, as well as protecting children themselves from educational disruption, sickness and Long Covid. Half term will also act as a natural brake on transmission as children mix less with others, especially in areas that have two-week breaks.
The other good news is that boosters too are incredibly effective at preventing infection and severe illness in older and vulnerable people. We have already boosted over 50 per cent of the over-80s, but we need this to speed up significantly to keep pace with the numbers becoming eligible every day. Accelerating the programme will directly protect older people and reduce hospital admissions and deaths.
We do have means at our disposal to complement high vaccine coverage: better case identification and isolation (including communicating the full range of symptoms and supporting people to isolate); reaching out to under-vaccinated populations; reinstating mask mandates in general and in secondary schools; investing in better ventilation; encouraging working from home; and considering the option of vaccine passports in higher-risk settings. None of these measures are anywhere near to lockdown measures—indeed, they make lockdown much less likely than if we continue to rely solely on vaccination and natural immunity, which appears to be the current plan.
While, in time, vaccines on their own are likely to be able to do almost all the heavy lifting of keeping cases very low, we are not there yet—and to have maximum impact we would need to offer teens their second dose, roll out vaccines (if approved) to 5-11 year olds and consider boosting all adults.
If we can combine accelerated vaccination with additional measures as soon as possible, we will be in a far better position to bring cases down rapidly and keep them there. This will reduce some of the current extreme pressure on the NHS, lower the risk of even worse variants emerging and give us the best possible chance of a sociable Christmas.
