Devi Sridhar: We should be treating Covid-19 like measles, not flu
Boris Johnson appears to have finally learned a lesson about the dangers of overpromising and underdelivering. The government’s roadmap for easing the lockdown allows for flexibility and is guided by the data rather than the dates. But there are still difficult problems to overcome.
Until 80% to 90% of the population has been vaccinated, a large percentage of people will still be susceptible to infection and hospitalisation, giving the virus plenty of opportunities to spread and strain the NHS. If England is to break the cycle of continuous lockdowns, it should learn a lesson from Israel: vaccines can be an effective way to suppress the virus, but only when they are also rolled out to younger age groups.
Prominent voices – including that of the health secretary – have told us that Covid-19 will become a seasonal infection, much like flu. But our public health approach should be more akin to measles. The UK should be aiming to suppress and eliminate Covid-19 through vaccines, mass testing and supported isolation. After we’ve achieved this, the UK should then help poorer countries in their vaccination efforts.
Unlike the early days of the pandemic, you will now find very few people advocating for the uncontrolled spread of Covid-19 (the so-called “herd immunity” approach). The real shame is that such voices ever had any influence over the government’s pandemic response. Over the past 12 months, Britain has lost almost 130,000 lives to Covid-19. Had the government pursued a zero-Covid approach from the start, following the example of countries like Australia, far fewer people would have died.
In the end, England seems to be on its way out of this pandemic, saved by vaccines and seasonal change. Outdoor transmission is a minimal risk, so it makes sense for the government to lift restrictions on outdoor socialising first. In fact, Scotland has allowed under-12s to play in small groups outdoors since July. This would be an easy win for England and other countries, too.
The imminent risk now is the full return of schools on 8 March leading to uncontrolled transmission. Scotland has taken a different approach, allowing younger primary students to go back on 22 February, followed by other students over the coming weeks in a phased process, as the impact on transmission is monitored and analysed. Again, England’s roadmap must be driven by data and science, and not by the loudest voices in the room.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh
Jennifer Dowd: The approach to Covid-19 in schools is one of dangerous exceptionalism
Many parents in England will have heaved a sigh of relief that schools are due to reopen on 8 March. But aside from testing pupils on a twice-weekly basis, ministers have offered no further detail on how transmission in schools will be prevented as part of the government’s roadmap for easing lockdown. As with many aspects of our pandemic response, England’s approach to Covid-19 in schools seems one of dangerous exceptionalism.
While there have been many spirited debates about the precise role that schools play in helping Covid-19 spread, two things are indisputable. First, schools bring people into prolonged physical contact with one another, talking and breathing indoors. Second, Covid-19 is spread primarily through aerosols that spread better in unventilated environments. Pretending that the rules of physics and biology somehow don’t apply in classrooms risks undoing the difficult sacrifices of lockdown.
To ensure the reopening of schools doesn’t bring the R number back above 1, England must put basic mitigation measures in place. Masks should be mandated in classrooms, and schools should be better ventilated. Opening doors and windows can have a significant impact on reducing the accumulation of aerosols. Where that’s not possible, portable high-efficiency particulate air (HEPA) filters can make a big difference at a relatively low cost. Kids of all ages around the world are wearing masks in school this year. The same should be the case in England. Arguing that masks inhibit classroom learning when the alternative is sending students home to self-isolate, or closing schools altogether, defies common sense.
Alone, each of these measures is imperfect. But taken together, they can have a significant effect on the rate of transmission. Mask-wearing in schools need not be perfect, and individual exceptions can be made. Unfortunately, we will never know how many Covid-19 cases and deaths in England could have been avoided if these basic school mitigation measures had been put in place last September. To ensure this lockdown really is the last one, we should not make the same mistake twice.
Jennifer Dowd is a professor of demography and population health at the University of Oxford
Graham Medley: The government’s gradual timeline seems sensible
During an epidemic there are only two directions a virus can take: up or down. If the R number is above 1, the virus is going to spread, and if it is below 1, the virus will decrease. At the moment, the UK’s epidemic is decreasing but we know it could double in size in a couple of weeks if transmission picks up again. Despite the progress made in driving down cases during the lockdown, we’re only a month away from being back in the same position as we were in December.
This is why a careful, measured approach to easing restrictions is sensible. The government’s roadmap proposes a gradual timeline for easing restrictions that will occur in four separate phases, with the final constraints lifted by no earlier than 21 June.
Of course, things are not the same as they were in 2020. We now have a vaccine, which we are deploying at a remarkable rate. There are two things that control the rate of transmission of a virus – the amount of contact between people, and the proportion of those people who are susceptible to infection. When these two things are at their highest levels, the R number for this virus is about 3. A year ago we were all susceptible to the virus, as there were no vaccines available and nobody had been exposed to Covid-19 before, so reducing contact was the only way to make R smaller. Now, with more than one-third of the population estimated to be immune to the virus, the maximum R can get to is 2, and fewer restrictions will be needed to keep R below 1.
But timing is everything. If the amount of social contact increases faster than susceptibility decreases, then transmission could dramatically increase. If susceptibility goes down faster, and lockdown measures are prolonged, then we will be unnecessarily restricting people’s lives and livelihoods.
Balancing the amount of social contact with the speed of the vaccine rollout will allow us to exit the epidemic with minimal damage from now on. This will not be the end of Covid-19, and there will be more twists in the tale. But the next few months will be a key step in learning how to live with it.
Graham Medley is a professor at London School of Hygiene & Tropical Medicine and chairs the Sage sub-group on pandemic modelling
Stephen Reicher: A coherent and sustainable long-term strategy is still missing
After a year during which the government responded to rising infections too slowly and lifted restrictions too quickly, Boris Johnson has promised that, this time, the easing of lockdown will be “cautious but irreversible”. In some ways, the government’s new roadmap for lifting England’s third lockdown looks very different to previous attempts. There will be no sudden reopening of the economy, and people will only be allowed to mix indoors in the third phase of the roadmap, which will be introduced no earlier than 17 May.
But in other respects, this roadmap throws caution to the wind. Opening schools in one go hardly seems like a prudent decision. On this issue, the government could have learned from countries such as Norway, which has adopted a “traffic light” system: in areas with higher levels of infection, children return to school for some of the time to allow for social distancing, and multiple safeguards are still in place. As infections fall, these restrictions are lifted.
The answer to whether this roadmap will ensure an “irreversible” lifting of restrictions is again found in the detail. The best way to irreversibly lift restrictions is to enforce other measures that can drive down infections when the lockdown is lifted. Vaccinations are clearly one of those measures, but for now at least, they are insufficient on their own.
England still urgently needs an improved test-and-trace system in order to identify new cases and variants. The government needs to provide adequate resources to people who are self-isolating, rather than simply instructing them to do so. England must find ways to make schools, workplaces and restaurants safer, with a common set of standards for what makes a place Covid-safe. And we need to properly control our borders, with robust isolation policies in place for people arriving from countries where variants are unknown. In short, we need a coherent and sustainable long-term strategy to suppress Covid-19. That has always been missing. It still is.
Stephen Reicher is a member of the Sage subcommittee advising on behavioural science