“Let’s use data, not dates,” Angela McLean, the UK government’s deputy chief scientific adviser, told members of parliament on Wednesday. In the process, she provided a catchphrase that will guide the difficult discussion the UK starts next week about the route out of Covid-19 lockdown.
With Boris Johnson set to announce a “road map” for lifting restrictions on Monday, the prime minister is under pressure from the more libertarian wing of his Conservative party and from some business groups to outline a timetable for reopening specific sectors of the economy over the next two to three months.
On the other hand, McLean was speaking for the vast majority of scientists who are urging great caution in lifting restrictions, with a flexible timetable that can be adjusted in the light of events and the evolution of the virus.
Johnson’s road map will be closely watched around the world, given that the UK is more advanced than most in rolling out vaccines. The country has also been one of the first to deal with new variants of coronavirus, which might be even more transmissible than the initial versions and better able to resist vaccines.
Behind the debate over easing lockdown, there is the growing public realisation that the new Covid vaccines — while representing a stunning scientific achievement — will not be the silver bullet they might have seemed in December, when the first trial results appeared. There will be no moment of liberation, a national summer street party with bunting and lemon drizzle cake.
Instead, governments and societies will have to learn how to manage a complex series of risks, both in the short term while only part of the population has been vaccinated, and in the long term as the disease lingers even after most people have received the jab. International travel could face restrictions for some time to come.
Some scientists describe a long drawn-out battle with an endemic virus that constantly evolves — with new vaccines and treatments being deployed in a way that they hope will allow much but not all of normal life to return.
“The challenge is to find a way to live with it without keeping huge restrictions in place,” says Azra Ghani, professor of infectious disease epidemiology at Imperial College London.
The UK has one of the strictest lockdowns among rich nations at the moment, although it is not alone — from Germany to California, many other places also face considerable restrictions.
But each government is starting to face a similar set of questions — just how quickly to restore normality as vaccines are rolled out among the population.
All available indicators of the UK Covid-19 pandemic have been moving in the right direction for more than a month. Infections, reported cases, hospitalisations and deaths are falling fast. On Thursday, for example, the React-1 study led by Imperial College London showed that infections in England — while still high — had fallen by two-thirds in less than a month.
So far infections have been driven down almost entirely by social distancing. Although vaccination started in the UK on December 8 and has already immunised more than 15m people — mainly aged above 70 — there is no clear signal from published data that this is reducing transmission. Infections among older people are not yet declining any faster than among young adults.
However, the most up-to-date analysis by Public Health England, presented to the prime minister on Friday, is believed to show that the scale of the BioNTech/Pfizer and Oxford/AstraZeneca vaccine programmes is starting to slow transmission.
The first signs of an effect are beginning to appear in UK hospitalisation and death data. On Thursday, Scotland’s first minister Nicola Sturgeon called a sharp recent decline in the proportion of deaths occurring in care homes “very strong and compelling evidence” that vaccination was protecting elderly residents.
One Whitehall official says that next week’s policy paper defining the road map for lifting restrictions in England would be driven primarily by “data, not dates”, echoing McLean’s words. Although the contents have yet to be finalised, the individual adds: “The plan is likely to say: ‘If we reach X data point, then Y measure can be relaxed.’”
All public health experts agree that schools should be first to reopen because of the educational and psychological damage caused by keeping children at home, with March 8 pencilled in as the date to return to the classroom. Primary schools are almost certain to reopen on this date, but secondary schools may follow later. Individuals will also be allowed to socialise again with one other person from the initial easing next month.
The next priorities are likely to be universities, followed by gyms and beauty businesses including hairdressers, then non-essential shops. Hospitality is expected to reopen initially with a focus on outdoor operation, with April pencilled in by some ministers as a likely date for pubs to serve takeaway pints. “Indoor dining and drinking will be challenging, don’t expect that to return in the near future,” one official warns.
Each loosening point is likely to be followed by a two to three-week interval so its impact on the virus’s reproduction rate, infections and hospitalisation can be assessed.
The road map paper is likely to set out several scenarios for the pace of leaving lockdown, based on how effective the Covid-19 vaccines prove at blocking transmission, as well as reducing serious illness.
Initial positive data from Israel — the world’s most vaccinated country per capita — showing that the BioNTech/Pfizer vaccine is 85 per cent effective after one dose, is one “straw in the wind” that Johnson has referenced in public.
In fact, though Israel has been praised for its breakneck vaccination drive, the nation’s emergence from lockdown is proving to be rather chaotic.
Faced with a dogged core of vaccine scepticism, Prime Minister Benjamin Netanyahu has decided to start opening up the economy from Sunday, with shopping malls and libraries opening to all Israelis. However, some leisure activities will be restricted to those who can prove — using a barcode on an app — that they have either received both doses of the BioNTech/Pfizer vaccine, or have recovered recently from Covid-19.
Health officials, meanwhile, are fretting that the decision is hasty. Less than 3m Israelis have received their second shot so far, while the extra-contagious B.1.1.7 variant still rages through the yet-to-be-vaccinated population.
This week, Netanyahu pleaded with some 570,000 unvaccinated people over 50 to come forward, after health officials found that twice as many as predicted had avoided making appointments. “I call on the young people among you to encourage your parents and grandparents to go be vaccinated,” he said. “You can save many of them from severe illness or, Heaven forbid, death.”
Public health experts in the UK say the staged relaxation of restrictions should be timed to keep R, the average number of people to whom someone with Covid-19 passes on the infection, below 1. That would maintain a decline in the epidemic.
Mass vaccination of the population is expected to make a significant contribution to reducing R, says Imperial College’s Ghani, though there is still little evidence from the real world — as opposed to clinical studies — to show by how much vaccines will cut transmission, particularly if the virus continues to evolve into more resistant variants.
“It is critical that people should not imagine that, if all the high-risk groups are vaccinated by Easter, we can relax everything,” Ghani says. “The vaccines will not be 100 per cent effective and in practice not everyone will be vaccinated.”
Just opening schools might add as much as 0.5 to R, which is now about 0.7 — requiring a pause before the next moves.
There is considerable uncertainty not just about the biological effects of vaccination and viral variation but also about how people will respond to reopening this time round.
The CoMix study at London School of Hygiene and Tropical Medicine, which has followed changes in social mixing during the tightening and relaxation of restrictions in England since last spring, published results on Friday.
“It’s difficult to say how things will play out when we lift this lockdown, but we are in a very different place from when we last exited a long period of lockdown last summer,” says Christopher Jarvis, CoMix lead author.
The original lockdown that started in March 2020 cut an individual’s average daily contacts with other people to 2.8, from 10.8 before Covid-19 appeared. “It took some time — a month or more — for people to start to increase their contacts when that lockdown ended and even then they returned to levels of about half what was recorded pre-pandemic,” Jarvis says.
He expects people to resume social mixing more rapidly this year when they are allowed to. “They were more scared of a new virus last time and people are finding this lockdown harder than the last one,” he says.
If Covid continues to mean some form of lockdown and long-term social distancing, says Steven Taylor, professor of clinical psychology at the University of British Columbia, it will be harder for governments to enforce restrictions.
“Humans are highly social creatures,” he says. “The longer the pandemic draws out, the greater the odds of pandemic fatigue and associated problems such as depression and withdrawal into forms of boredom-focused coping such as substance abuse.”
Though he also notes, it can provoke extremes of altruism. “We can expect that communities will rally, finding new and creative ways of countering the pandemic blues.”
Overseas travel restrictions
One of the most controversial questions is when to remove restrictions on travel, particularly between countries. Devi Sridhar, professor of global health at Edinburgh university, says she is “optimistic” about a return to somewhat normal domestic local life in the next six-eight months in rich countries as vaccines are rolled out. But limitations on overseas travel might be needed to prevent new outbreaks.
“Restricted international travel would be the trade-off for greater freedom at home,” she says. “We should have a hierarchy of needs when we open up — and the last one is international mobility.”
The longer term future remains cloudy even for the most far-seeing epidemiologists. The big biological unknown is how much evolutionary scope the virus has to generate new variants that may be more transmissible or deadly than those circulating today. Then there is political and economic uncertainty over how willing the world will be to sacrifice prosperity and mental health in the battle against Covid-19.
Few see total eradication as a possibility, in the way that smallpox was wiped off the face of the Earth 40 years ago, because the Sars-Cov-2 virus mutates far faster than smallpox, it often transmits when there are no signs of infection and it can replicate in other animals.
So societies will have to live with Covid for the indefinite future, hoping that better drugs will be developed to treat symptoms while vaccines keep pace with the ever-changing virus.
“We all know the old evolutionary idea that infectious diseases become milder and more transmissible with time,” says Ghani. “This coronavirus may become something like a common cold, but we can’t be sure.”
Additional reporting by Emma Jacobs
— to www.ft.com