An interesting comment in The Lancet respiratory medicine by Tony Kirby dated February 19th 2021 discusses this issue.

The United Kingdom has been one of the world’s countries hardest hit by the COVID-19 pandemic.  

As of February 15th 2021, there have been more than 117,000 deaths and more than 4 million confirmed infections.  

The country is in the depths of a third national lockdown which began on January 4th 2021 after a new SARS-CoV-2 variant B117, caused infections to soar nationwide.  

However, there is some good news.  As of February 15th  the United Kingdom have vaccinated more than 15 million people, mostly vulnerable people aged 70 years and older, as well as health and social care workers. 

With lockdown, and now the rapid vaccine rollout, these procedures have combined to lower the daily death count and the number of patients hospitalised with COVID-19. 

The UK has now rapidly moved into vaccinating its next priority groups, with plans to vaccinate all adults 50 years and older by April.  This will protect people who, prior to vaccination, represented 99% of the deaths and 80% of COVID related hospitalisations.

Boris Johnson is due to announce his government’s plan to exit lockdown today, February 22nd.  It is widely anticipated that he will confirm the return of primary schools on March 8th, with secondary schools returning that same date or perhaps one week later.  He said in an interview on BBC News, “our children’s education is the number one priority.  Then working forwards to getting non-essential retail open as well, then in due course, when we can cautiously and prudently do so, of course, we want to be opening hospitality as well.  We do not want to be forced into any kind of retreat – I am optimistic, I will not hide it from you, but we have to be cautious.” 

In a study published in Anaesthesia by Tim Cook of the Royal United Hospitals Bath NHS Foundation Trust and John Roberts of the COVID-19 Actuaries Response Group, showed that vaccinating priority groups 1-7, that is everyone aged 60 years and older and those 16 years and older with pre-existing conditions will reduce deaths due to COVID-19 by 96%, hospital admissions by more than 80%, and intensive care unit ICU admissions by 65%. 

 As these numbers become ever more evident to a lockdown weary public, continuing the lockdown will be increasingly difficult to justify.  

The COVID Recovery Group, a group of 70 conservative members of parliament want restrictions lifted quickly.  They wrote to Boris Johnson on February 14th saying that the tremendous pace of vaccination makes it harder to justify COVID restrictions.  They argue that once all people aged 50 years and older and those 16 years and older with pre-existing conditions have been vaccinated, there is no justification for any legislative restrictions to remain. They said that the vaccine gives us immunity from COVID, but it must also give us permanent immunity from COVID related lockdowns and restrictions.  They added that the government itself had said that the vaccines currently approved can prevent disease and death from all currently circulating variants.  

It is also felt that if Boris Johnson does not announce near immediate relief on at least some lockdown restrictions, there is a risk that people will break restrictions anyway.  

Now that almost all people aged 70 years and older have had vaccine in the United Kingdom, people might be willing to take more risks as they know the most vulnerable have been protected by vaccination.  

Adherence to this latest lockdown has overall been very good, but with a tacit understanding that this will be the last lockdown needed and that it will not proceed for more than a few months.  

It should be remembered that Boris Johnson had previously promised at the start of the vaccination rollout that the Easter weekend would look very different.  

Scientists have a wide range of views when it comes to lifting lockdown.  Professor Neil Greenberg, a Consultant Occupational Forensic Psychiatrist and Professor of Defense Mental Health at the Institute of Psychiatry King’s College London says that due to data collection delays, it is not yet clear how this latest lockdown has affected the United Kingdom’s Mental Health. 

However, previous lockdowns have been linked to a rise in reported symptoms of depression and anxiety.  He urged that the community’s mental health should be considered when determining the right time to ease restrictions.  

However, in the long term it would not be helpful for people’s mental health to have to endure further sustained lockdowns, so it is vital that short term distress or mental health difficulties are not given undue weight in the difficult judgment the government have in deciding when and how to ease lockdowns. 

Greenberg is of the view that should Boris Johnson’s lockdown exit plan appear to extend restrictions unnecessarily in the public’s view, there will be consequences.  

Evidence shows that in order for a population to comply with lockdown, they have to see lockdown as being a proportionate response to the nation’s difficulties.  If the death rate and hospitalisation rate is low but restrictions remain high, then compliance is likely to reduce considerably.  

Andrew Pollard, Professor of Paediatric Infection and Immunity at the University of Oxford and a Lead Investigator of the Oxford AstraZeneca vaccine trial praised the superhuman effort of the UK National Health Service and volunteers managing to vaccinate 50 million people, but added, there is still a long way to go to make sure all those at the greatest risk are vaccinated. 

We need to keep going and protect everyone by vaccination, and not forget that we have a moral responsibility to those in other countries who are vulnerable to help them in this time of crisis, and to make sense for our own health security.  

Pollard believes that the emerging evidence is encouraging that the vaccines developed so far can stop all currently known variants from causing serious illness and death, but cautions that monitoring is still required.  He adds if we can stop serious disease with vaccines, we can learn to live with the virus even though it causes colds in most people and rarely severe disease. 

There are two possible scenarios with the variants: The current vaccines do most of the heavy lifting and preventing lower respiratory tract infections and we learn how best to manage the infrequent cases of severe disease; or the virus keeps changing and still causes severe disease and we have to regularly update vaccines as we do with influenza to keep us all safe.

A study by Cook and Roberts shows that the pressure on ICU’s and hospitalisations in the United Kingdom will not lift for some time and therefore there are elements of lockdown that cannot be lifted, but once the public understand all these indicators are plummeting, the pressure to lift restrictions will be intense.

Savulescu, Professor of Practical Ethics at Oxford University has written about the justifiability of selective lockdown of older people greater than 50 years as a way of managing the pandemic, saying this could have substantially reduced population transmission in six months.  He believes that young people could freely mix, socialise, be educated and work with a much lower likelihood of getting seriously ill, if the over 50s and elderly were protected throughout lockdown.  

Now vaccination has arguably made that unnecessary by protecting those most likely to become seriously ill to need hospitalisation. Future lockdowns could just be restricted to those aged over 50 he says.  

Richard Horton, the Editor in Chief of the Lancet suggested that if the UK maintains its existing lockdown measures, community transmission could largely be halted towards the end of February. 

If suppression is stable for several weeks, one could envisage some easing of the lockdown mandate by mid-March. Referring to the vaccination of 15 million of the most vulnerable people in the United Kingdom by February 15th, Horton adds that once vaccination has been translated into immunity early March, the protection of the most vulnerable, temporarily combined with very low levels of community transmission, will give compelling force to more libertarian voices who wish to see the earliest possible reopening of society.

Israel’s experience lends support to this view. 

However, Horton reflects on the difficulties that politicians will face in the coming weeks concluding, do we continue with physical distancing with persistent disruption to schools, universities, workplaces and leisure activities, until about three quarters of the population are immunised and then achieving herd immunity or do we agree that a finite number of deaths must be accepted if we are to return to relatively normal lives? 

Our society has normalised deaths for many diseases. Why should COVID-19 be any different? 

In England, deaths from influenza vary from several thousand to as many as 30,000 per year.  

The question politicians will have to answer is this:

  1. What number of COVID-19 deaths are they willing to accept? 
  2. Will the public trust their answer?

Dr Paul Ettlinger

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