Johnson’s Gamble: hoping the COVID-19 chain stays broken

There is no gambling like politics.

Benjamin Disraeli UK Prime Minister 1868 and 1874–1880

The British Government is gambling. Cases of coronavirus are doubling every 10 days in England and hospital admissions have risen over 50% in the past week alone. Yet today the government is set to lift restrictions, from social distancing to mask wearing, in a bid to restore normality to the economy. Prime Minister Boris Johnson has said “if not now, then when?” with regard to lifting restrictions.

The new UK Health Secretary Sajid Javid has warned that the country is entering “uncharted territory” as the last COVID-19 restrictions are likely to be removed by July 19th and UK daily cases could reach an unprecedented 100,000. Neil Ferguson, a leading epidemiologist at Imperial College London and government modeller on COVID-19 called this a “slight gamble”. This article is not about arguing for perpetual lockdown. It is rather an attempt to explore what that gamble means using the data available. For it is a gamble. And, if it goes wrong, more than a “slight one”.

At the peak of the second wave on 29th December 2020 81,517 people tested positive in one day. Of these 3,249 (3.99%) were admitted to hospital and 1,939 (2.38% of the daily cases) were in hospital requiring mechanical ventilation. 656 people (0.8% of the daily cases) died. This was at the start of the UK vaccination programme. On 3rd July 2021 22,230 tested positive for SARS-CoV-2. 386 (1.74%) were hospitalised, 327 people (1.47%) required mechanical ventilation and 20 (0.09% of the daily cases) died.

A key challenge for the vaccination campaign and a mantra often quoted in the media is to ‘break the chain’ of hospitalisations and death. Whilst a vaccinated person may still fall unwell due to COVID-19 the point is to prevent serious illness which requires hospitalisation. These data suggest that the chain has been broken. Sajid Javid’s gamble is that this stays the same. It may not.

The Delta variant (previously called B.1.617.2.) was first identified in India in December 2020. It is now the dominant strain in the UK. Delta is 50% more contagious than Alpha (previously called B.1.1.7 or the Kent strain) which emerged in the UK in September 2020 and was itself 50% more contagious than the original SARS-CoV-2 virus. This means that while a patient infected with the original coronavirus strain could be expected to infect about 2.5 other people, someone infected with the Delta variant in the same environment would pass it on to 4.5 or 5 people.

By 3rd July 63.8% of the UK adult population had had two vaccine doses. Current data suggest that the Pfizer-BioNTech vaccine is 96% effective against hospitalisation after 2 doses and the Oxford-AstraZeneca vaccine is 92% effective against hospitalisation after 2 doses. This is obviously good news and suggests that nearly two-thirds of the UK adult population have >90% protection from hospitalisation due to Delta. However, this may change.

Viruses, like all life on Earth, use a genetic code. A genetic code is a series of letters. Whenever a genetic code is replicated there may be ‘spelling mistakes’ much as we might make a mistake copying out text and one or more letters may be replaced with another. This is how mutation happens. Sometimes these mutations may result in disease. Sometimes they may convey an advantage. This is how virus variants such as Alpha and Delta emerge. Mutations that convey an advantage (such as greater infectivity) mean that the virus particles with that mutation are more likely to be spread. Although SARS-CoV-2 seems to have a relatively slow rate of mutation compared to other viruses such as influenza, the more chances it has to spread and replicate the more chance it has to mutate. If the government allows a situation where 100,000 people a day in the UK are contracting SARS-CoV-2 they are permitting a fertile environment for new variants. The gamble is that a new variant won’t emerge against which the vaccines aren’t as effective and the chain of hospitalisations becomes unbroken. This is why Pfizer/BioNTech are trialling a version of their vaccine which targets the Delta variant as well as publishing guidance to add a third ‘booster’ vaccine six to twelve months after the two-dose regime. Boosters and new versions may become the norm. There is also the chance that a variant may emerge in other parts of the world with much lower rates of vaccination (currently only 2% of the population of Africa have received two doses of COVID-19 vaccine).

The data for 3rd July projected for 100,000 daily cases suggests 1,740 hospital admissions a day and 90 daily deaths. All less than the data for 29th December. However, if a new variant emerges which pushes us back to the data for 29th December then with 100,000 daily cases the UK would see 3,990 hospitalisations, 2,380 patients on ventilation, and 800 deaths. Nearly ten times the number of deaths based on 3rd July data. This is the government’s gamble: that the current modelling continues and a new variant doesn’t disrupt the benefits of vaccination.

The British Medical Association reports that between March 2020 and April 2021 there were 3.5 million fewer elective procedures and 22.27 million fewer outpatient attendances. The total number of patients waiting over 18 weeks for treatment has increased to 1.8 million.

This clearly is not sustainable. Sajid Javid faces a big challenge to get the NHS back to what President Biden would call normalcy. But even that would not be enough. The COVID-19 pandemic followed the 2018/19 winter when all non-emergency and non-cancer care was cancelled for a month. The NHS needs more than claps if it is going to be able to focus on non-COVID-19 care. The ramifications of Johnson’s government’s gamble are huge. Let’s hope it pays off.

http://JamesThomas.me Doctor and Educator. Podcast https://www.takeaurally.com Blog on Medical Education and History of Medicine https://mcdreeamiemusings.com