At the start of the pandemic, the ideal path – for those countries able to control their frontiers – was elimination of the virus within their borders pending the arrival of vaccines and treatments.
The UK didn’t make that choice – and it has paid the price in ways we know all too well. However, we’re now in a different phase, with highly effective and safe vaccines allowing us to work towards population immunity through inoculation rather than natural infection. We also find ourselves in the position of being a Petri dish for the latest variant, Delta, and how vaccines hold up against it. So far the signs are hopeful – but since the protection offered by one dose of the vaccine is much lower, there’s every incentive to get as many people double-jabbed as quickly as possible.
All of this makes the significance of 19 July, England’s “freedom day”, even greater. As the number of infections increases, we await three crucial pieces of information: first, will the wave in younger people be followed by an increase in older people? Second, what level will hospitalisations reach, what percentage of these people will need intensive care, and will the NHS be able to cope? And finally, exactly what level of protection do two doses of the vaccine provide, especially to elderly and vulnerable groups? This is why scientists are cautious about saying that we’re nearing the time when we can simply “live with the virus” and let it spread uncontrolled.
On the flipside, we know that continued restrictions cause harm, and that many businesses need to run at full capacity to stay profitable. At what point should governments deem it is “safe enough” to accept a high level of transmission? You could make the analogy with road safety: at the start of the pandemic, it was as though everyone was riding motorbikes at high speed, with no helmets, on icy motorways. In that context it makes sense to shut the motorways down. But with vaccines and testing and some useful treatments, it’s more like driving in a car with airbags and seatbelts in good weather. Allowing the roads to reopen, albeit with speed limits, seems justified. So does that mean we can largely stop worrying about case numbers?
There are some complicating factors. The first is long Covid, the chronic illness that this virus can cause in those who may never need admission to hospital but may suffer for months with recurring fever, heart damage, lung scarring and breathlessness. Luckily, preliminary research from Yale University indicates that vaccines seem to make this condition less likely and ameliorate the symptoms of those suffering. Even so, ignoring case numbers means accepting there will be more long Covid sufferers.
The second thorny issue is how to manage young people and educational disruption. We know that many children are at home isolating because there has been a positive case in their class. Given the low risk of severe disease, it’s been suggested that we just let infection spread through schools, treating it like respiratory syncytial virus or flu, both of which can be serious but don’t result in mass isolation measures.
On the other hand, we know that between 300 and 400 children have died of Covid in the US, making it one of the top 10 causes of child death in 2020 . Again, there are no easy answers here. The US has decided that the simplest path for secondary schools is to vaccinate all those aged 12 and over with the Pfizer vaccine, which was trialled in this age group and found to be safe. There’s the hope that vaccinating adolescents will have the knock-on effect of protecting younger age groups. The UK’s Joint Committee on Vaccination and Immunisation has yet to decide whether to allow children to be vaccinated.
The third issue concerns the possible development of more serious or more infectious forms of the disease. Periods in which the virus circulates at high levels are fertile ground for the emergence of new variants. It’s natural for the virus to mutate as it reproduces, and more virus means more opportunities to do so. Again, vaccines that reduce the likelihood of infection, and of passing an infection on, are vital tools in this respect.
I offer no easy answers and cannot say with certainty how the coming weeks or months will look. We can only return to what we know. We know that two jabs of any of the approved vaccines are highly effective at stopping severe disease, and our best hope of easing restrictions. We know that continued restrictions and educational disruption bring their own harms. And we know that the NHS is dealing with a massive backlog and would struggle with another wave.
What options are left on the table? Not very many beyond continuing the vaccination push into younger age groups, screening international travellers by requiring them to be double vaccinated or face a 10-day quarantine, offering mass PCR testing to the public so that positive cases can isolate, maintaining face coverings indoors until there’s more certainty over vaccine protection, and being prepared for a bumpy winter with flu added to the mix.
Will we have to wear face masks and socially distance for ever? Of course not. The 1918 flu pandemic led to many behavioural changes, but those didn’t last for decades. What makes us human is the ability to mix, hug, socialise, go to theatres, dance in clubs, travel and attend large weddings. These will return. It’s now just a question of time.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh
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