Covid-19 update: 20 November

After last week’s revelation about the positive efficacy results for the vaccine from Pfizer and BioNTech, the good vaccine news just kept coming. US company Moderna released early data showing that its possible new vaccine is nearly 95% effective.

The phase 3 study involved more than 30,000 participants in the US, with half being given two doses of the vaccine, four weeks apart.  The trial included 7,000 people over the age of 65 and 5,000 people under 65 but with high-risk chronic diseases. In total, medically high-risk groups represented 42% of participants. The UK government has secured an initial agreement for five million doses.

A Russian vaccine – known as Sputnik V – is also reported to be 92% effective, although the study involved a smaller 16,000 strong sample. And this week the AstraZeneca-manufactured Oxford vaccine got in on the act. While this vaccine is also undergoing stage three trials, results from earlier stages – where safety and the body’s response are tested – showed the potential vaccine produced a strong immune response in adults in their 60s and 70s.

And a UK vaccine being developed by pharmaceutical company Janssen has also begun phase 3 trials this week, involving 6,000 volunteers.

Responding to concerns about access to effective vaccines, deputy chief medical officer for England Jonathan Van-Tam clarified that vaccines would not all come at once, or in large quantities in all cases. ‘Nor will they be delivered in volumes or over timeframes we can fully predict currently, and their storage characteristics may differ,’ he wrote in a letter to The Guardian. ‘We will have to use the vaccines that are authorised, in the quantities they become available, according to expert advice.’

Professor Van-Tam added that if the choice was between the eligible public accessing a safe vaccine with a lower interim efficacy or having no vaccine at all, the former would be chosen. ‘Some protection is absolutely better than no protection.’ Waiting for the very best vaccine would cost lives. He confirmed that the UK had targeted seven vaccines, procuring, over time, a total of 355 million doses.

European view

While the news of vaccines has everybody looking forward with optimism, the Organisation for Economic Co-operation and Development was keen for people to look back and learn the lessons from international experience with the pandemic so far. It’s Health at a glance: Europe 2020 report provided a first look at comparative data on how European countries have responded to Covid-19.

Europe has again become a Covid-19 hotspot and by the middle of November 10 million people had been infected across the continent, with more than 265,000 dying and numbers rising rapidly. OECD secretary-general Angel Gurria (pictured) said the news of a vaccine was encouraging. ‘But tackling this pandemic is a marathon not a sprint,’ he said. ‘International collaboration will be key to ensuring mass production and widespread distribution of the vaccine. But countries also need to reinforce their support for the healthcare sector and workers, and extend the scale and effectiveness of testing, tracing and isolation policies.’

In general, the report said the pandemic had exposed the insufficient preparation of countries to cope with major public health emergencies. ‘The costs of having more resilient health systems pale in comparison with the huge economic consequences of failing to do so,’ it said. Multilateral cooperation was the key to facing up to public health threats of the magnitude of Covid-19.

The National Audit Office was also in review mode as it looked back at the government’s performance at the start of the outbreak. Its report into the procurement of some £18bn of goods and services during the first months of the pandemic highlighted a lack of transparency and adequate documentation for key decisions. Some £10.5bn of new contracts were awarded directly without a competitive tender process.

In a selected sample of 20 contracts, the NAO found examples where departments failed to document key decisions such as why they chose a particular supplier and failed to document how they had managed any conflicts of interest.

‘While we recognise that these were exceptional circumstances, it remains essential that decisions are properly documented and made transparent if government is to maintain public trust that taxpayers’ money is being spent appropriately and fairly,’ said NAO head Gareth Davies (pictured). ‘The evidence set out in our report shows that these standards of transparency and documentation were not consistently met in the first phase of the pandemic.’ (See Early Covid procurement lacked transparency, says NAO.)

In prime minister’s questions in the Commons, with prime minister Boris Johnson attending virtually while isolating, Labour leader Keir Starmer also highlighted that suppliers with political connections were 10 times more likely to be awarded contracts. ‘Can the prime minister give a cast-iron assurance that from now on all government contracts will be subject to proper process with full transparency and accountability?’ he asked.

Mr Johnson complained that the opposition leader had ‘bashed the government’ at the time for not moving fast enough. ‘It is absolutely absurd that Captain Hindsight is now once again trying to score political points by attacking us for moving too fast,’ he said. ‘I am proud of what we did to secure huge quantities of PPE during a pandemic.’

Current position

The reality of the current situation is that England remains in lockdown and much of Scotland has effectively just joined it, with 11 local authority areas moving to the highest level 4 restrictions for three weeks. Northern Ireland will enter two weeks of tougher restrictions from next Friday.

An additional 22,915 cases were reported on Thursday as the latest daily count from across the UK – and with lockdown 2 now two weeks old, the country is at the tail-end of infections that will have been contracted pre-lockdown. Hospital admissions remain around the 1,600 mark each day. Both these numbers will be instrumental in informing decisions around what happens at the beginning of December when the lockdown is due to end.

A report from the BMA this week warned that lifting lockdown without new measures in place risked deepening the current crisis in the health service and could leave hospitals and GP practices overwhelmed. Exiting the lockdown – a strategy for sustainably controlling the transmission of Covid-19 in England called for widescale reform to the testing and contact tracing programme before lockdown ends. For example, a far greater proportion of the national budget for track and trace should be given to local public health teams.

Then post lockdown, the rule of six should be replaced with a two-households rule to reduce social mixing. There should be no travel across different lockdown tiers. And there should be targeted support for clinically vulnerable individuals and for communities that have been hit hardest by the pandemic, including black, Asian and minority ethnic communities.

A blog from NHS Providers’ chief executive Chris Hopson (pictured) reinforced this view. While it was too early to tell if the current national lockdown is having the consistent effect needed, the NHS still needed to ‘navigate the hump of winter – late December to March’ when the service is at its busiest. By the end of lockdown, the country would be in a ‘halfway house’. ‘We should only come out of national lockdown if we are certain the NHS can cope with this second phase,’ he said. And to avoid a third phase in January the restrictions associated with the different tiers that set out social distancing rules should be strengthened.   

Tracing concerns

The BMA is not the first body to call for NHS Test and Trace to use the lockdown to improve performance, however the continued high levels of positive tests mean there has been little breathing space for the service. The latest weekly report said that nearly 150,000 people tested positive for coronavirus at least once in England in the week to 11 November – an 8% increase on the previous week.

Nearly 157,000 people were transferred to the tracing system and 85% of these were reached and asked to provide details of contacts. This means nearly 24,000 people were not able to be contacted. Of the 133,000 who were reached, just under 109,000 provided details of 314,000 recent close contacts. And just 61% of these were reached. Ignoring the leakage in the earlier steps, this means that more than 122,000 were not contacted and asked to self-isolate.

However, there were very small improvements in the time taken to deliver test results. For in-person tests in the community, 38% were received within 24 hours – up from 37.5% in the previous week. Considering all testing routes, 20% of results were delivered within 24 hours – up from 19%.

NHS Confederation director Layla McCay (pictured), said that she would have hoped to see improvements in the test and trace figures by this stage of the new lockdown. ‘But instead, contacts are being successfully traced for only two out of every three people who test positive for COVID-19 – although these people are at least being reached a bit more quickly than in recent weeks.’

Dr McCay said the new figures showed two important things. ‘The number of positive cases is rising steeply, up 11% week on week; and despite our reliance on the test and trace system to help bring us out of lockdown, thousands of contacts continue to slip through the net every day, inadvertently contributing to further spread of the virus.’  

The remaining weeks of lockdown had to be used to make faster progress and there needed to be greater involvement of local health protection teams, who reached nearly 99% of close contacts, she added.

This process is already underway. For example, the London Borough of Redbridge announced this week that it had developed a local track and trace solution in partnership with software company Civica. The platform uses datasets from Public Health England to proactively track residents who may be at risk, based on their contact with people who have recently tested positive. The system provides those asked to self-isolate with a series of messages to reinforce positive behaviour.

But there are increasing calls for the government to do more and, in particular, to give local teams earlier access to data.

York's Labour MP Rachael Maskell (pictured) this week called on health secretary Matt Hancock to give the city’s contact tracing team immediate access to data. ‘York’s contact tracing work has proved to be incredibly effective, not just in its reach but in persuading people to isolate,’ she said. ‘However, it is not getting data through until around day five, when people are having a test, and it could be so much more effective if it had that data on day one.’

The health secretary promised to work with Ms Maskell, the local public health director and NHS Test and Trace to ‘make sure that the link-up is as effective as possible’.