Covid-19 update: 26 February

The UK was placed in highest Covid-19 alert level at the beginning of January as the country entered a national lockdown. The reduction in alert level comes in the same week that England and Scotland set out plans to slowly lift lockdown measures. The change in alert status reflects an assessment that healthcare demand will not exceed forecast capacity for at least the next 21 days across all UK nations and regions.

However, the statement, from Chris Whitty (England), Michael McBride (Northern Ireland), Gregor Smith (Scotland), Frank Atherton (Wales) and NHS England national medical director Stephen Powis, warned that health services remained under significant pressure.  ‘In time, the vaccines will have a major impact and we encourage everyone to get vaccinated when they receive the offer,’ they said. ‘However, for the time being it is really important that we all – vaccinated or not – remain vigilant and continue to follow the guidelines.’

NHS Providers chief executive Chris Hopson echoed the need to recognise the continuing risk from Covid-19. ‘There are still 12,500 Covid-19 patients in English hospitals, with almost 1,000 new cases being admitted a day and 46% more critical care beds occupied than this time last year,’ he said. ‘Weekly case rates across the UK are 115 per 100,000 people compared to the 25 we would need to de-escalate to level 3. We must not squander the progress of recent weeks by letting down our guard now. It’s vital that everyone continues to follow the restrictions.’

In fact, the latest figures for England on the government Covid-19 dashboard shows more than 13,000 Covid patients in English hospitals in the middle of the week, with more than 16,000 across the whole UK.

However, the reducing impact of the virus on health services is clear. At 16,000, the number of patients in UK hospitals is now back at the level it was at in early December and compares with a second wave high of more than 39,000 in mid-January. The just over 1,900 Covid patients in mechanical ventilation beds is also effectively half the January peak.

In England, the weekly winter sitrep report showed that, looking at all patients, last weekend some 4,241 adult critical care beds were occupied, with headroom both nationally and for most acute providers.

Danny Mortimer (pictured), chief executive of the NHS Confederation, said the decrease in critical care bed occupancy was positive, and the NHS had ‘a little more room to breathe in some parts of the country’.

‘It is important to remember, however, that pressure is being felt in other services, particularly as a result of the longer-term impact of Covid on people’s health, pressure on waiting times and the rising demand in the need for mental health support,’ he said. ‘This longer-term pressure is being distributed across primary care teams, community and mental health services as well in our hospitals and ambulance services. The government must take further steps to support the NHS in the forthcoming budget, and must be clearer as to when it will complete its desperately needed plan for social care.’

And Darren Hughes, the Welsh NHS Confederation’s director, said the improving picture was encouraging. ‘But pressures will not be going away any time soon,’ he said.

Pay problems

Staff are a major concern. Since the pandemic began, staff have performed heroically, often working long hours in difficult circumstances. But there were major doctor and nurse vacancies even before the virus outbreak, and the pandemic has exacerbated difficulties with increased staff absences either because of contracting the virus or having to self-isolate.

Addressing the shortage in nursing staff is recognised as a key challenge that needs to be addressed, with the Health Foundation this week estimating the NHS in England could need an extra 639,000 staff by 2033/34. A report from the Institute for Fiscal Studies this week suggested that national pay mechanisms may be compounding recruitment and retention problems. It said that the relative value of nurse earning varied considerably across the country. The median hourly earnings for a nurse in London in 2018 were 11% higher than a nurse living in Burnley. But the average house price was six and a half times more.

‘National pay-setting affords NHS hospitals little flexibility to respond to economic conditions in their local area,’ said Isabel Stockton, IFS research economist. ‘When, as a result, nurse earnings do not keep pace with local increases in cost of living, this prompts more nurses to exit NHS hospitals, particularly in expensive areas. The existing system of supplements and retention premia is not fit for purpose.’

Responding to the report, James Buchan (pictured), senior visiting fellow at the Health Foundation, said the nursing workforce was under incredible strain. ‘Over 35,000 nursing posts are vacant and sickness absence rates are high as a result of Covid, with one in 10 hospital nurses reported to be off work in January,’ he said. ‘This report provides further evidence that the government needs to urgently develop a comprehensive national workforce plan that enables the NHS to recruit and retain nurses where they are needed most.’

In England the roadmap out of lockdown will see schools reopen on 8 March, followed by further relaxations on outside sport (29 March), shops and outside dining (12 April) and hospitality in general (17 May). In Scotland, with schools already open for early learning years, further school opening will be phased in from 15 March to 5 April with shops, pubs and restaurants reopening at the end of April.

All dates are subject to the virus staying under control and there being no surge in hospital admissions. Governments will also be looking for confirmation that vaccinations are reducing the number of Covid-related deaths and hospital admissions.

Vaccination impact

Early evidence already appears to be very positive. Data from Public Health England’s Siren study of healthcare workers aged under 65 shows the risk of catching infection reduced by more than 70% with just one dose of the Pfizer/BioNTech vaccine. This rose to 85% after a second dose. This suggests that the vaccine may also help to interrupt the virus transmission, as a person can’t spread the virus if they do not have an infection.

Mary Ramsay, head of immunisation at PHE said the initial findings were very encouraging. ‘But protection is not complete,’ she said, ‘and we don’t yet know how much these vaccines will reduce the risk of you passing Covid-19 onto others.’

Further data from Public Health Scotland, from the Eave II project, showed that there was an 85% and 94% drop in risk of hospitalisation four weeks after having had an initial dose of the Pfizer or Oxford/AstraZeneca vaccine respectively.

The vaccination programme continues to move ahead well. There were a couple of days in the last week when daily vaccinations dropped below 200,000 – reportedly due to supply issues – but by the middle of the week, the programme was again delivering close to 500,000 vaccinations a day. The delivery of second doses is also starting to increase with more than 30,000 follow-up jabs administered on Wednesday.

By the middle of the week, 18.2 million people across the UK had received a first dose of vaccine with nearly 670,000 having had a second dose.

There is also evidence that vaccinations are indeed producing high numbers of antibodies in those receiving the jabs. The latest report from Imperial College London-led React 2 study suggests 14% of England’s population have antibodies against the coronavirus. The study was based on 155,000 people and for the first time included 18,000 people who had had at least one dose of vaccine – so the antibodies detected could be from a prior infection or the result of vaccination.

After two doses of the Pfizer BioNTech vaccine, the proportion of participants testing positive for antibodies was high across all age groups – 100% in those under 30 and 88% in those 80 and over. For individuals receiving a single dose after 21 days, the proportion testing positive for antibodies was 95% in those under 30 but this dropped with increasing age – falling to 35% in those aged 80 and over.

Existing research suggests those aged over 80 take longer to develop an antibody response to infection. (Antibodies are just one part of the body’s immune response with vaccinations also inducing T-cell-related protection.)

The study also explored attitudes towards vaccines and reported that 92% of 172,000 people responding to a questionnaire had either had the vaccine or intended to do so.

‘It is very encouraging to see that uptake and confidence in the vaccination programme is so high, and that most people develop a detectable antibody response after one dose,’ said Helen Ward, professor of public health at Imperial. ‘Our findings suggest that it is very important for people to take up the second dose when it is offered.’

On Friday, the Joint Committee on Vaccination and Immunisation published its interim advice for phase two of the Covid vaccination programme. It said that the programme would continue to prioritise people by age. ‘This is because age is assessed to be the strongest factor linked to mortality, morbidity and hospitalisations, and because the speed of delivery is crucial as we provide more people with protection from Covid-19,’ a government spokesperson said. The whole UK will follow this approach, subject to the final advice given by the expert committee.

The spokesperson added that the UK remained on course to offer a vaccine to all those in the phase one priority groups by mid-April and all adults by the end of July.

The latest report from NHS Test and Trace in England also reflected the reducing incidence of the virus. Just over 84,000 people tested positive for coronavirus in the week to 17 February – a 21% decrease compared to the previous week, continuing a six-week trend. Some 83,000 cases were transferred to the contact tracing system and nearly 73,000 of these were reached (88%). Just over 54,000 of these people (75%) provided details of 147,000 close contacts. Nearly 94% of these were reached and asked to self-isolate.

Results of 87% of in-person tests undertaken in the community were delivered within 24 hours, with this figure dropping to 38% when all testing routes are included.

NHS Providers’ Chris Hopson welcomed the continued fall in positive cases but again drew attention to the leakage at the different stages of the process. ‘We are consistently seeing a very high proportion of positive cases being transferred into the Test and Trace system each week,’ he said. ‘But one in eight of these are still not being reached and asked to provide details of their contacts. More needs to be done to ensure there are no gaps.’

There are continuing concerns about new coronavirus variants taking hold in the country, with more testing and genomic sequencing being deployed in some areas aimed at monitoring and suppressing the variant first identified in South Africa. Mr Hopson called for Test and Trace to start to ‘report regularly on its own assessment of how ready and able it is to combat any new variant Covid-19 strains that, in future, provide the greatest threat.’