Covid-19 update: 9 July

A final decision on the planned move to step 4 of the roadmap out of lockdown – removing legal limits on social contact – will be taken on Monday. But prime minister Boris Johnson made it clear that the 19 July is now firmly expected to be ‘freedom day’.

This will mean an end to limits on the numbers meeting indoors and outdoors. All businesses will be allowed to re-open, including nightclubs. Limits will be lifted on named visitors to care homes and on people attending concerts, theatres and sports events. And there will be no more one-metre-plus rule on social distancing. Controversially, Mr Johnson also said there would no longer be a legal obligation to wear a face covering.

The government later announced that the 19 July would also see an end to the requirement to quarantine on return from an amber-listed country for all those who have been fully vaccinated.

These changes are despite an acknowledgement that Covid cases are rising rapidly. New cases were already at 25,000 a day last weekend (and have risen further this week) and are predicted to be at 50,000 a day by 19 July. And health and social care secretary Sajid Javid told BBC Radio 4’s Today programme on Tuesday that this could double again in the coming weeks. ‘As we ease and go into the summer, we expect them to rise significantly and they could go as high as 100,000 case numbers,’ he said.

The previous high point for daily cases (by the date reported rather than specimen date) was just over 68,000 on 8 January this year. However, Mr Javid said that the key metrics were hospitalisations and deaths, and not cases. And the link between cases and hospitalisations and deaths had been ‘severely weakened’.

He told the Commons on Monday: ‘The last time we had 25,000 new cases a day, we had around 500 deaths a day. The level now is a thirtieth of that.’ Mr Johnson also argued that the arrival of summer and the school holidays provided a window of opportunity. ‘If we can’t re-open our society in the next few weeks, then we must ask ourselves, when will we be able to return to normal?’ he said.

The removal of restrictions was welcomed by the travel and hospitality industries. And there were reports of a surge in holiday bookings.

Keep the mask

However, Labour leader Keir Starmer described taking all the protections off in one go as ‘reckless’. ‘We should open up in a controlled way, keeping baseline protections such as masks on public transport, improving ventilation, making sure the test and trace system remains effective, and ensuring proper payments for isolation,’ he said. ‘The prime minister cannot just wish away the practical problems that 100,000 infections a day are going to cause.’

The British Medical Association (BMA) said that the emphasis on personal responsibility around mask wearing rather than rules did not make sense. ‘This cannot be about personal choice when the risk comes from others around you not wearing them,’ said BMA leader Chaand Nagpaul (pictured). Pointing out that many people have no choice but to use public transport or to be in confined spaces, he called for the government to reconsider its course of action until the ‘rampant spread of infection’ had been brought under control and more of the population was fully vaccinated.

Dr Nagpaul was also one of more than hundred scientists and doctors to sign a letter in The Lancet medical journal this week. accusing the government of conducting a ‘dangerous and unethical experiment’. It said the government’s approach, accepting that infections would surge, meant that immunity would be achieved by vaccination for some, but by natural infection for others – predominantly the young. And infection could still cause substantial morbidity in both acute and long-term illness. ‘Unmitigated transmission will disproportionately affect unvaccinated children and young people, who have already suffered greatly,’ the letter said.

And the UK’s approach was also brought up in a World Health Organization (WHO) briefing on Wednesday. A BBC journalist asked if the UK government’s reasoning for opening up – gambling that cases would go up sharply and then fall back down sharply – made sense. Michael Ryan, director of the WHO Health Emergencies Programme, said he did not think this was the logic behind the UK proposals. ‘But the logic that more people being infected is better is, I think, logic that has proven its moral emptiness and its epidemiological stupidity previously,’ he said.

Daily reported cases were already at 32,551 on Thursday. The most recent figure for daily hospital admissions across the UK – last Sunday – was 456, with the seven-day average doubling in around three weeks.

Scotland has faced particularly steep rises in recent times. Tayside, Lothian, Greater Glasgow, and Fife are in the top 10 Covid hotpots across Europe, in terms of incidence per 100,000 population, according to the WHO European sub-national tracker.

Scotland first minister Nicola Sturgeon said this week that there appeared to be a ‘slow down’ in the seven-day average with cases levelling off. The country is moving towards its own level zero on 19 July – with a decision due to be taken next week – and ‘beyond level zero’ on 9 August. However, Ms Sturgeon insisted the country could not ‘throw caution to the wind’ and that a move to level zero would not mean an end of restrictions.

She said there was always pressure for Scotland to follow suit with the UK government. But the path chosen for England in lifting all restrictions and removing the requirement for basic mitigations like facemasks against the backdrop of sharply increasing case numbers was ‘something of an exception’. The Scottish government would ‘think carefully’ about the steps it will take.

NHS pressures

NHS Grampian this week announced that non-urgent procedures were being postponed due to the increase in Covid patients and an increase in staff absences due to self-isolation. The board’s Aberdeen Royal Infirmary and Dr Gray’s Hospital have both been at black status (maximum capacity) in recent days. ‘Choosing to cancel procedures or appointments is never a decision we take lightly,’ said medical direction Nick Fluck. ‘However, it is our only option if we are to relieve some of the pressure and allow staff to concentrate on the most urgent and emergency care.’

Workload is also increasing for English hospitals. The Leeds Teaching Hospitals NHS Trust issued a statement on the back of rising Covid admissions. ‘We have had to postpone some planned elective operations to ensure patients who require urgent treatment are prioritised,’ it said.

And NHS Providers said that current pressures meant that the predicted rising infection rates for Covid would inevitably affect the speed at which trusts could recover backlogs. The body’s chief executive Chris Hopson said there were four factors driving the pressure.

‘First, trusts are working flat out to address the backlog of care which is bringing huge pressure on services and staff,’ he said. ‘Second, demand is worryingly high for urgent and emergency care with a number of trusts reporting record levels of daily demand in June. On top of that the NHS is currently operating with significant capacity constraints because of continuing infection control measures.

‘And finally, there is real pressure on staffing levels, given how many staff are having to self-isolate.’

He added that this would get worse on 19 July and that staff were also due to take well-earned annual leave. So even though Covid admissions in this wave are likely to be lower than previous waves, thanks to the successful vaccination programme, something would have to give. And in many places this would be the speed of care backlog recovery.

The latest performance statistics for the English NHS show the scale of the recovery challenge with 5.3 million patients waiting to start treatment at the end of May and 336,733 waiting for more than a year. This represents an increase of 180,000 on the waiting list since April, although there has been a further reduction in the 12-month waiters.

Matthew Taylor, NHS Confederation chief executive, said the NHS had been working relentlessly. The average wait for elective care was now 10.8 weeks, down by 29% on May 2020 but the challenge was huge.

‘Record A&E attendances highlight the scale of demand,’ he said. ‘Across the NHS, our members are telling us that it feels like January in July, with our urgent care system running a winter-like service in the middle of summer.’

He warned that the country must go into the next phase with its eyes wide open and acknowledge that ‘much of the care the NHS can provide to patients is likely to be disrupted further, including in the community’.

Siva Anandaciva (pictured), King’s Fund chief analyst, pointed out that the waiting list was now larger than the population of Norway. ‘And with many more people now coming forward for treatment, this list will continue to grow,’ he said. He called for the NHS to be given ‘time, resources and a credible workforce plan’.

Vaccine effectiveness

The vaccination programme continues to make good progress, with 80 million vaccines now administered – 46 million first doses and 34 million seconds. This means 87% of UK adults have now received a first dose, with 65% having had both jabs.

Public Health England said this week that in England the vaccines had prevented an estimated 30,300 deaths, 46,300 hospitalisations and 8.2 million infections. Its weekly vaccine surveillance report continues to show good effectiveness against symptomatic disease for both the main vaccines currently used in the UK – AstraZeneca (70%-85%) and Pfizer/BioNTech (85%-90%) – based on a range of earlier studies. There are further figures for effectiveness against hospitalisation, death and infection.

The report also suggests there is good protection against the more recent Delta variant, particularly from two doses of vaccine – although there is a 10% reduction in effectiveness compared with the previously dominant Alpha variant.

However, there are a bewildering array of numbers flying around, based on different studies and different vaccines. For example, a study published this week by the Ministry of Health in Israel found a more marked reduction in effectiveness of its main vaccine (Pfizer/BioNTech) in preventing infection and symptomatic illness with the Delta variant.

An article in The New York Times explains why the range of numbers thrown out by various studies are in fact what you would expect. The focus should be on the overall story told by the studies collectively – particularly the good protection against serious illness and hospitalisation – rather than looking at the precise percentages in one study or another.

One of the key reasons for last month’s delay in ending social restrictions in England was to make more progress with the vaccination programme – in particular giving more time to get the country’s over-40-year-olds vaccinated. This group accounts for nearly all of the Covid deaths to date. And Mr Javid said this week that the interval for doses for under-40s is now being reduced from 12 to eight weeks – helping build his ‘wall of defence’.

The sooner this wall is built, the better given the planned easing in restrictions and the increase in social interactions that will follow. If daily cases do rise to 100,000, then the UK’s various test and trace services could face a major increase in activity.

Tracing challenge

The latest report from NHS Test and Trace in England said that 136,000 people tested positive for coronavirus in the week to 30 June – a 71% increase compared to the previous week. Nearly 113000 cases were transferred to the contact tracing system and 282,000 close contacts were identified, with 86% of these contacts reached and asked to self-isolate. NHS Providers deputy chief executive Saffron Cordery said the service’s performance ‘really needed to improve as Covid-19 infections continue to climb’. This is even more important as we approach the lifting of all Covid-19 restrictions on 19 July,’ she said.

The government announced this week that if the move to step 4 goes ahead in England, then from 16 August double vaccinated people will no longer be required to self-isolate if they are identified as a close contact of a positive Covid-19 case. It is not clear how this might impact on the workload of NHS Test and Trace, however all close contacts would still be contacted and advised to take a PCR test.

Scotland’s Test and Protect service has also faced criticism in recent weeks. Official statistics for the week ending 4 July show that just 73.2% of cases within the system were closed within 72 hours – below the WHO  target of 80%.

Scottish Conservative shadow health secretary Annie Wells said it was clear the system was completely overwhelmed by the recent surge in Covid cases. ‘Ministers need to be upfront about their failings and admit they took their eye off the ball,’ she said. ‘A robust Test and Protect system remains a critical tool in fighting the virus, but the SNP government has failed to ensure it has all the resources it needs.’

Rising cases are now being met by an increase in the Test and Protect workforce. One hundred extra staff have been secured through on of the service’s commercial partners, while existing bank staff are also being mobilised. However, health secretary Humza Yousaf said the success of the system going forward would not simply be about staffing numbers.

‘We are now using a variety of methods to contact people, including using digital methods like SMS messages for lower risk cases and prioritising calls for higher risk cases,’ he said. ‘These changes, along with extra staffing, will ensure that people are contact traced, and begin self-isolation, as quickly as possible. I’m confident that the performance of Test and Protect has started to improve in recent days.’

New analysis of public health data has underlined the fact that children and teenagers face an extremely low risk of severe illness and death from Covid-19. However, the virus does increase the likelihood of serious illness in the most vulnerable young people, those with pre-existing medical conditions and severe disabilities – although these risks remain low overall.

Preliminary findings have been published in three pre-print studies led by University College London, the University of Bristol, the University of York and the University of Liverpool. They will be submitted to the UK’s Joint Committee on Vaccination and Immunisation, the Department of Health and Social Care and the WHO to inform vaccine and shielding policy for the under-18s. One study found that 251 young people under 18 in England were admitted to intensive care with Covid-19 in the first year of the pandemic – equating to a 1 in 50,000 chance of being admitted to intensive care with coronavirus during that time.

These studies did not look at the impact of long Covid. However, there are growing calls for a greater focus on the longer-term impacts of Covid as well as treating acute cases.

The app-based Zoe Covid symptom study estimates there are 500 cases of long Covid a day among unvaccinated people in the UK. Tim Spector, lead scientist on the Zoe app, said that while the vaccines had weakened the link between cases and death, there was still a correlation between new cases and long Covid. ‘Unfortunately, if new cases continue to increase then many more thousands of people, especially the young, will be affected by long-term symptoms that leave sufferers unable to live life normally,’ he added.