The Only Way Out of the Pandemic: Suppress, Vaccinate, Eliminate

The Only Way Out of the PandemicSuppressVaccinateEliminate

Dr Dominic Pimenta offers his plan for escaping the clutches of COVID-19

The 31 January 2021 will mark the one-year anniversary of the first case of COVID-19 in the UK. But, despite a full year of battle against the disease, we find ourselves worse-off than in March 2020, when the Government imposed its first national lockdown.

Daily COVID-19 deaths are the highest they have ever been; more patients are being admitted to hospital and intensive care units (ICUs) than ever before; the days are darker, colder; and somehow this current lockdown feels harder than in March, despite mobility data suggesting that it isn’t proving to be nearly as effective.

There are new challenges, too, namely mutations, a depleted NHS workforce and persistent COVID-19 denialism. But there is also hope. There are new tools in the fight against the disease, the health service has been able to learn from more than a year’s worth of data, international experience and clinical trials – and hundreds of thousands of people are being vaccinated on a daily basis.

However, the question now on all of our minds is: what is the way out of this and how can we get there safely?

Broadly speaking, the potential strategies can be distilled into three distinct routes:

1. Vaccinate the top four priority groups – care home residents and their carers, the over-70s, frontline clinical staff and the clinically extremely vulnerable – and then open up to normality in mid-February. Also known as ‘focused protection’.
   
2. Vaccinate a wider at-risk group – the above plus the over-55s – and open up by Easter, allowing the virus to become endemic in the young. 
   
3. Maximally suppress the virus, vaccinate the entire population and eliminate COVID-19 entirely.

Let’s take each option in turn.

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Vaccinate Top Four Priority Groups and Open Up by Mid-February

This is a non-starter.

Firstly, around one-third of the UK population is at-risk of severe COVID-19, not just the elderly.

Secondly, with the 12-week vaccination regimen, these at-risk groups will only start to receive both doses by early March.

While a single dose of the vaccine appears to be effective from clinical trials – somewhat supported by limited real-world reports from Israel – we still don’t know if this immunity is sustained, and for how long in the elderly.

In either case, even with a likely significant increase in protection for the elderly after one dose, this strategy doesn’t really help hospital capacity, specifically ICUs, where the average age of patients is 60.

If we release lockdowns by mid-February, with the majority unvaccinated, we will see a surge in younger hospital patients and many tens of thousands more deaths. 

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Vaccinate Wider At-Risk Group and Open Up by Easter

This option is more nuanced.

The risk of death from COVID-19 among those aged 55 is around 0.4%, rising to 15% once you are over 85. The risk to a healthy 25-year-old is less, 0.01%. This may not sound like much, but COVID-19 is actually the leading cause of death in the 25 to 44-year-old age group in some countries.

While this strategy may see a decline in hospital and ICU pressure, one in five patients will suffer from long-term health problems, including lung disease, heart disease and possible infertility after COVID-19.

Indeed, long COVID isn’t unique to adults – symptoms persist in one in eight children as well. The risk of death also doesn’t end with the acute illness. One in eight adults discharged from hospital after a COVID-19 admission died within four months, an effect which was more pronounced in younger patients (under-70). 

Although severe disease in young patients is rare, with a highly infectious variant circulating freely, we can expect to see millions of infections in the young and consequently tens of thousands of younger people dying needlessly.

Most importantly, widespread infection rates invite further mutations. The process behind mutations is a literal genetic lottery. With every replication, the virus might make one or two mistakes in its genetic code. Most of the time these mistakes, like lottery tickets, do nothing and are meaningless. Very occasionally, a mistake might change the virus. Again, like a lottery, this prize may yield very little, but very, very rarely the virus may hit the jackpot – a change that makes it more competitive.

The more of the virus there is in circulation, the greater the chances that it will hit the jackpot. If we engineer an environment where we have both high levels of virus circulation and a partially immune population, a variant that escapes immunity is almost inevitable.

We have been lucky so far – the current UK variant B.1.1.7 appears to be neutralised by our current vaccines – but there are already variants around the world that look like they could escape that immunity. Then we are firmly back to square one, with hospitals overwhelmed and deaths in the tens to hundreds of thousands.

COVID-19 is genetically similar to even more deadly coronaviruses, like SARS (10% mortality) and MERS. Uncontrolled circulation is not good for anyone – neither the UK nor the world in general.

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Suppress; Vaccinate; Eliminate

The virus has few options for survival in the world. It cannot last long on surfaces or in the air, the vast majority of human hosts will successfully kill off the virus within two to three weeks of infection and a small minority will die with it.

Either way, the virus has a very small window to reach a new host or perish. No new human hosts means no more virus. This is why elimination is not only biologically possible, but has already been achieved in many countries around the world.

We must suppress the virus as the population is immunised. As vaccination occurs, lockdown measures become more effective, and the rate of transmission (the ‘R’) falls further still. And as we come into the spring and summer, we gain the additional advantages of better weather, better ventilation and easier outdoor gatherings.

At the current impressive rate of vaccination of nearly 500,000 doses a day, we can administer 120 million in the next eight months, which is two doses for nearly the entire UK population. We will reach herd immunity long before that and, with the possibility of new, single-shot doses, we can go even faster still.

This must be our harshest and longest lockdown yet, but it also must be our last.

So here’s what we should do:

• Keep schools closed until Easter
• Keep the borders closed
• Mandate and supply minimum N95 masks for public and all healthcare workers
• Increase self-isolation financial support
• Mandate businesses to allow staff to work from home properly
• Support, by any means necessary, businesses and the self-employed financially
• Move testing and contact-tracing under the umbrella of the NHS (like the vaccine programme is) so it is functional and cost-effective
• Vaccinate, as many as we can, as fast as we can

By the late spring, we could be in a good position, with a significant majority of the population already fully vaccinated and new case numbers in the hundreds per day. At that point, we must not drop our guard, but keep going for a little longer, keeping the R rate as far below one as we can manage, aiming to eliminate COVID-19 from the UK entirely. 

This is our only feasible chance to get back to a normal life. We must not waste it.

Dr Dominic Pimenta is a London-based doctor and writer. His book ‘Duty of Care’ is available now, with all royalties going to Heroes, a charity supporting healthcare workers