Here we are again. In the alarming but familiar situation where the UK (or rather England's) covid-19 cases are soaring while government fails to act appropriately. The situation that kicked off my first posts, before the March 2020 peak: Part 1, Part 2, Part 3. Then for the even worst autumn/winter wave: Part 4...
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... Except that this time, the death rate has been greatly diminished by vaccination: case-fatality rate down roughly 12-fold, from ~2% to 0.16% [Twitter]. For the older, vaccinated portion of society, at least. And as expected, it looks like high deaths really were the only thing holding our government back from pushing through herd immunity by full infection, with a reckless abandon that I feel is a crime against humanity.
Here's a somewhat concise list of reasons why their particular interpretation of "living with Covid" is so dangerous and unnecessary, how it's been enabled (A to D) and a possible upside (E). Followed by a brief overall look at the current pandemic situation in other parts of the world (F) and personal anecdotes (G). Finally, some nice graphs further down (H) that explorer some of the topics in more detail. {Update 2021-07-30: why did cases suddenly start to fall, just before re-opening (I) & (J)?}.
(1) Mask mandate removed - now basically voluntary, everywhere, although the Mayor of London made them (theoretically) compulsory on their public transport network [FT].
(2) No ventilation - initiative to improve safety in schools or workplaces, still! Highly recommend by [SAGE, Oct 2020] Probably the biggest oversight of our pandemic response, that's got stuck on surface contact/disinfecting [iNews]. Better ventilated rooms might not stop contagion between adjacent people, but will reduce outbreaks, which are key to Covid, with it's high dispersion factor [my Blog part 4]. Aside from Covid, this would improve high indoor CO2 concentrations, already identified to seriously impact cognition and health [Nature, via Guardian].
(3) Test and Trace still infective - with no still decisive reforms or effort to improve (financial) support to enable case isolation! In January [part 4 blog (5d)] I mentioned that 18% of infections were not isolating (most not going for testing). Improving integration with (more efficient) local public health resources have been very slow and incomplete. The huge budget would be OK value, if it worked [UK Parliament Committees]. But the majority of tests come during peaks of high transmission, when contact tracing is overwhelmed and so too slow to be effective. The structural failures of this largely privatised system [Twitter] have been a recurring focus of Independent SAGE, for their whole existence [Twitter].
Of its expansive and expanded [Wikipedia] £22Bn budget, from May 2020 to April 2021, £13.5Bn (unaudited number) was actually spent [National Audit Office]. "£10.4 billion on testing; £1.8 billion on identifying and containing local outbreaks; and £0.9 billion on tracing." [NAO]. For scale comparison, the total NHS budget for last year was £129 [NHSproviders]. Unknown spent of current £15Bn budget, to April 2022. Testing expense has mostly transitioned to LFD (lateral flow) tests (instead of PCR labs). with 691Mn units distributed in England. But only 14% had results registered (verses their forecast 95%), raising huge questions. As with PPE purchases, there's serious concern of possible corruption over their sourcing (and therefore worrying conflicts of interest!). Decision making was opaque, with communications via private email addresses and huge contracts fast tracked via "VIP lanes", awarded without tender, to tiny companies often owned by social contacts of ministers [GoodLawProject, Guardian].
(4) "Pingdemic" - headlines [e.g. BBC] creating a narrative that dissociates from fact that disruption of rising app notifications is due to high virus transmission! (In combination with more social proximity than during the winter peak.) It's as myopic as raging at the car directly in front of you for not moving in a traffic jam. Minsters ordered contact notifications to be scaled back [BBC]! Which seems like a very short term fix to disruption, likely to make things worst, thereafter. There's an argument that excess sensitivity will cause more people to simply uninstall the app [Guardian]. That's happening anyway, with check-ins down from 14.5Mn to 12.5Mn during June. It's estimated the app averted between 100k to 900k cases, from September through December 2020 second wave) [Nature]. Which I thinks is fairly insubstantial and will be less effective with slower testing turn-around times, during this infection surge.
(5) Ministers contradicting policy - constantly undermining messaging and public motivation. E.g. Sunak and Johnson initially declaring themselves to conveniently be in the T&T isolation exemption scheme, after Javid (double vaccinated) tested positive. And who preceded to incorrectly suggest people with symptoms to take lateral flow tests, instead of PCR. Stephen Reicher (a sub-group member of SAGE and Independent Sage) has equated all this to "a massive disinformation campaign that undermines the conditions for informed decision-making" [BMJ].
(6) No vaccination for teenagers - despite UK's MHRA (Medicines and Healthcare Regulatory Body) finding Pfizer safe for kids, the JCVI mysteriously did not recommended it [Dr Gabriel Scally Twitter, Reuters]. Israel, Italy, France and US are now vaccinating all teens, with Germany offering an opt-in [Guardian]. There are some rare harms (not all fully acknowledged), but these pale in comparison to the long term health burden of the huge wave of infections that is incoming/ongoing.
The issue is that UK initially ordered 40Mn Pfizer doses [Guardian]. The only vaccine currently with sufficiently good safety data for youngsters. But 20.4Mn first doses have already been used (as of 21st July) [GOV.UK, via Twitter]. Meaning that the whole remaining supply should be reserved for second doses (with the next order not due until September). So, like with the early mask shortage, presentation of the science is seemingly twisted to manipulate the public into a policy of triage, rather than admit a (politically damaging) shortfall. With the same long term impact of severely muddying the water in terms of messaging and perceptions of efficacy/safety. And the media aren't jumping on this. Also, Long Covid (in kids) is being disregarded, see (C.5) below.
(7) Delta variant let in - we watched high case load in India causing chaos, with explosive growth from mid February [ScienceTheWire] and seroprevalence data suggesting that actually 30-40% of the population had been infected by mid-April! UK experts were lamenting, in early to mid April [Guardian], the mysterious decision not at add India to the travel "red list" (i.e. greatly reducing flights and requiring 10 day quarantine for returning Brits). As was already the case for other countries with much lower levels of infection (e.g. Pakistan).
This eventually happened on the 23rd, after Johnson's visit to India (for post-Brexit trade talks with Prime Minister Modi) was cancelled on the 19th April [Guardian]. There had been 77 detected cases (in UK) by April 17th. If not holding off for the state visit, it would probably have been expected to have red listed India 3 weeks earlier, at the start of April. Although, given our ramshackle travel precautions and lack of suppression strategy, overall, this specific failure merely accelerated the take-off of Delta in the UK. But, football socialising would have amplified case numbers far less, with a lower starting number of the more transmissible Delta. And now we're probably amplifying that again with this re-opening, just before we can quite finish vaccinating the young.
(8) Symptom lists inexplicably not updated - on the official government website [Gov]. Still saying "cough, anosmia, fever" when much more common (after vaccinations) are: headache, runny nose, sneezing, sore throat, loss of smell [Dr John Campbell YouTube]. So many not aware to get tested or isolate.
◄B► Avoidable harms of high transmission:
(1) Breeding new variants - with maximised chance of immune & vaccine escape! Endangering the whole world, again. "Living with the virus", as in, accepting an unending endemic state, is probably the most efficient way to promote new variants [Diego Bassani Twitter thread].
(2) Long-Covid (LC) - 100s of thousands more cases in all ages. Potentially doubling up existing numbers, if spread now goes unchecked. See graphs of LC incidence, symptoms, etc, in Fig.15, 16, 17, 18, below. {2021-07-29: An early small study from Israel indicates LC still occurs in ~20% of cases, 6 weeks on from 'breakthrough' symptomatic infection of fully vaccinated individuals [NPR]. Although vaccination does significantly reduce numbers with symptoms.}
(3) NHS overcapacity/collapse - more knock-on effects increasing health burden and deaths. Higher proportion of younger patients means more eligible for ICU instead of palliative care. Harder decisions. Staff destroyed through illness, burn-out and no (real terms) pay rise (see Fig.19, below).
(4) Disruption to workforces and economy - more acute than any previous peaks. "Pingdemic", with app notifying 620k people to isolate in last week, currently being blamed for some empty supermarket shelves and a few closed stores [Reuters via Twitter].
(5) Stress greatly increased for vulnerable shielding. Families having to choose between kid's education and major health risks, etc. Now with even less support; burden moved from state to unfortunate individuals. A study recently showed shielding was also far less effective than hoped [Guardian]. They were 8 times more likely to have a test confirmed infection (during the first wave in Glasgow and Clyde). Then, of course, 5 times more likely to die from that infection (than low risk individuals). Many vulnerable won't have even been able to be (effectively) vaccinated, now, for health reasons.
(6) Cognitive deficits after recovery - Covid literally leaves us dumber, on average [EClinicalMedicine]. Those at home with respiratory symptoms lost roughly the equivalent of one IQ (intelligence quotient). Scaling up 7 IQ, for those in hospital on ventilators - worst than stroke cases. See (Fig.18) below for more details.
(7) Parkinson's epidemic - in rhesus macaques, used as a model for (human) infection, SARS-CoV-2 cause brain inflammation and Lewy bodies to form, which are associated with Parkinson's [biorxiv]. People born during the time of the 1918 Spanish flu outbreak had a 2-3-fold-increased risk of Parkinson's Disease [WorldCongress]. The burden of worsened health, from all these infections, is likely to keep piling up for many decades.
(8) Brexit harms amplified - I predicted these during the previous peak, too. I didn't experience any severe impacts personally. But I only see my local Sainsbury's and the odd Amazon delivery. There's many more consequences of Brexit still developing over time. Most visible is currently the HGV lorry driver shortages. They were in chronic short supply, pre-pandemic, with EU drivers brought in to stave off crises during demand peaks (e.g. Christmas and summer salads). Pandemic control measures may have decreased some HGV haulage demand, via shut-down sectors. But it also caused many EU drivers to return home and now cannot return, due to new points-based immigration rules [BBC], first outlined last year by Priti Patel [Guardian]. Training of new drivers was slowed by restrictions and overall shortage is estimated at 22k to 30k, 7-10% of 300k total driver demand, with half of existing over 55 and heading for retirement [UK Haulier].
Transport secretary, Grant Shapps, announced relaxation of safety limits on how long drivers can work for [Guardian]. Prompting parody headlines of "Government to supply HGV drivers with amphetamines to combat tiredness – “Like WW2 fighter pilots” " [LCD Views]. Also, moves to fast track the licensing processes (to help with the 25k application backlog) will likely not help at all before Christmas [Guardian]. Logistics UK estimating 90k HGV driver shortage (don't know why different numbers), with 25k EU drivers returned home, and only immigration accommodation likely to help sufficiently. A rolling crisis throughout 2020, with delivery fulfilment currently at a dismal 80% (normally >98%). Offering drive pay increases of 15-20% has reportedly not helped recruitment. But 3k drivers are planning as "stay at home" action on 23 August, to protest poor pay and working conditions [Guardian]. The "pingdemic" impact has been mitigated, here, with exemptions from contact isolation for food distribution centres.
(9) Ongoing political distraction - so far hiding bills passed to hasten privatising the NHS. An upcoming draconian bill enabling press to be jailed for "embarrassing" the government [Twitter, Guardian]! Plus the endless revelations of staggering corruption by ministers. And hiding harms of Brexit that are unequivocally entirely of this government's making.
(10) Being sick is really rubbish - millions of people are probably going to have a week or two (or five or more) of experience the effects of a very unpleasant infection. Predominantly the young adults and kids who have been impacted the worst by social restrictions. Now we need a huge swathe of them to get infected (if no vaccination), to reach herd immunity [Professor Pagel Twitter]. Getting hit with a worst strain of the virus, that's about 2.5x more likely to require hospitalisation, if unvaccinated [Imperial Modelling paper page 25, point 8]. We may need them to then get vaccinated too! Because we won't be able to tell reliably who's been infected. And immunity against transmission might be lower than with vaccines (or at least a booster), although infection does appear better for this (see E.1).◄C► This reckless re-opening was enabled by:
(1) Public - rightly fed up of social restrictions, many families and individuals feel near breaking point. Desperate to believe in a return to normality, or feeling powerless and resigned to whatever is imposed.
(2) Political rhetoric - "Now or never" from Johnson and oligarch press, created a false dichotomy that's impossible to argue against. Like the EU referendum was asking the wrong question, but succeeded as a culture war. So too "Freedom day" put the focus on dates rather than data. Banishing fruitful discussion of subtleties, like continued mask mandate or fact that it won't achieve what it claims.
(3) Vaccinations - good success (see H.Fig.7, 8, 9), but not yet as thorough as is generally made out. Nor far ahead of comparable EU countries, ultimately. They have generally been maintaining far better suppression and now also using their more ample supply of Pfizer to vaccinate teens, too.
(4) National exceptionalism - that we yet again seem to ignore the rest of the world, many of whom are watching our mass infection experiment with horror. (Media in some other countries supposedly referring to our Freedom Day as the "English experiment".)
(5) Long-Covid is disregarded - because post viral illness and ME/CFS has been ignored, psychologised and mistreated for so long (medical system inertia). A sociologist apparently speaking for JCVI, minimising existence of LC and using debunked psychological framework [Twitter].
(6) Health secretary change - Matt Hancock eventually resigned after photos of a sordid office fling, rather than for his lying, incompetence and corruption. Ultimately bad news for us, as his replacement, Sajid Javid, is even more deliberately callous [e.g. Twitter]. He's a banker and former chancellor, who's clearly aligned with Rishi Sunank's counterproductive finance-over-people thinking.
(7) Johnson's Lying - not being reported by press, BBC, etc, despite voluminous clear-cut documented evidence [Peter Stefanovic Twitter]. It's currently forbidden to call it out for what it is in parliament! Dawn Butler was ejected for this [Twitter], referring to his false assertion that vaccines have "severed" the link between cases and hospitalisation/deaths, as opposed to just greatly diminishing it (a relatively small twist of the truth, for him).
(8) Tory MP backbenchers - many more far right that ever, making unrealistic or outright anti-science demands. Pressuring Johnson. Some associated with anti-vax agitators, e.g. MP Mark Francois with those talking about Nuremberg trials hanging of doctors [Twitter].
(9) Absent political pressure - from Labour party (alternatively silent or ignored). Nor from electorate, as voting intention poles continue to favour Conservatives [Survation], despite everything.
(10) Scientific advisors toe government line - e.g. Whitty and Vallance did implicitly contradict minister's care-free language and approach, by publicly urging a "slow and cautious" lifting of restrictions to reduce the rise in infections [EveningStandard].
But Whitty also verged on hyperbole, by asserting that an exit wave is inevitable. With hospitalisations and deaths not really reduced by further delay (and at some point NHS would be under more stress from other factors, during winter). Professor Pagel hotly contested this inevitability, citing Israel's successful cautious exit after being first to complete vaccinations [Twitter1, 2]. Reintroducing some measures now due to importing Delta [FT]. Discussion continues under image Fig.20, way down below...
(11) Criticism is impossible - Before we see the consequences of pandemic decisions, one is told that we can't possible know any better. Then afterwards, you're just "captain hindsight". Same for Keir Starmer, in parliament, as between friends in private discussion. Or that other countries have problems too (true, but doesn't negate our failings).
(12) Avoiding use of "herd immunity" term - This flimsy veil of plausible deniability means that the media, e.g. BBC News here, refuse to accept criticism of government on this basis [Twitter]. Not even acknowledging scathing criticism from the director of the WHO, specifically aimed at this approach. A SAGE advisor, Prof Robert West, has explicitly stated that this appears to be their plan, with talk of "caution" as a way to pass the blame to the public [Guardian].
(13) North of England has seen the most intense outbreak so far. Much easier for government to ignore that, compared with London's leading role in the previous waves.
(14) Football - with England reaching the finals of the Euros, many fans have been gathered in pubs, houses, the stadium and tearing up the streets for no good reason, bumping up cases (just about) visibly after each match (see H.Fig.21 graphs, below). This should probably be in my section A or D. But the accompanying nationalism and distraction factor also bolstered government, with minsters keep to wrap themselves in glory. Despite scathing criticism rightly directed at them by the players on the team. If only we could switch their jobs, we'd be in much better shape.
◄D► Re-opening despite:
(1) UK cases rising exponentially - (e.g. graph H.Fig12). We had, I think, the 2nd highest infection rate in the world (of major countries). Hospital and ICU admissions were above the level where restrictions were introduced last year, rising at the same rate as in previous waves [John Burn-Murdoch Twitter].
(2) Alert levels ignored - Gov totally contradicting their own roadmap criteria, again (shown below).
(3) Outcry from scientists and health experts - here, and around the world. 1200 health academics and doctors [JohnSnowMemorandum] officially backed an open letter in the [Lancet], directly co-signed by 122. It mentions many of the points discussed here. British Medical Journal urged continued caution [BMJ]. All 4 of UK's public health bodies warned “Living with Covid-19 is not the same thing as letting it rip.” [Guardian]. The executive director of the WHO said on the topic of the UK: "a rush to re-open economies that accepted infections as inevitable and encouraged them to occur “sooner rather than later” amounted to “moral emptiness and epidemiological stupidity” " [Nature].
(4) Delta variant - 2x more virulent and transmissible (R0 of ~5 to 8) than the original virus (R0 ~2.6) and 50% more than Alpha (AKA "Kent", R0 ~4). Spread ramps up much more sharply, harder to get back under control later and much higher (almost perfect) population immunity needed for full suppression.
(5) The Netherlands reopening - 2 weeks ago sending their falling case numbers rocketing, doubling every 2 days and forcing a partial reversal (graph below).
(6) Vaccinations give stronger immunity - against symptomatic infection for longer [JHSPH]. Although more severe illness generally confers stronger immunity, it tends to wane by 6 months and isn't guaranteed against variants. Natural immunity appears extremely variable between individuals [Research Square, via NewAtlas]. Reduction of transmission may work differently (see E.1, below).
(7) No evidence of increased deaths from lockdowns themselves [BMJ via Twitter]. No signs of uptick in suicides (as yet). Non-Covid deaths, during large outbreak lockdowns, associated with redirected medical resources and potential patients scared away from healthcare settings by high case numbers. Fast acting nations actually saw up to 6% mortality reduction from reduced flu, alone [Guardian].
(8) Vulnerable people - are being hung out to dry. 3.8Mn clinically vulnerable, left to shield with less/no support [Frances Ryan Guardian]. An anti-freedom day, introducing traumatising stress, while the media over-hyping the psychological challenge to ditch lockdown anxiety, as if everything's fine now. Many having to make hard choices, e.g. between protecting an immune compromised, vulnerable parent verses sending their kid(s) to schools, that no longer have mitigations or even notifications about confirmed cases.
(9) Cummings dishing dirt [BBC] on Johnson's reckless incompetence (presented in a self-serving fashion, of course). Also confirming Johnson's dithering was to blame for Autumn/Winter wave and Delta [Twitter].
◄E► Upsides & Successes:
(1) Infections *might* protect far better than vaccines [Edit: I don't think so, see J.4] - against transmitting the virus: close to 100% verses 60% protection from 2 doses of Pfizer, according to this Israeli information [Yanic Erlich Twitter]. I don't know what level of uncertainty is associated with this; I've not seen the 100% protection of infection published or talked about elsewhere (in fact I've heard anecdotally of "breakthrough" re-infections). The "preliminary study compiled by the [Israeli] health ministry" is reporting Pfizer at 64% effective against transmission of Delta, here [FT].
Erlich roughly calculates, his number would mean Israel's population resistance to transmission is ~42%, from vaccines and infections combined. Which is only just enough cancel out Delta's higher R value (back to the same as the original Wuhan virus). Effectively setting pandemic control measures back to March 2020. Implying that countries will either need to continue suppression strategies, embrace mass infection, or rely on updated vaccines. Not far off, in the west, but manufacturing boosters will set back the global supply situation further.
(2) Delaying re-opening - from Jun 21st to July 19th was a very good move. Full re-opening during the football-enhanced spread (and schools all weeks away from holidays) would have been much more disastrous! We seems like we also got lucky with a heat wave, around the delayed relaxation date, which means additional social contact will have been much more outside, or at least with windows side open.
◄F► Other Countries (the grass isn't always greener...):
(1) India - where the Delta variant probably originated, in the later part of 2020, with citizens dying on the streets earlier this year. Seroprevalence studies there have seen Covid-19 antibodies in 67.6% of the (randomly sampled) population of 1.3Bn people, verses 24% in January [Guardian]. Which is probably the main explanation for their falling case rates, given only 13% are fully vaccinated, 24% with one dose. Despite being the world's biggest vaccine manufacturer & exporter [CNBC]. Their official death toll stands at 400k, but [Centre for Global Development] analysis estimates the true toll is an order of magnitude greater, at 3.4Mn to 4.9Mn! More than the official total for the rest of the world combined. Really putting the hand wringing of this blog post into a different perspective.
(2) US - Delta is now taking off there, too [Twitter]. Potentially an even bigger problem for them, given lower levels of vaccination, due to greater anti-vax sentiment (from Republican party nonsense, Trump legacy, conspiracy theories, disinformation, etc). I think the UK could have delayed our Delta outbreak about equally as far, if we had taken measures against travel to/from India at a more reasonable time.
(3) Japan - obviously has the Olympic games going on right now (a year delayed). Even with no audiences [Channel 4 News YouTube], there's still an expectation for it to double case numbers []. There's only ~15k official deaths, in a population of 126Mn. A far better record than UK, US or EU countries. But there were reports of their hospitals being overwhelmed in May [Reuters]. Despite the highest number of beds per per in the world (~13 per 1k verses ~2.5 per 1k in UK) and same for ICU places and ventilators [Wikipedia].
Japan's testing rate is tiny, currently totalling 0.14 tests per person, verses UK's 3.45 [WorldOmeter]. But I don't think there's scope for the kind of massive under-reporting seen in India, where death certificates aren't issued regularly, so excess mortality can't be even checked. Japan's not really seen excess deaths [Economist]. So, these were perhaps only regional outbreaks, with ICU capacity and drug shortages mostly limited to Osaka. But Japan's vaccination rollout was delayed, a few months behind ours (with reliance on pharmaceutical imports). So they are more vulnerable to a Delta outbreak, for now.
(4) Brazil - is not stranger to poorly controlled outbreaks. President Jair Bolsonaro has been as bad as (or worst than) Trump. Things have been so bad his popularity has been plunging, while he faces corruption charges, previously contracted Covid himself and is now hospitalised for uncontrollable hiccups [CNN]. With the Southern hemisphere currently mid-winter, Brazil is seeing 1000 deaths per day, atop 544k total and 20Mn cases. That's official figures; probably much worst in practice, given they've never managed to bring cases back under control .
A rising tide of cases, earlier this year, brought to much more transmissible P.1 (Gamma) variant, with some immunity escape. It emerge from the badly hit city of Manaus, with endemic spread for most of 2020. These conditions allowed mutations to accumulate and variants compete, including within the 30% of individuals previously infected [Diego Bassani Tiwtter]. P.1 spread to other South America Countries, causing problems in Chile and Uruguay, previously lauded for good Covid management [BMJ]. Chile being the most well vaccinated country in the world, over 10M population, where over 70% of the population's had one dose (or two).
(5) Africa - Scary times incoming! With virtually no vaccinations, deaths from Delta are now kicking off, in the countries we have data for, at least. See Fig.5 and 6 images, below.
(6) Myanmar - has seen an explosion of cases in the last month, having been relatively under control. It's still under military (junta) rule, following the coup in February, which took power back from the recently elected government [Guardian]. Part of that move famously taking place in the background of this viral workout video [Twitter].
Now there are reports of citizens being shot at by junta forces, while standing in line for oxygen bottles [Guardian]. Doctors also being arrested, having been at the forefront of anti-junta strikes. Journalists also targeted, making accurate information difficult. The headlines are of it becoming a possible "super-spreader" state, on the board of most mainland Asian countries. Certainly a humanitarian disaster, but with a population of 50Mn, that threat seems almost quaint, adjacent to the 900Mn plus quietly infected in India, within the last year.
(7) Thailand - next door, is also seeing a rapid rise in infections, with a warehouse recently repurposed as a 1800 bed field hospital [Guardian]. Making our ExCel centre "Nightingale" look well equipped. Thailand currently have only ~5% vaccinated, with excessive reliance on domestically produced AstraZeneca from a royally owned manufacturer that's never supplied vaccines before.
(8) UK's affect abroad - We generously gave the Alpha variant to the world (the most successful until Delta). But government succeeded in the parliamentary vote to cut our overseas development (foreign aid) budget from a minimum of 0.7% GDP to 0.5%, for at least the next 3 years, probably indefinitely [Reuters]. Despite open condemnation by our previous PM, Theresa May (architect of the "hostile environment" for migrants, a home secretary), leading a limited backseat Tory rebellion. It's mostly narrow minded penny pinching, at the expense of the most vulnerable in the world (whose lives are cheapest to improve). But with the huge Brexit hit to UK exports, our trade deficit will be ballooning - more £ headed out than returning, devaluing our currency abroad.
Then there's UK's ongoing blocking of a vaccine patent waiver [New Statesman], along with Canada and German (which have big pharmaceutical industries). This despite Biden's US surprisingly having reversed it position, to back a waiver in May [Nature]. The WTO (World Trade Organisation) won't negotiate until all member agree (including UK, etc). If this is passed, there would then need to be knowledge sharing and finally massive investment in (global) manufacturing capacity. Obviously pharmaceutical companies are very unhappy and Bill Gates joins their chorus, saying it's not practical.
Ultimately I can't see a better way, than building up a world wide, rapid response immune system [my Twitter]. Ready to tackle new variants and new viruses before they cause so much chaos again. As things stand, only 14.7% of the world's population are fully vaccinated (1.1% in low-income countries). With widespread dependence on an AstraZeneca vaccine that's being blocked from export by India and already down to only ~60% effective against the dominant variant, anyway. Unless we radically overhaul the situation, there's no chance we'll be able to clamp down on global endemic spread, which will inevitable produce the worst possible variants.
(9) Australia [2021-08-07] - Is in a precarious position, locking down to try containing spread from almost 300 cases of Delta in New South Wales [Meaghan Kall Twitter]. The problem is that under 20% have been vaccinated, so far, so spread will be devastatingly explosive, if it gets out of control. Note, this is a failure of vaccine program, *not* a double edged sword of previous success in preventing spread; less than 20% of the UK population has antibodies from past infections, adding only ~2 to 3% extra atop the 90% of adults with antibodies from 1 or more vaccine doses [Twitter].
◄G► Personal anecdotes:
(1) Personally - I was lucky enough to get a Pfizer vaccination a little early, by phoning my surgery. That was 3 weeks after they apparently lost the 2 page letter I physically posted to them, justifying why my ME/CFS should have had me included in the JCVI's priority group 6. My parent's were vaccinated months before that, of course. So our household has as much protection as anyone in the world.
But I'm acutely aware that other family and friends (in their 30s) have only had their first doses, with full (neutralising) immunity still many weeks away for them. Already much safer in terms of mortality, but unlikely to be protected against (symptomatic) infection itself. (In fact, one young family member mildly symptomatic, as of a couple weeks ago.) So they, and their kids (more so), are still quite vulnerable to long-Covid.
(2) Serious vaccine side effects - an generation older cousin of mine got hit badly by vertigo and fatigue (I think) with neurological issues arising directly after their Astrazeneca jab. A relative of a friend was hospitalised with clots from this, too. And while the majority of my online ME/CFS contacts recovered from vaccination side effects (some temporarily improved, even), at least one continues to suffer significant leg weakness, many weeks after the temporary worsening of chronic symptoms faded.
(3) Supermarket experience - the only place I ever get out to (once a week). The day after re-opening, I was initially pleased that the vast majority continued to wear masks, there. But at the end I say a lot of 20s/30s, young families, in particular, it seemed, not wearing masks. Despite continued loud speaker announcements asking for it. Ironic, if they weren't fully vaccinated (or previously infected); I think the concept of protecting the elderly from death has overshadowed other considerations, with government (mixed) messaging that youngster are 'safe'.
The Perspex dividers between checkouts had all been immediately removed, too. Which some have lamented, but I wasn't worried about, given that there's no strong evidence of their effectiveness; they are just as likely to inhibit ventilation of aerosol particles, that are the main vector of transmission [SAGE on Gov.UK, via Twitter 2021-07-30].
A couple of empty shelves, too, but nothing drastically beyond normal for the time of day.{Update: the week after, all the fresh food was well stocked (in the morning), but the freezer section was very depleted. Like they've been prioritising the limited haulage to perishables; plenty in the country, difficult to distribute to shops.}
◄H► Graphs with more detailed discussion:
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[Fig.1 - My annotations on graph from CEMB, R0 figures from BBC News] As more transmissible variants evolve, the requirements for herd immunity rises too, following this curve. The original variant would have needed only 60% of the population to be *totally* immune to the virus, in order to contain it with no other mitigations. Or 100% of the population to have received a vaccine that's 60% effective. That's against *transmission*. Delta probably requires ~85% immunity, but adults comprise only 79% of UK's population [Professor Pagel Twitter]. Meaning that *all* adults and many children also need to be vaccinated (or infected) to achieve herd immunity. Evidence suggests the best current vaccines don't reduce transmission nearly enough for this, either. So non-vaccine mitigations are needed to control spread until more effective vaccines come along. Or very widespread infection, *if* that does provide greater protection, as discussed (E.1) above. Note: mumps has R0 of 12, measles 18, and we contain their spread, mostly through vaccination. So this should be entirely possible for Covid. |
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[Fig.2] Microbes (bacteria, here) have been found to evolve improvements in their relative fitness (competitive success at existing) on an apparently never-ending basis. Even in an extremely simple, static lab environment. Graph screenshot from "The Longest-Running Evolution Experiment" on [Veratasium, YouTube]. So we should expect that Covid-19 will be no different; the more transmission and hosts it's incubated in, the more improvements it will evolve. It's a certainty that not controlling spread will create more transmissible/virulent variants. (Even before considering vaccine escape.) For a ballpark feel, from looking at R0 values of variants more than doubling (Original ~2.5, Alpha ~4.5 and Delta ~6.5) verses the timing of their first notable occurrences (December 2019, Sept-Dec 2020, Oct-Dec 2020), it seems like we're probably still on the early, steep part of the curve. Before it's 'knee'. Which would be bad. Of course rate of evolution will be proportional to number of infections, not to the passage of days, alone. And vaccines + immunity are changing the landscape for the virus quite drastically. Possibly counter-balancing the benefits of high transmissibility, favouring immune escape mutations instead, if theses are mutually exclusive. {Apparently there is no trade-off for mutations of recently emerged (zoonotic) viruses [Twitter]!} |
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• Pfizer (BNT162b2) - 94% vs Alpha, 88% vs Delta. • AstraZeneca (ChAdOx1 nCoV-19) - 74% vs Alpha, 67% vs Delta. Unknown efficacy against (asymptomatic) transmission. |
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| [Fig.4 - Twitter] Vaccines really work against mortality! Comparing between the start of wave 2 (with no vaccination) and the start of this 3rd wave. Death scale normalised up by a factor of 100. But... |
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| [Fig.5 - Twitter] Vast swathes of the world are approximately nowhere, when it comes to vaccine roll-out (as expected in my Part 2 blog). Which means Africa, in particular, is really starting to get hammered by Delta... |
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| [Fig.6 - John Burn-Murdoch Twitter] Sideways versions of the (fig.4) graph, above. UK and Portugal deaths almost invisible, compared to previous waves (UK CFR (case fatality rate) reduced 12-fold). While Namibia's deaths explode, proportionately higher than previously. Tunisia, South Africa and other countries with low vaccination rates, also now being hit harder. |
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| [Fig.7 - Financial Times, 2021-07-22] • EU counties vaccinating as fast as UK's impressive program, just under 2 months behind. • US apparently struggling to reach high uptake, with vaccine hesitancy. But note that various counties will have used more or less of single/double dose vaccines, so raw numbers not entirely comparable. • Israel apparently stopped at just 60% of their population (all Pfizer), with a far bigger child population demographic than UK, etc. They recently started including teens too. • Japan struggled even more to get started, but again, trajectory is now the same as other leading nations. But low population immunity a worry for Olympic games. |
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| [Fig.8 Indie SAGE YouTube 2021-07-16] We are approaching full coverage of adults, to be fair. But note there are 4 age groups missing from the left, of kids who aren't vaccinated at all, yet are still vulnerable and contagious. Ignoring this has allowed government to use more reassuring percentages for vaccination program (implicitly stated for adults only). |
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| [Fig.9 - Indie SAGE YouTube 2021-07-16] It seems like vaccine uptake has been falling off for the last month. Hesitancy about possible side effects, from some under 30, is probably a significant factor, e.g. regarding fertility [Guardian]. Along with Government's mixed messaging implying young adults are virtually immune from consequences. But there's also much talk of the initial Pfizer supply (40Mn doses) being used up. |
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| [Fig.10 - Twitter] As vaccinated older generations face greatly reduced chance of needing hospital, the relative share of hospitalisations has shifted decisively younger. Over 50% are now under 50 years old, compared to under 20% near the start of vaccine program. Which is not so bad, overall, provided cases don't keep rising. Version of graph scaled by absolute case numbers, shows average hospitalised age slide down from 65 to under 50, across the same time period [Twitter]. |
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| [Fig.11 - John Burn-Murdoch, Twitter] Netherlands (an extremely similar country to the UK) recently had a similar kind of national re-opening, which inverted their falling case numbers into an extremely steep rise, doubling every 2 days! Triggering a major revision of this policy, curbing transmission, and a (sort of) apology from their government. |
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| [Fig.12 - Financial Times, 2021-07-22 ] It seems like many EU countries, US and Israel have also struggled with on/off control measures. But most recently, moving into mid-summer, with high levels of vaccination in all of these, only Netherlands and UK have really spiked cases, by relaxing control measures. Japan may be substantially under-testing. |
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[Fig.13 - BBC News] Government's own alert level system currently reads a 4 for "Stage of outbreak", but the measures have been relaxed more than level 2. Reference above for (D.2). |
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| [Fig.14 - Indie SAGE YouTube 2021-07-16] The role of schools for transmission between school age children is very clear, here, dropping right off during holidays. Over 1Mn pupils (14% of total) missed school due to Covid or self isolating as a contact, in this last week. |
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| [Fig.15 - Deepti Guardasani Twitter] The enormous scope of Long-Covid incidence! 20% still have a symptom a month after first infection, with apparent asymptote at ~12%, after 3 months. The control participates are those who did not test positive via PCR, in this ONS study of a randomise representational sample of over 300k people across the UK. Their decisively lower symptom reports clearly dismiss the notion (of psycho-somatic theories) that lockdowns and anxiety are causing such symptoms. |
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| [Fig.16 - Deepti Guardasani Twitter] The REACT-1 study (over 500k people sampled) shows that it's not just individual minor nuisance symptoms, as 20% of Covid cases had 3 or more symptoms, 12 weeks after. |
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[Fig.17 - ONS via Deepti Guardasani Twitter] Over 1Mn people in UK currently affected by long running symptoms, 2/3rds saying it impacted their day-to day activity, 400k symptomatic for over 1 year... The full [Twitter] thread is a really good summary of many other aspects of the health burdens following Covid infection. And note (again), that Long Covid incidence is not associated with symptom severity, so medical research experts, like Danny Altman, see no good evidence to suggest vaccinated cases should expect lower chance of lasting illness. |
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[Fig.18 - EClinicalMedicine] Referenced above (B.6) - average cognitive deficit by Covid severity. An SD of -1 would be equivalent to -15 IQ points. This was sampled from the 80k participants of the Great British Intelligence Test (Jan to Dec 2020). Cognitive impairment is for all cases, not just Long-Covid patients, who I'd expect would be a lot less likely to participate, the more severe their brain fog and cognitive symptoms (a bias towards under-estimating overall impact via this opportunistic study). |
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[Fig.19 - Twitter] "Nursing pay has fallen [around] 10% in 10 years." Yet government is only reluctantly offering a 3% pay rise, which may equate to a relative cut, if inflation hits predicted 3.7%, and which excludes (already hard done by) junior doctors [Guardian]. It may also mean taking money away from other parts of the health budget, with no mention of extra funding. Clearly there's no interests in mitigating NHS staff burnout, let alone giving fair compensation for an horrendously harder job, during the pandemic. |
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[Fig.20 - Government Modelling by Imperial College London] This paper is presumably what persuaded Johnson to postpone re-opening by 4 weeks (from Jun 21st to July 19th). Dropping from the apocalyptic blue curve, down below the pink, closer to the yellow (which was modelled for 26th July). In any case (barring delay until December) the peak in infections is expected to significantly exceed the winter wave. The 9 graphs show optimistic, middle and pessimistic cases for both transmissibility and immune escape (huge unknowns).Given the delayed opening, they appear to have been expecting, from this modelling, over: 125k to 500k cases per day (mid 375k). All well above the daily case rate last winter, and far more than the "100k per day" I've heard them warning about in the media! Hospitalisations expected to be substantially reduced, of course, at roughly half up to 2 times above the winter peak. [Continuing from (C.10), above...] Whitty claimed the modelling showed very little difference in detrimental effects, dependant on time (month) of reopening. But the paper itself repeatedly emphasises huge uncertainties, depending on it's many assumptions [GOV.UK]. These include continued transmissions controls (like mask wearing) plus test-trace-isolate and good hand hygiene; continuing vaccination rate of 2M doses a day (which has actually dropped off a lot); no booster shots; no vaccination of teenagers ever modelled; high protection against any infection; many other aspects. Whitty also later made fairly stark warnings, in separate statements: with the 100k cases per day (touted by Javid), that long-Covid increases (in kids) will be a serious problem [Twitter], and we could need lockdown in 5 weeks, if wave doesn't top out [Sun YouTube]. |
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[Fig.21] Football! • Top [FT] - subtracting female cases from males, shows a signature of more guys meeting up in person to watch the "Euro 2020" tournament in pubs, homes (and the stadium), as the England team progressed to the finals. • Bottom [Mirror] - for overall context of case numbers, the number of cases by age group and gender for the week up to the 16th July. |
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| [Fig.22 Twitter] The global south now broadly struggling with overwhelmed hospital provisions. With more infection variants, much less vaccination (and winter in the southern hemisphere). |
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[Fig.23 - Twitter via Boing Boing] As Delta now dominates the US, there' currently a strong association between high cases in the states voting Trump. With lower vaccine (and mitigation) uptake, where more have bought into Covid misinformation and Republican governors have previously banned officials from cajoling people into getting vaccinated.  The case rise has been scary enough that a whole bunch of prominent Republicans, and even Fox News(!), suddenly changed their tune, last week, now very explicitly recommending vaccination to their supporters [FT]. Although, false beliefs are notoriously impossible to correct. So there's no way US will reach herd immunity by Vaccinations alone, now. A lot more infections to come, I expect. Far worst than UK. Maybe Long-Covid will even become a core Republican party issue...? |
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| [Fig.25 - Professor Pagel, Independent SAGE YouTube, plus my annotation in red.] |
(1) It's not herd immunity (alone) - the drop in cases is too steep, when an immunity-only decline would look like a plateaux with slow falloff. All regions of England have dropped exactly in sync, too, despite varying degrees of vaccination and immunity that will split the timing of this effect kicking in.
• Some people less diligent about getting symptoms tested, given 'freedom day' rhetoric.
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| [Fig.26 - YouTube] |
• Case and contact isolation of school children reached over 1Mn pupils, by the end of term. Over 25% of all pupils in Northern regions, where cases have been highest. This will have slowed spread.
• 'Pingdemic' - will have been doing its job, to some extent, isolating infections and reducing overall social contact. App isolation notifications continued to rise in the week up to the 24th, too. To their highest level to date [BBC]. Despite positive cases dropping over this time period. Presumably this indicates a significant lag in reporting of test results and tracing of contacts...?
• Elevated caution - among many of the population, in the face of exponentially growing cases and, of course, Johnson's over-confident re-opening verses warnings from experts. Or rather, just sustained caution, for the most part. With ~70% of people surveyed, intending to continue sanitising hands, self isolating if necessary, wearing masks in shops and public transport, avoiding crowded places [ONS, via YouTube]. Although <50% of under 30s on these last two, so they'll continue to drive cases. But maybe their high incidence of past infection will help to mitigate cases more than with other age groups.
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| [Fig.27 - GOV.UK] |
Which leaves us still revaluating "why?". All the above points still apply, including the public still mostly being just as cautious, or maybe more so (compared to during Football fever). But also, I think it seems increasingly likely that schools were driving cases far more strongly than anyone expected. Having been used to the previous variants, where kids were less susceptible to infection and caused less transmission. That's no longer as true with Delta. Kids also virtually entirely unvaccinated, whereas young adults, now back in night clubs and pubs, have a significant amount of vaccine immunity. On top of their higher rates (than other demographics) of past infection based immunity.
I think that's why the Netherlands saw such a steep rise, on their reopening, by comparison: their young adults had almost no vaccine immunity. At that point they were still catching up with UK (rapidly). And this is also why the US is about to be in an even worst position than currently, given their schools are due to go back soon. Although they have vaccinated millions of school aged kids.
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[Fig.28a GOV.UK] PHE week 30 report on flu and Covid (a little hard to make out). This Delta wave, cases among primary school (orange line) and secondary school (green line) kids have been significantly higher. However, this is roughly in line with the increased testing rate for primary school children (graph below). So some/most of the increase in that age range may be accounted for in that increased testing. Secondary school case increases exceed that a little more. And Fig.14 (way above) showed how much more quickly the number of pupils off school, for Covid/contacts, was growing after May/June half term, compared to before. College/university students (black line) have a significantly higher case rate, still. Also significantly higher than 20-29s, despite a very similar rate of testing as the overall population. So it's probable that (post-16) higher education was driving cases even more. With Uni end of term, plus A-level and GCSE exam years, finishing a little before schools. In fitting with the (marginally) pre-re-opening downturn in overall cases.  [Fig.28b - GOV.UK] Testing rate by age groups. To better interpret raw numbers from previous graph. |
Cases and hospitalisations continue to hold at a high level, after only a small decline in admissions. In fact, it looks like cases continue to grow on a linear trend, upon which the Euro 2020 football peak sits neatly:
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| [Fig.29] Official figures downloaded from coronavirus.data.gov.uk and graphed in Google Sheets, with dotted trend line added in Google Draw. Also shows that vaccinations have reduced hospital admissions by a factor of ~3x, relative to cases. |
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| [Fig.30 - ONS via Independent SAGE YouTube] There was only a small uptick of people socialising indoors after the July 19th "Freedom Day" (Step 4 relaxation), barely rising above outdoors for the first time this year. The much bigger transition happened in mid May, in line with easing of Step 3 restrictions. Those meeting indoors shot up from 10% to 50%. So it's no surprise case rate climb has been ongoing since that point. |
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