Despite the humiliation of Matt Hancock’s exit, Sajid Javid, the new Secretary of State for Health, might in fact find him a tough act to follow. After an appalling start to our Covid-19 response with missing PPE, high care home deaths, and delays to lockdowns and border controls, under Hancock’s watch the UK is now one of the most vaccinated countries in the world and appears to have decoupled deaths from Covid-19 infections. We seem on track to remove the remaining restrictions in July and deliver some of the strongest economic growth in the world as we bounce back. But Sajid Javid, as he considers other health issues such as dealing with the backlog caused by Covid, winter threats, staff recruitment and social care, should also worry that to date Covid has managed to throw up surprises. This rosy picture of our recovery could be disrupted under his watch. The most immediate threats are from variants and an unacceptable level of deaths amongst the unvaccinated. He and his team need to get a programme ready to address them.
To comprehend the risks our new health minister faces, it is important to understand that our wonderful vaccine programme is unlikely to suppress infection rates as we remove non-pharmaceutical interventions such as social distancing, masks, and lockdowns. As I have explored before, the suppression of the virus through herd immunity relies on a sufficient proportion of the population not catching the disease because they have been vaccinated or have antibodies from a previous infection. The level of herd immunity is dependent on the rate at which each infected person passes on the virus. With the original Wuhan strain, we perhaps needed around 65 per cent of the population protected by antibodies to suppress the virus. The increased transmissibility of the so-called Alpha strain, first identified in Kent, and now the Delta strain, first identified in India, could raise the level of herd immunity to nearly 90 per cent. So, we would need to have 90 per cent of the population (and that includes children) perfectly vaccinated to stop a growth in infections. But we also know that our vaccines are not perfect at suppressing transmission, especially with the new variants. So, it’s easy to see that, even if we offered vaccinations to all, it might not be sufficient to suppress the virus as we return fully to normal and relax all lockdown interventions.
We are already starting to see this since the May release of restrictions. Currently around one in 400 of us have Covid, according to the ONS’s Covid Infection Survey, with the number of infected people doubling every ten days or so. Further unlocking is likely to accelerate this growth. I heard about an illicit post-final exams party where nearly 100 of the 150 attendees ended up catching Covid. Super spreader events like this will be a frequent occurrence when we unlock fully, and they become legal. It’s easy to see that by August we could exceed the one in 50 infection rates we saw at the start of the year.
So, does it matter if the virus becomes endemic, with a high level of infection? Many of the at risk over 50-year-olds are now very well protected by the vaccines. While we are seeing a growth in infections including among the vaccinated, we are not now seeing the same growth in hospitalisations we saw with previous waves. So, the risk of death for them has been substantially reduced. For the young, who have not yet been offered two jabs of the vaccine, and for those where the virus breaks through the vaccination protection, Covid-19 could still be a nasty illness and there is the risk of long-Covid. But the risk for these groups will probably be acceptable given the substantial benefits to society of unlocking further. Think of it as a bad flu outbreak. The challenge is going to be for the elderly who have not been vaccinated because as we let the virus rip, it will eventually find them, and they are not protected.
Very roughly 5 per cent of the over-50s have not had a vaccine and around 10 per cent have not had their second shot. A few of these have declined the jab for medical reasons (for instance the immunosuppressed), but the vast majority will have declined the vaccine by choice, albeit in many cases influenced by untrue anti-vax propaganda. This number is skewed towards minorities, with around 30 per cent of Blacks and 15 per cent of South Asians over 50 not being vaccinated. In England, this non fully vaccinated elderly group is around one and a half million individuals, a group that could be very vulnerable if the virus becomes endemic. Deaths among the unvaccinated could be for Sajid Javid what deaths in care homes were for his predecessor.
The new health minister’s second area of concern should clearly be variants. We have already seen how Covid mutates. Most recently, the Alpha and Delta variants that became dominant in the UK have higher transmission rates than previous variants. This should not be a surprise as a higher rate of transmission gives a variant a natural selection advantage over other variants. To date there has been limited natural selection advantage for variants that are better at busting through the protection from vaccines, as the vaccinated were relatively few. But this summer around the world we could have a high infection rate (and so a high number of mutations) and a big natural selection advantage for those strains able to beat the vaccine – a dangerous mix for generating vaccine busting variants.
There are five measures that the new Secretary of State might want to take to prepare for these two risks.
First, we must redouble our efforts at encouraging take-up of the vaccine. We have already innovated with ambassadors such as Sir Lenny Henry, and by setting up vaccination centres in mosques. But progress has been painfully slow. At the current rate of progress as measured by Oxford University’s OpenSafely, it’s going to take over a year to close the gap for some minorities. We might want to vaccinate the 25 per cent of adult care home workers who are currently refusing the jab. These care professionals have real influence in their communities.
Second, we must get much faster in manufacturing, testing and administering top-up vaccines this Autumn. Our vaccination programme is really world class, but it will still take us over a year to fully vaccinate the UK again. In a world spitting out variants, that is still too long a period to lockdown if we face a vaccine busting strain. It’s technically possible to manufacture, test for safety, and distribute a new vaccine in around three months. We should target that turnaround time and establish sufficient manufacturing capacity – a several fold increase to what we have now. We could even train more of the population to administer a vaccine (apparently, it’s not that hard) so each post code could have their resident ‘home-guard vaccinator’. We need to find a way of simplifying the administration of the pre-jab questionnaire. We might even explore whether we can identify possible future vaccine busting variants so we can test and stockpile a cocktail of vaccines in case they arrive.
Third, we are going to be thoughtful about an acceptable level of social distancing and other non-pharmaceutical interventions even after our July unlock. For instance, we might want to keep mandating the wearing of masks on public transport and avoid super-spreading packed mass transport by continuing to work from home, at least some of the time. We might allow tables to be closer together in the hospitality sector but stick with Continental-style table service so as to avoid the infection sharing melee at the bar.
Fourth, we need to be much better at stopping the import of variants from overseas. While recent history shows that dominant variants eventually spread globally, better border controls will give us more time to develop and administer a vaccine should a vaccine busting variant develop somewhere else in the world. Most immediately, we should worry about the Beta or South African variant as this is better at escaping existing vaccines. We should adopt a no-blame approach to learning from the arrival of the Delta variant from India.
And finally, we need to continue pushing on treatments. In April this year, we belatedly launched our antiviral taskforce. We need to build on the success of finding Dexamethasone, to develop and stockpile a basket of other treatments to further decouple catching Covid from death (full disclosure, I have an investment in some treatment innovators). In particular, we should focus on broad-spectrum antivirals as these are likely to work on future variants.
The new Secretary of State needs to drive the completion of our vaccination programme and push hard to get greater take-up. But on its own that is unlikely to be sufficient. We need to design a much faster version of the next vaccination programme and supplement it with smart social distancing, testing and treatments. By doing that we can safely return to close to normal but, more importantly, be ready for what the virus next throws at us. And our experience to date shows that the virus is unlikely to allow us to win without some surprises. Sajid Javid needs to be ready.
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