A year on from the start of the UK’s first lockdown, the Prime Minister announced the country could be back to normal by 21 June. For GPs on the front line, this might seem a bit optimistic.
The vaccine programme has brought some hope, but there are still so many variables around efficacy.
Costanza Pearce asked some prominent experts about the best, worst and most likely case scenarios, and the effect of treatments, to find out whether there really is a light at the end of the tunnel
Best case scenario: Eliminate the virus, back to ‘normal’ by 2022
• High levels of efficacy
• High uptake
• New variants cause little trouble
• A lot of luck
‘It has been achieved before with vaccines that you can essentially eliminate a virus completely, so it just doesn’t exist anymore,’ says JCVI member and professor of paediatrics at the University of Bristol Professor Adam Finn. ‘That is theoretically possible with this coronavirus.’
The start of the vaccine programme has been very encouraging. The UK easily passed its target of vaccinating 15 million people by mid-February. Despite concerns around uptake among some ethnic minority groups, take-up levels in general have far surpassed expectations – almost 95% of over-70s had been vaccinated by 18 February – a ‘fantastic achievement’, as RCGP chair Professor Martin Marshall put it.
The vaccines have also been shown to have very good efficacy. A real-world study by Public Health England has shown a single dose of either Covid vaccine – Pfizer or Oxford – is ‘more than 80% effective at preventing hospitalisation’ in the over-80s, around three to four weeks after the jab.
However, it is far too early to say these initial findings will eliminate the virus, says Professor Finn: ‘I think we’d have to be quite lucky for that.’
This would ‘require very high levels of immunisation with vaccines that were very effective over a long period of time in all local populations’, he says. This effectiveness would also need to cover current and future variants.
This is unknowable as yet. It is even too early to make any declaration about efficacy against transmission.
Dr Susan Hopkins, PHE senior medical adviser, said in a briefing for science journalists last month that the most effective way of reducing transmission is by ‘reducing the number of people both symptomatic and asymptomatic’. And Dr Hopkins is confident those vaccinated will transmit less: ‘We don’t yet have the viral loads from these individuals so we will be looking at that to see if they are lower, but we suspect that they will be.’
Dr Peter English, a former GP and chair of the BMA Public Health Committee, says this may spell good news for later in the year, if the vaccines remain effective: ‘If that means we get enough people immune to push the R value below one with no other interventions or restrictions, that would allow a return very much to normal.’
Most likely scenario: Covid circulates like flu
• High uptake continues
• New variants continue to mutate, but without devastating impact
Health secretary Matt Hancock tempered expectations last month, saying we could be living with Covid-19 as we do with flu in the long term.
Professor Finn says there’s likely to be an ‘endemic epidemic picture’ as with flu, where the virus ‘constantly changes to evade our immunity so we’re always playing catch-up with it and it moves around the world with the seasons to find populations with insufficient immunity’.
There are already indications this is the way the Government is thinking – it has already announced there will be booster vaccines from this autumn.
Professor Finn adds: ‘We’re going to continue to have to live with the virus, but it’s uncertain just how bad a problem it’s going to be over the next few years.’
Dr English says that, as this scenario plays out, there will come a point where healthcare leaders ‘decide to allow the virus to circulate more widely while expecting there to be fewer serious cases’.
This scenario would be acceptable to most – Professor Finn calls it his realistic ‘best case scenario’ – but in order to achieve it, vaccination uptake will need to remain high.
Dr English says: ‘The more we can get the number of cases down, the fewer opportunities there will be for mutations to arise.’ He suggests we may move to a system of ‘opportunistic vaccination’, adding: ‘The bottleneck at the moment is availability of vaccine; but in six or nine months time, we’ll be swimming in it, and it will be feasible to offer people a dose when they arrive, well, anywhere.’
However, he warns vaccines on their own won’t be enough if they are unable to reduce transmission. We will need a functioning test and trace system, including a ‘support system in place where people will be content to isolate because we compensate them adequately. You can’t feasibly do that with lots of cases, it’s just impossible’.
This scenario would entail the Government getting to grips with test and trace. Former NHS Clinical Commissioners co-chair Dr Steve Kell tells Pulse that though this ‘seems to be working better than it was, the actual figures and transparency behind it need to be improved’.
Could new treatments help provide a way out?
Treatments for Covid-19 have been discovered in the past year and more could become available – but experts say vaccination will be more crucial in our quest to get back to something close to normal.
In hospitals, the corticosteroid dexamethasone is being used widely and ‘will have saved tens of thousands of lives already’ in the UK since it was authorised for use in the NHS last summer, says Professor Jon Bennett, a respiratory consultant and chair of the British Thoracic Society. Trials showed the drug – which is low-cost and widely available – prevents one death for around eight ventilated patients, or one death for around 25 patients requiring oxygen alone.
The anti-inflammatory tocilizumab has also been rolled out in hospitals in recent weeks, after trial results showed for every 25 patients on oxygen treated with it, one additional life would be saved.
In primary care, the inhaled steroid budesonide could in future be used as an early intervention. A study by the University of Oxford, which has yet to be peer-reviewed, involved 146 people who had tested positive for Covid-19, half of whom were given 800mg of budesonide twice a day and the other half received the usual care. Use of the inhaler reduced the relative risk of needing critical care by 90% over the study period. The researchers also found a quicker resolution of fever after 28 days.
Problematic scenario: uptake and mutations lessen vaccine efficacy
• Uptake decreases
• New variants are more damaging
The vaccine uptake so far has been impressive. But we can’t take this for granted, the experts say. ‘When a 22 -year-old person is offered the vaccine [in the next few months], whether they accept it or not might be different to what they’re saying now,’ says professor of immunology at the University of Surrey Professor Deborah Dunn-Walters.
Meanwhile, there is real concern about uptake among minority ethnic groups.
This isn’t necessarily a case of anti-vaccination sentiments, says Hackney GP Dr Jonathan Tomlinson. ‘There are a lot of people who do want to get it and maybe they’re not in secure housing, we can’t get hold of them, they might be homeless, or just moving around all the time.’
In his area, which is a deprived part of London, he says rates are at ‘70% to 80% of over-80s, which isn’t great. That’s a problem’.
GPs will be vital in increasing uptake. ‘There are a lot of problems with vaccine hesitancy and a lot of it is about who people trust and their messaging, so public messaging by GPs is key because they’re a trusted voice,’ says Professor Dunn-Walters. ‘People either implicitly trust this Government or implicitly distrust it, but our society does believe in the NHS, and GPs are the most trusted voices in the country. It’s rare that people lose trust in their nurses and doctors.’
But as the vaccination programme continues at pace, it seems the focus could move away from GP-led sites towards online bookings into mass centres. For Professor Dunn-Walters, keeping vaccination services local and GP-run will encourage uptake among the vaccine-hesitant.
General practice is ‘absolutely the right place’ for the programme, says Dr Kell, but it needs funding for the additional workforce to sustain vaccination alongside normal services. ‘I’m confident general practice could do that but it will need to be well resourced.’
The alternative is worrying: poor uptake would allow the virus to ‘evolve away from the vaccine’, Professor Finn warns.
Dr English, who is also a consultant in communicable disease control and a former editor of Vaccines in Practice, says this will mean an ‘arms race’ between vaccines and the new mutations, warning that we are seeing the effect of mutations already and shouldn’t expect to see a vaccine for the South African strain before ‘mid to late autumn’. In a problematic scenario, he adds, we might not see the R value below one until ‘possibly two or three iterations of new variant vaccines’.
There is good news though. The Government has said it is confident ‘tweaked’ versions of the jabs can be developed at speed.
Worst-case scenario: next winter replicates this winter
• New variants render current vaccines ineffecive
Worst of all, next winter could look no different to the situation we’re living through now. ‘If we’ve got variants that are evolved away from the immunity we’ve got at the moment, the worst-case scenario is that we’re no further forward next winter than we are now,’ says Professor Finn. ‘I’m hoping that’s not the case, but it is a possibility I’m afraid.’
The modelling by researchers at Imperial and Warwick universities, used by the SAGE committee in advising the Government, makes sobering reading. Even with vaccine efficacy fairly high, and four million doses administered per week, we could still expect 30,000 deaths between 1 February and 1 June.
But if the vaccine turns out to have lower efficacy than suggested by the initial results, we could be looking at a further 100,000-plus deaths while the country emerges from lockdown.
And the Armaggedon scenario?
Professor Rafael Ramirez, director of the Oxford Scenarios Programme at the University of Oxford, says the vaccines will need to be effective around the world to avoid ‘exacerbating health inequalities, and giving rise to new strains’.
But in the Armageddon scenario, where new strains outstrip the vaccines, we are looking at a new society, he says. ‘As hospitals focus on Covid, GP work in the UK would become MSF medic work in a war zone – with treatment becoming less complete than we are accustomed to.’
There are still a number of variables: the efficacy of the vaccines against transmission; how successful treatments will prove to be; whether vaccination rates hold; and, perhaps most importantly, how the virus mutates.
Much of this won’t become apparent until everybody has been vaccinated and had their second dose, says Professor Dunn-Walters. She adds: ‘It’s going to need some patience and some watching but it’s encouraging the way the numbers are coming down and the way that people believe in vaccination. We’ll have to wait and see.
‘I understand for GPs it’s a tremendous amount of work, but I think it’s worthwhile. There are signs that we’re going in the right direction.’
Additional reporting: Helen Quinn