Zero COVID – It is possible!

Summary

• Zero COVID is a philosophy which seeks to eliminate community spread of Sars-Cov2.

• Many countries have adopted this approach and have done well in terms of health outcomes and economic impact. Taiwan, New Zealand and Norway shine out.

• A raft of public health measures are needed to keep COVID at sufficiently low levels to be manageable, including but not only vaccination

• After the third wave, The UK now has another chance to try to get this right, but political priorities seems elsewhere.

Introduction.

When I retired as a GP I wondered how thinking less about science and health would play out. Lo and behold, looking after my own MS, helping to provide an NHS healthy living clinic and now COVID19, with a bit more time thrown in has given me more interest then ever in the connection between the world we live in and our health. So, when the chance came along to join a webinar on Zero COVID, I could not resist. Surely this is something we could all agree on – a Zero Covid world would be a good thing!

What is Zero Covid

So what exactly is Zero COVID? Well, there is not absolute agreed definition. The literal interpretation might mean no viruses in existence – but that will, it was agreed by all, never happen.

The general consensus of the webinar experts seemed to settle on Zero COVID meaning levels of infection low enough to be managed by isolation of cases or outbreaks by local public health teams without the need for prolonged or damaging lockdowns. In other words, little or no effect of society. This is not utopian – 30 countries and 23% of the worlds population already live with Zero COVID and experiences from Taiwan, Norway and New Zealand, amongst others, point the way to achieving this. Zero COVID means lower death and illness but also relatively little damage by way of lockdowns and its economic hit.

Comparing nations is tricky – those with less inequality, better public services and different cultures will do differently, but comparing our outcome in terms of death rates to nations adopting a Zero tolerance approach to the pandemic is nonetheless very sobering…..

How to get to Zero COVID.

In a way, the UK is a study of how not go go get there. Public messages need to be clear and the aims of actions need to be understandable. For the first year of the pandemic in the UK they certainly were not. The image of the packed Cheltenham races, Liverpool vs Atletico Madrid, and worst of all BoJo shaking hands with health staff stick in my mind and set the pattern for some terrible early pandemic management.

The problem with this is that a pandemic is rather like a forest fire – if you watch out for it and put out small fires early, you can continue to go about your business unscathed. If you delay, or have no firefighters, then it rapidly gets out of control, and you have to accept much higher levels of damage due to late and more difficult interventions. When we gave up on community testing that is what we did and in the UK we have been paying the price ever since.

So an integrated system of Testing, tracing, isolation and support to prevent wider spread are the pandemics firefighters. The opportunity to expand established, if pared back, public health systems was ignored in favour of new private sector contracts which are an ongoing failure. A recent parliamentary public accounts committee report states:

“National and local government have tried to increase public engagement with tracing, but surveys suggest that the proportion of contacts fully complying with requests to self-isolate might range from 10% to 59% “

Government tends to emphasise our high level of testing, but it does not matter how good the testing is if people are not isolating when they need to do so. We are still far from getting this right. This contrasts to Zero COVID nations where levels are low enough for every case to be individually managed and supported well enough to isolate effectively.

Another key message is that early sharp short and perhaps local lockdowns work. Rather like firebreaks, the later they are put in place, the more widespread they need to be, the longer they need to last last and the more damage they do – UK Style. Border controls and quarantine of arrivals needs to be put in place early as in NZ, ours – one whole year late. Full income should be maintained during isolation in particular for those key workers and disadvantaged who have born the brunt of the pandemic. None of this was done in the UK.

Losing the summer

Despite this, last summer we had the chance to get to Zero COVID. The opportunity was thrown away in a futile attempt to get back to and illusory but politically appealing ‘normal’. During the summer, over 1000 cases of infection were imported into the country by holidaymakers. Impersonal call centres laid idle while community cases continues to spread, particularly in deprived areas where people could not afford to isolate, and where isolation at home was not only impossible, but likely to increase spread to other household members. Infections smouldered on and ignited when the conditions for spread became favourable for the virus in the Autumn. Key workers, many of whom are living on low wages, people of colour, those living in poor housing and those who have to go to work to keep all our utilities going cannot help but help the virus spread.

Lockdowns and the economy

The graph below showing data from last year reveals the unique position of the UK – the higher up, the more deaths, the more to the left the bigger the economic impact. We are world leading in both measures. For me, GDP is on outdated measure only useful in times of war. It is about as useful as measuring human wellbeing in terms of how many calories a day you consume, but it makes the point.

Another way of putting it is the the overall cost of the pandemic to date is about £250 billion, about £12,500 per family in the UK.

John Ionnidis, a Stanford professor is not keen on lockdowns and holds some strident views. Hardly surprising from someone who wrote the paper “Why most published scientific findings are false” He made a few points: first that late lockdowns will have done far more hard than good. Then that management of care homes was key; Singapore managed to have very low levels of infection and only 3 deaths of care home residents by getting management of care homes right. As an example of bad science, he highlighted the increased death rates that would have happened with wider use of Hydroxychloroquine for people admitted to hospital. He railed that many times more lives can be saved by aiming for Zero Tobacco than Zero COVID – who could disagree with that, even though it is sadly certain never to happen – Zero COVID already is. He railed against the lack of logic in many of our political approaches, in particular late, last resort lockdowns.

Despite his controversial stance, it was pretty much agreed by all that targeted early restrictions work better than blunderbuss lockdowns which are most felt are needed when all else has failed.

Views from around the world

The webinar moved on to specialists from around the world.

New Zealand had some had luck early in the pandemic, the initial phase starting in their summer, but their strategy of elimination of COVID has brought health and economic benefits with a mortality from covid of 5 per million as compared to our 1834/million.

Norway, had a sharp initial lockdown, then border controls relaxed during the summer though with strict quarantine and management of local outbreaks. Incredibly, they have had no increase in overall mortality.

Taiwan was well rehearsed after their experiences with SARS in 2003, but have done far better than Japan who opted for suppression (like us) as opposed to Taiwans drive to elimination.

In Canada, the pandemic has highlighted the structural problems with Western society with poverty and racism driving spread there. Canadian high earners were 200% more likely to stay at home while key workers either had to work for the good of society or could not afford not to. This effect was magnified in the second wave. The first wave affected all classes more equally as it was introduced by better off travellers, the second wave preferentially hit disadvantaged sections of society. The conclusion there was that to control the pandemic you have to support marginalised sections of society, and if you don’t, the hospitals will fill up. Zero Covid would be more readily achieved with Zero inequality

Other pandemic side effects….

We were reminded that during the pandemic the huge shift of wealth from the young to the better off older members of society was accelerated. There will be costs in terms of health, physical and mental which will become evident with time. Like long COVID, there will be a ‘Long Lockdown’ to deal with once the pandemic fades and this is something we are just beginning to see. Sadly, with social inequality built in to our system, inequality has increased.

There is also a worry that with our normal seasonal flu and colds suppressed by anti COVID measures, they could become less mild as we have missed a winter of immune boosting infections. We shall discover the effect of this next winter.

Take home messages

In terms of viral ecology, the illness may well become a milder endemic form, but this is not guaranteed, and has not been the experience so far – so emergence of more virulent strains is a real threat. The EIU are discovering this as we speak.

It was felt that extending the vaccination campaign to children was not logical or desirable. That will be an argument playing out shortly as trials are under way to assess safety in children with an aim, it is hoped, to target vulnerable children such as those with lung disease rather than children as a group.

It is wise to learn the experiences of others. Looking around the world we can see how to manage pandemics – and how not to. Some nations put their own recent coronavirus pandemic experience to use, those more distant from SARS1 and MERS did not. We also ignored our own flu orientated pandemic planning. Despite what can reasonably be called ‘vaccine triumphalism’ the UK has done very badly.

A better World Health Organisation – The contributors to the webinar felt that improvements would result from a stronger role for the WHO. After all, this is a global pandemic and despite the increasing co-operation of the science sector, politicians need to be dragged away from nationalism which fosters a bigger global problem. That is not to say there are no problems with the WHO, but a global organisation is critical. (We shall have to leave Biden, Xi Jinping, Putin and others to sort this out!)

Disadvantaged groups take the brunt of illness, are more likely to become ill and have to work to keep society going. This facilitates viral spread. Support for them, and measures to address poverty and inequality politics are critical in controlling this and future pandemics. This means levelling out of wealth and poverty as opposed to the facile concept of “levelling up” which aims to alleviate poverty without addressing the problem of wealth distribution. Isolation is best provided in hotels for those who cannot isolate at home.

Aiming for elimination of COVID is the best approach, because ‘tolerating’ poorly defined levels of infection results in more cases, hospitalisations, complications, deaths, the need for more comprehensive lockdowns and more economic damage. In the UK we have failed to get this right, but now, with cases falling we have another opportunity to reach Zero Covid.

Politician versus experts?

Back in the real world, it seems the UK government is back in the pre-pandemic groove. They propose spending untold billions on expanded nuclear weapons, needless vanity projects like new airport and road capacity as well as the destructive and outdated HS2 – spending not only like there is no tomorrow, but as if it were yesteryear.

Meanwhile they are cutting the pay of the NHS staff who have bailed them out. Back to cuts in the foundations of the NHS it seems and nothing in the budget speech about the critical areas of social care or pandemic preparation. This means that Zero COVID in the UK is not around the corner.

This might seem small fry when the superficially affable Chancellor, Rishi Sunak displayed incredible inhumanity by simultaneously encouraging the bombing of Yemen through selling weapons to Saudi Arabia and cutting aid to utterly destitute Yemeni civilians.

Another Government priority right now is the Police, Crime, Sentencing and Courts Bill which will use the pandemic as an excuse to limit the freedom to protest. The need for demonstration is forever increasing due climate change and the many other areas in which people need to be able to at least try to influence Government. There is the clear message that you can go to prison for 10 years if you damage statues of slavers who made fortunes out of the misery of others.

So we’re heading back to the politicians ignoring the experts once again. The unequivocal messages of the pandemic – that investment in public health works, the public sector needs adequate funding to be ready for the next pandemic, that global approaches to health are crucial, that we need to live more locally, and that less inequality in society means better physical and mental health seem to be fading to the background.

For some, it beginning to look as if the pandemic had never happened.