Covid-19 update: 9 April

Following the Easter weekend, daily case numbers across the UK fell to around the 3,000 mark. Fewer than 250 people are being admitted to hospital each day because of the virus and numbers in hospital continue to fall – just over 3,000 according to the latest data, representing a 25% fall on the previous week.

With the country clearly witnessing the demise of the second wave of the virus, prime minister Boris Johnson confirmed that England will proceed with stage two of the roadmap to end lockdown. Giving a green light to the planned easing of measures from 12 April, he said: ‘We see nothing in our present data that makes us think that we'll have to deviate from the roadmap.’

So, from Monday, outdoor hospitality reopens for groups of six people or two households. And non-essential retail including hairdressers and gyms can also re-open. Wales also eases some restrictions, allowing travelling in and out of the country, the reopening of non-essential shops and the return of all pupils to school. Scotland has already opened hairdressers and more shops and Northern Ireland is relaxing its stay-at-home message and moving to click-and-collect services for retail. The government also raised the prospect of foreign holiday travel under a traffic light system. 

However, these positive steps towards normality come with warnings that the pandemic is not over. Many countries in Europe are experiencing a major surge in cases, with some imposing lockdowns in response. And there are real concerns about the spike in cases in France crossing the Channel. Minutes from the government’s Scientific Advisory Group for Emergencies’ (Sage) meeting last week state that ‘updated modelling continues to suggest that an epidemic resurgence (third wave) is highly likely, though there remains uncertainty about the timing, scale and shape of this’.

That modelling, assessed by the Scientific Pandemic Influenza Group on Modelling, Operational sub-group, suggested that in most scenarios the peak will be smaller than the wave seen in January. ‘However, scenarios with little transmission reduction after step 4 [of the roadmap] or with pessimistic but plausible vaccine efficacy assumptions can result in resurgences in hospitalisations of a similar scale to January 2021,’ it said.

One modelling report from the London School of Hygiene and Tropical Medicine put the third wave peak in late July to early August. However, it acknowledged that it has made pessimistic assumptions for the impact of vaccines on infection and transmission. A further report from Imperial College London’s Covid-19 response team agrees that vaccination alone will not be sufficient to keep the epidemic under control. While the magnitude of a further wave was uncertain, it was expected to be lower than previous ones, as long as the vaccine roll-out continues at high pace and depending on variants.

Vaccinations on track

The UK vaccination programme clearly has a major part to play in countering any third wave. First doses administered at the beginning of April were down on March figures, as expected, due to supply issues. Administration of second doses increased significantly towards the end of the week. NHS England and the British Islamic Medical Association urged Muslims to continue to receive vaccinations in daylight hours during the holy month of Ramadan, insisting they would not be breaking the fast. Ramadan is due to begin on 12 April, and vaccination sites have been asked to be flexible in terms of opening hours and in booking appointments at a later date.

Cabinet Office assumptions about vaccine rollout – revealed in the modelling papers – show a significant slowing down compared with earlier assumptions. The central rollout scenario is now that 2.7 million doses per week will be administered until the end of July (then falling to 2 million) compared to 3.2m per week in earlier assumptions (and 3.9 million thereafter). A reduction in supply in April has been widely trailed.

Downing Street has confirmed the programme remains on track to meet its targets. And to support this goal, the two existing vaccines – Pfizer/BioNTech and AstraZeneca – have now been joined by a third product from Moderna. Wales this week became the first UK nation to administer the new vaccine, with supplies expected to start flowing across the country during April. Reports suggest that Johnson and Johnson’s Janssen vaccine could also be available by July.

The major news on the vaccine programme this week came with the announcement of a ‘course correction’ by England deputy chief medical officer Jonathan Van-Tam (pictured). Further reviews of links between the AstraZeneca vaccine and very rare blood clotting events have again confirmed that the benefits of vaccination continue to outweigh any risks. However, the Medicines and Healthcare Products Regulatory Agency said that evidence of a link was growing stronger, although more work was needed before a conclusive link could be established.

In response, the government has adopted a precautionary approach to use of the vaccine. Adults aged 29 and under without underlying health conditions will be offered an alternative Covid-19 vaccine if one is available. A statement from the independent Joint Committee on Vaccination and Immunisation advised that all people who have received a first dose of the AstraZeneca vaccine should continue to be offered a second dose, irrespective of age.

Some 79 cases of rare blood clots have been reported up to 31 March out of 20 million doses of the AstraZeneca vaccine. Of these cases, 51 were women and 28 were men, aged 18 to 79. In total, 19 people died. The risk of this kind of side effect is about four in one million, MHRA chief executive June Raine told a press briefing. ‘This is extremely rare and the balance of benefits and known risks of the vaccine is still very favourable for the vast number of people,’ she said.

The decision to change the approach for young adults is based on an assessment of the risk of potential harm versus the direct benefits of vaccination for different ages. Professor Van-Tam described three scenarios from virus prevalence lower than current UK levels, marginally higher than current levels and at levels comparable to those in the second wave. At the low exposure level, the risk-benefit for 20-29-year-olds was ‘relatively finely balanced’, while the figures were ‘overwhelmingly in favour’ of the vaccine for older age groups. And as the virus’s prevalence increases, the benefits from vaccination also start to increase for the younger group, changing the risk-benefit calculation.

Professor Van-Tam said that the effect on the vaccination programme would be ‘negligible’, describing changes in preferences for vaccines as ‘business as usual’.

Health secretary Matt Hancock said the AstraZeneca vaccine remained safe, but if adults under 30 wanted they could have an alternative vaccine instead. ‘We have more than enough of the Pfizer and Moderna vaccine to be able to offer all those under 30 one of those two vaccines,’ he said. There are 10 million people aged between 18 and 29 in the UK, with 1.6 million already vaccinated because they are care workers or clinically extremely vulnerable. This leaves 8.5 million of these younger adults still to be vaccinated.

In Scotland, Jason Leitch, Scotland’s national clinical director, said that if you end up in intensive care you have a one in four chance of a serious blood clot, which ‘knocks the other risks out of the park’ so vaccinating everyone is the crucial message. The three vaccines were safe, effective and available. ‘There are about 700,000 under 30s still to do [in Scotland] and they will be given Pfizer and Moderna,’ he said. He described the change as a ‘bump on the road’ with the safety mechanism showing ‘exactly how the system should work’. The crucial message was ‘if you are offered a vaccine you should absolutely take it’.

European view

The European Medicines Agency also confirmed that the overall benefit-risk remained positive for the AstraZeneca vaccine. Based on its own review of 62 cases of cerebral venous sinus thrombosis and 24 cases of splanchnic vein thrombosis up to 22 March, it said no specific risk factors had been confirmed. It called only for the risk of unusual blood clots with low blood platelets to be listed as very rare side effects of the vaccine. Individual countries were still considering how the EMA’s conclusion should impact their own vaccination programmes.

Ruth Rankine, director of the NHS Confederation’s primary care network group, said the key message from both the EU and the UK regulators was that the benefits of the AstraZeneca vaccine still outweigh any potential risks. ‘Our members have not reported a significant impact on numbers turning up for their vaccination, and we hope that by clarifying the recommendations and their basis, [the] announcement will be helpful in boosting people’s vaccine confidence. As Professor Van-Tam pointed out, vaccination is one of our strongest tools in the fight against Covid-19, and it is vital that the programme continues at pace. We will therefore need ongoing clarity on supplies, whoever the manufacturer.’

The latest report from Imperial College London and Ipsos Mori’s React-1 study into infection levels in England found that 1 in 500 people had the virus between 11 to 30 March. This represents a 60% reduction from the last study in February, which put prevalence at 1 in 204.  London and the South East showed the largest drop.

While the currently reduced levels of virus in the population have reduced pressure on NHS Test and Trace in England, it is arguably at such times that the service is at its most important. A highly effective service should have a major role in spotting and containing virus hot spots and outbreaks.

The weekly report on the service showed a further decrease in the number of people testing positive for coronavirus. The just over 29,000 cases in the week to 31 March represents a 21% decrease in positive cases and means detected positive cases have been reducing for 12 weeks now. Some 26,000 cases were transferred to the contact tracing system with just over 23,000 (90%) being reached. Of these nearly 20,000 (85%) collectively provided details of 84,000 close contacts and 90% of these contacts were reached and asked to self-isolate.

The React study also provides evidence of a divergence between prevalence of infection and deaths, a further indicator that the vaccination programme is having an impact. Paul Elliott, director of the React programme from Imperial’s School of Public Health, said the fall in infections was encouraging and shows the country is heading in the right direction. ‘However, in our most recent data there has been a flattening off in the infection rate with an R number now around one,’ he said. ‘This shows that we need to continue to approach the situation with caution and keep sticking to the rules.’

Miriam Deakin (pictured), director of policy and strategy at NHS Providers, underlined this message. ‘We need to be alert to a possible rise in Covid-19 infections with lockdown restrictions being eased next week and the ongoing risk from variant strains, which now pose the greatest threat to our efforts to control this pandemic,’ she said. ‘Covid-19 is still here, it's still highly contagious, and people are still dying because of this disease.’