COVID-19 Healthcare Challenge - what science 'R' we following now?

Previously, we wrote about localised lockdown approaches in use in the Northern regions of the UK and how they have helped previously to slow down rate of case increase per population, which was the measure used to support the enforcements.

What we do know is that since a low on the 10th July, the number of recorded cases per day has risen to over 4,900, deaths have increased by a relatively low 980 at the time of writing and hospitalisations have been creeping up to over 230 per day.

Markedly though, many have noted there has been less discussion of the science - the viral reproduction or R rate or otherwise - to support the new nationwide restrictions, so where are we now?

From the 23^rd September:

• people in England are limited to mixing with multiple households outdoors and one other indoors;
• those in Scotland cannot mix households at all;
• hospitality venues are to close at 10pm;
• face-coverings will be a legal requirement for hospitality workers;
• ‘mingling’ within groups of over 6 in any setting is not allowed.

Interestingly, it would seem that although care homes make up the largest proportion of infections (an average of 45%), no new restrictions were announced for care homes by the government as of the time of publishing this article. Conversely, strict new restrictions came into force in bars and restaurants which proportionately make up for 5% of infections.

In other settings besides work (which everyone is encouraged to do from home where they can) and schools, the Rule of Six is now enforceable by a £200 fine. 

What science is being used to inform these decisions? We are aware that a complex mix of economic considerations, legal considerations and social considerations have also been made when considering previous lockdowns and ideally should not be made in silo. 

Differing views from scientific experts

A group of scientists recently wrote to the prime minister, chancellor and the UK's four Chief Medical Officers (CMOs), warning the government is using the wrong anti-COVID approach and must reconsider its policy to suppress the virus by adopting a targeted approach instead. Professor Sunetra Gupta and Professor Carl Heneghan from Oxford University, Professor Karol Sikora from Buckingham and Sam Williams of the consultancy Economic Insight issued their warning, with 28 other signatories.

Yet support for the CMOs and government, who appear to be advocating greater restrictions, was given by a letter signed by second group of scientists, headed by Professor Trisha Greenhalgh at Oxford University and backed by 22 others.

There are clearly differences in how the UK's scientific and medical communities believe a second spike in cases - and inevitably hospitalisations and deaths - can be avoided.

Some scientists are warning the focus on case numbers and the R number (showing the rate of infection) is not the correct approach and they are subject to interpretation; instead they encourage an approach based on outcomes mattering, not case counts.

Blanket restrictions are argued to be damaging to the economy and margianalise at-risk groups, with the National Institute of Economic Research imploring governments to end widespread lockdowns due to their detrimental economic effects. Charities have warned of elderly care home residents losing the will to live due to a lack of contact with loved ones. 

A return to “normality”, scientists backing the CMO approach has said, must be balanced with variable restrictions to control the virus “which respond to the day-to-day and week-to-week changes in cases. Normality is likely to be a compromise for some time to come" they say in their letter.

The scientific approach cannot stand alone

Some of the signatories of the letter and members of International SAGE, who have recently acknowledged that the science behind new lockdown rules itself cannot be definitive. “Whilst it is always helpful to have more data and more evidence, we caution that in this complex and fast-moving pandemic, certainty is likely to remain elusive.

“A research finding that is declared ‘best evidence’ or ‘robust evidence’ by one expert will be considered marginal or flawed by another expert. It is more important than ever to consider multiple perspectives on the issues and encourage interdisciplinary debate and peer review,” they say in their letter.

Meanwhile, the Lancet writes about the ongoing search for viable vaccines and what we can expect from the first generation of these medicines. It could be that in the end the balance between the scientific and socioeconomic evidence for one approach versus another may only be found in the presence of one of modern medicine's greatest achievement - universal vaccinations.