Endgame

Friday 15th May 2020

Figures for 14th May

UK COVID Deaths 428 / Total 33,614

James Cook Hospital – Total COVID deaths – 215

All COVID cases within South Tees Hospitals Trust – 57

James Cook Critical Care COVID cases – 13 (7 ventilated)

James Cook Critical Care non-COVID cases – 36 (14 ventilated)

I’ve spent today in the office or at meetings. There are lots of issues around how the Critical Care team look to deal with the ‘new normal’. We will need to change the way we work in order to deal with the virus in the longer term. We will need more beds than we used to have in order deal with the need for separate intensive care units for COVID and non-COVID patients. We will need more cubicles and isolation rooms to place ‘suspected’ patients and to protect non-COVID patients and we have to adapt to being spread out in more separate locations. We have also been working an emergency ‘surge’ rota. Whilst we have cut our hours a little, we are to remain on this rota until we are sure we are past a second peak of cases. However, continuing to work this way in the long-term will not be sustainable. It does not suit a world where there is low-level virus transmission and a need to admit small numbers of COVID cases for some time to come.

A few days ago I was asked about what difference lockdown would ultimately make and whether the number of deaths would ultimately be the same regardless of the rate of spread until a vaccine was found. In other words: what was the endgame?

Certainly, it initially appeared that the Government strategy was looking like one of herd immunity. This is where vulnerable people are shielded until enough of the UK population has been infected. At this point, sufficient people would be immune to the disease so that it would stop circulating in the population and your vulnerable groups would be at minimal risk of becoming ill.

The trouble with this strategy is that approximately 70% of the population would have to be infected before herd immunity was sufficient. Given how infectious the virus is, that would have led to a huge peak in new cases, hospitals becoming over-run and many more people dying because they were unable to access appropriate healthcare.

A report from Imperial College London at that time forecast that without any restrictions put in place, 500,000 people would die. The virus would probably have petered out by late summer but at a dreadful cost. Even with the restrictions in place that the Government had proposed initially, the death toll was estimated at 250,000.

The UK had, up until this point, not imposed the tough restrictions that most other European nations had. Do you remember the original ‘Contain, Delay, Research and Mitigate’ strategy? The Imperial College report changed all that and led to the Government changing tack and imposing lockdown on 23rd March.

So what options were available to world leaders?

Option 1 – Stop and then Restart

Stop all social interaction, close schools, universities, public transport and all non-essential retail. Strictly confine people to their homes and disinfect all public areas until new infections stop. Deploy the police and the military to enforce the draconian lockdown, and all confirmed cases are taken to government-controlled facilities to prevent spread of the virus. This is what happened in China. Once there are no new infections for a few weeks, you can restart society gradually. International borders must stay closed or closely monitored to prevent new infection.

Option 2 – Track and Trace

Impose some restrictions but use exhaustive testing and technology to track each and every new infection. Then trace potential new cases and enforce strict quarantine on those exposed. This avoids the severe lockdown used in option one. This is the model used by South Korea but it only works if you start the process before you have many cases. It requires rapid, huge investment in technology and testing.

Option 3 – Flattening the Curve

This is what the UK and many other nations are doing. The social restrictions that we have already seen will lower the peak of new cases, until the epidemic has run its course. Particularly vulnerable people will need to self-isolate for the foreseeable future. There will be many deaths but any patient who needs healthcare, be it oxygen, CPAP or ventilation will get it, helping to keep deaths to a minimum. Once infection rates fall, some of the social restrictions can be relaxed but there is a danger that that transmission again increases until the death rate becomes unacceptable again – this is what some have called an ‘epidemic yo-yo’.

None of these strategies does anything other than prevent infection of the population or allow infection levels to be kept to a minimum. Even when the virus has burnt through the population, this new coronavirus could become endemic and may ultimately behave like seasonal influenza.

It is possible that some treatment will be discovered that will improve survival. Examples that have been proposed include hydroxychloroquine, steroids, the anti-viral agent remdesivir and using plasma from survivors. My personal opinion is that whilst some treatments may have a modest effect it is unlikely that any of them will be a ‘magic bullet’.

The experience of physicians treating COVID-19 is growing and hopefully the survival rate will improve as a result. We are already better at treating patients than we were nearly two months ago. This should translate to improved survival.

Ultimately, a vaccine would appear to be the only endgame in town. When this will come is difficult to say. A vaccine will provide individual protection and mass vaccination is another way of achieving herd-immunity and stopping viral transmission. This will also protect those who haven't been vaccinated. Whilst widespread uptake of vaccination could conceivably eradicate COVID-19 over time, much like smallpox or polio, there will be many people who are not prepared to be vaccinated. This means we may sadly never really see the end of COVID-19.