17 June 2019

'How likely is a second spike?'

Infectious disease expert Prof Paul Hunter, from UEA’s Norwich Medical School, has been a leading voice throughout the coronavirus pandemic.

In a recent public lecture, he tackled the subject of why experts disagree about our response to the virus, and answered a series of questions from the public on testing, school closures, and government policy, among other things. We publish the Q&A here. Scroll down to watch the full lecture. 

Is it possible that the virus will mutate and become either more or less virulent?

All viruses change subtly as they pass from one person to another, and sometimes those changes are associated with significant reduction in the virulence of the virus and sometimes associated with a dramatic decrease. When people have looked at specific mutations for MERS, which is a very similar virus, those that effect the spike protein tend to be associated with a dramatic reduction in virulence. We will have to see how it develops. It’s a big concern with a vaccine if the virus changes. Whether we have an effective vaccine and whether it will continue to be effective, we will see. I'm not hugely worried at the moment, but as time goes by in future years we will almost certainly see some change. But we’ll have to wait and see whether that leads to a more aggressive form of the virus.

Do you think that mass public testing is actually going to be able to provide the sort of information that will give us a much more granular view of what's going on in the community? 

Yes, I think large scale testing is going to be quite helpful and it's going to answer a lot of questions. I think one of the big problems with using data down to local authority level is that, within local authorities, there are diverse populations. Even within the same local authority you can have very densely packed housing tower blocks, where people really struggle to socially distance, and yet a mile down the road you have mansions with big gardens where you don't need to see your neighbour from one week to the next if you don't want to. Local authority level data is not that helpful because of that.  

What’s the most confusing UK Government message that you've heard over the last few months about Covid 19? 

I think the most confusing message was that it's okay for political advisers to go on days out to Barnard Castle, but not for the rest of us. The public's attitude to lockdown does seem to have changed as a result of that. One of the most depressing things was how the chief medical officer in Scotland, one of the senior scientists on Sage and a senior adviser to the Prime Minister who also attended Sage, didn't think that the policies applied to them. That, in my view, will be a low point in the way that the Government interacted with the British population.
 
In your MED archive article, you say that closing educational institutions has had a big impact on the epidemic. How should this finding influence planning for September in the UK, for schools and universities?

I think that's a big question. One of the things about reopening schools elsewhere is that there have generally been quite small steps so far. As I understand it, Denmark has allowed primary school children to return, but not necessarily older children. And although people say Sweden didn't close schools, Sweden did close schools, it closed secondary schools and universities, but it didn't close primary school and junior schools.

The big thing is to monitor what happens. If infectious disease is low in the community at the moment, then the risks within schools exacerbating that are probably going to be quite low. If the disease is spreading more rapidly elsewhere in the community, then certainly there are likely to be risks. I think there are various approaches that have been proposed around the world to how you manage that. Trying to keep class sizes relatively small. Trying to overlap break times in a way that as few children as possible go out. Trying to keep the rotation of teachers through classes as low as possible, which is feasible actually in primary schools but I don't think that is going to be feasible in secondary schools. You can't have the maths teacher teaching French.

I think we have to have a really important debate, and it has to include teachers, it has to include education and public health people and modellers. To be honest, I'm not sure how we do it safely. There's still no universal agreement of how risky it is anyway, and so I think these are decisions that need to be taken by a group, not by small groups of people in the education ministry.

 

How likely is it that there will be a second spike and how likely is it that it will be more serious than the initial pandemic in the UK? 

I think it's inevitable that we are going to see a further rise in cases. In about half of the countries that have started relaxing their measures, about a third are already seeing increases in cases, moving into a second wave. And I don't see how the UK is going to be any different. Maybe it would be sufficient to have an effective test and track system in place before the autumn. Maybe it would be sufficient to have an effective vaccine. But I'm not convinced either of those two things are going to happen before the autumn. 

The other big problem though is the other pressure on the NHS in winter. I very much doubt we will have bad influenza this year, as I think all the social distancing will reduce the risk of influenza. Even if the Covid 19 peak is not as big [as earlier this year] but coincides with other pressures, then I think it's going to be worse for the health service than the first peak.
 
What about herd immunity? Is lockdown always a good thing longer term?

I think the first thing to say is herd immunity is real. Herd immunity is probably why we're not dying from other coronaviruses that have been circulating in the population. There is another quite similar coronavirus to Covid 19 that has been with us for decades, if not centuries. Some suggest it was the cause of the English sweats in 1530 and some suggest that it was the cause of a pseudo influenza outbreak in late Victorian times, and in both those episodes there were large numbers of deaths. But then the virus sort of settled down and became part of our normal flora. It probably settled down because it infected a lot of children, and children don't get sick very often, and therefore by the time they are adults they have a degree of immunity. Even if they do get an infection they have already got some immunological memory they don't get severe illness. So herd immunity is real.

To pursue that as a strategy does mean that you're going to accept that up to possibly half a million people would die from that within the UK. I think probably that's an overestimate and I always thought that was a bit of an overestimate, in part because I think the evidence is coming out that some of us are probably more intrinsically resistant to the virus than others. You have probably heard that if you are blood Group A you are rather more likely to die than if you are blood group O. 

In conclusion, a herd immunity strategy will ultimately lead to many more deaths than we've seen so far.
 
What is your experience of the media throughout the pandemic? Have the kind of questions you are being asked changed? Do you think journalists are asking the right questions, and do you think the public are being well served by the coverage in the media?

On balance, yes. I have been remarkably impressed with most of the reporting that's been done in both traditional print, broadcast media and indeed on the internet-only media.  And the journalists that I speak to, by and large, are wanting to get it right. They are always looking for a scoop, but they are not looking to create mischief. They are trying to get it right. Some of the most enjoyable meetings and discussions I have had are with journalists, helping them go through some of the complex and difficult issues that we are dealing with. 

And that doesn't mean to say we have always got it right. In January most of us, myself included, thought it was going to be a lot less severe an issue than it turned out to be. I thought it was going to be over by July. Other people thought it was going to be little worse than a bad influenza year and it wasn't really until Italy happened that we realised it was actually as bad as it was. But overall I think the British media particularly have done remarkably well. All of them, even the tabloids, have generally done very well I think.