Losing control of the virus

The previous weeks have seen a break in the quiet consensus on Covid at Holyrood.  In this article Graham Checkley, a member of the Zero Covid Scotland campaign, examines the fault lines of a change in pandemic policy that went badly wrong.

“They have lost control of this virus” [1]

“We are, rightly, being cautious in order that, as we start to lift the restrictions, we make sure that we have as much certainty as we will ever have in such a situation that we will not immediately be overtaken by spread of the virus.” Nicola Sturgeon, speaking to the Covid-19 committee, 10th March 2021.

On 2nd September 2021, Anas Sarwar, leader of the Scottish Labour Party, told the Scottish Parliament that “It’s clear the virus is out of control”, and that the Scottish Government now had no clear strategy for tackling the pandemic [1].

Mr Sarwar was quite correct, but sadly 71 days too late.

In fact, the Scottish Government lost control of the pandemic on 22nd June this year.

This was the day when the avowed policy of “suppress the virus to the lowest possible level and keep it there” changed to “suppress the virus to a level consistent with alleviating its harms while we recover and rebuild for a better future” [2].

Making the wrong choice

At that point the number of Covid-19 infections had been rising steadily since early May [3], yet no additional restrictions nor mitigation measures were being considered by the Scottish Government. It believed that the vaccination programme had broken the link between Covid-19 cases and hospitalisations, and that the number of cases could now, effectively, be ignored.  From now on it would rely on vaccination alone, rather than vaccination plus mitigation.

But their new focus on hospitalisation and deaths rather than infections meant ignoring the long-term health effects and disability suffered by a significant minority of people of all ages after Covid-19 infections, regardless of how mild or severe the initial symptoms had been.  There would also be unnecessary death, and the ongoing, awful, risk of a new and even more infectious, severe, or vaccine resistant virus variant developing in a partially vaccinated population.

How did it come to this?

Timeline

DECEMBER 2020

Scotland is in a second lockdown. While it had been effectively virus free that summer, a new, more infectious variant of Covid-19, the Kent variant, has spread throughout the UK.

The Scottish Government relaxes some quarantine restrictions in December, frees up other Covid regulations just before Christmas Day, and offers advice “you can, but don’t” about loosening controls.

JANUARY 2021

As part of its work to scrutinise the Scottish Government handling of the pandemic, the Covid-19 committee establishes a Citizens’ Panel to add lived experience to their recommendations on how the pandemic should be managed.

FEBRUARY

12th February.  The US Centre for Disease Control reiterates a call to prioritise teachers for Covid vaccines.  Ignored by Scotland.

18th February.  The Covid-19 committee publishes the Citizens’ Panel report.  The report recommends that “The Scottish Government should implement an elimination strategy as far as possible in 2021 and where this is not feasible should aim for maximum suppression of the virus.”

21st February.  Dr Deepti Gurdasani, writing for The Herald Scotland, calls for added mitigation in schools.  John Swinney insists that a return to school is safe. Jason Leitch said that children were less likely to catch and pass on the virus.

MARCH

10th March.  Nicola Sturgeon states that Scotland’s objective must be “to eliminate” the virus [5].  Speaking before Holyrood’s Covid-19 committee, she said that striving to get new case numbers as low as possible was the only way to keep it under control.  Ms Sturgeon said, “the virus won’t play ball” with any effort to maintain case numbers at a “medium level”.

Chief Medical Officer Dr Gregor Smith said he did not believe coronavirus could be “eradicated”, but that an elimination strategy of driving case numbers as low as possible would make outbreaks more manageable.

Scottish Green Party MSP, Mark Ruskell, who sits on the Covid-19 committee, said: “It is welcome that the first minister has moved away from talking about suppression of the virus and is now talking about eliminating it. The Scottish Greens support an elimination strategy, as pursued by countries like New Zealand, but to get there we need to see more ambition on testing and support to self-isolate.”

APRIL

The first cases of a new, more infectious variant of Covid-19, the Delta variant, are reported in the UK [6].

18th April.  The Zero Covid Scotland campaign writes to Nicola Sturgeon, Jeanne Freemand, and Jason Leitch, expressing “deep concern over the possibility of new Covid-19 variants reaching Scotland”, and asking the Scottish Government to “consider its commitment to allow 12,000 spectators into Hampden Park for UEFA matches this summer” [7].  Reply, 16th June [11].

MAY

5th May.  New cases of Covid in Scotland reach the lowest point in 2021.  85 new cases reported [3].

Covid-19 (oversight) committee is disbanded.

A Covid-19 recovery committee is established.

John Swinney is appointed as the Cabinet Secretary for Covid Recovery,

23rd May.  Media reports appear that the Scottish Government is considering ditching the official policy goal of maximum suppression of Covid-19 infections. The new policy would look at hospitalisation, mainly ICU admissions, and no longer at case numbers when lifting restrictions further.  This at a time when only one-third of the population are fully vaccinated [8].  The proposal also ignores the advice of the Covid-19 advisory group that stressed the need to “learn from previous waves and get case numbers as low as possible to reduce the risk of harm from further variants arising, which might undermine the vaccination campaign” [9].

31st May.  Professor Devi Sridhar writes an opinion piece for the Guardian, “In rich countries, vaccines are making Covid-19 a manageable health issue”.  Professor Sridhar continues, “If governments are able to vaccinate 80-90% of their population, Covid-19 will increasingly become a manageable health issue, much like other vaccine-preventable diseases such as measles or pertussis (whooping cough).”  The article appears to be influential and is quote retweeted by Nicola Sturgeon.  By this date, 38% of the Scottish population have been fully vaccinated.

In the US, some states support the CDC position on the vaccination of 12–15-year-olds.

JUNE

The Delta variant is now the UK’s most dominant strain and spreading through schools [10].

16th June.  A Scottish Government response to the Zero Covid Scotland letter of 18th April states, “Our aim remains to Suppress the virus to the lowest possible level and keep it there, while we strive to return to a more normal life for as many people as possible. We understand how challenging pursuing elimination is, but we can strive towards this as a goal. Even if we fall short of elimination, our collective efforts will have contributed to suppressing the virus to the lowest possible level.” [11].  The letter also stresses the safety precautions that would be applied at Hampden.

22nd June.  6 days later, the Scottish Government policy changes from “suppress the virus to the lowest possible level and keep it there” to “suppress the virus to a level consistent with alleviating its harms while we recover and rebuild for a better future” [2].  By this date 48% of the Scottish population have been fully vaccinated [8].

28th June.  New Scottish Covid cases pass 3,000 to reach new record high [12].

30th June.  Football is linked to 2,000 Scottish Covid cases [13].

JULY

1st July.  Covid cases in Scotland surpass 4,000 for the first time since mass testing [14].

2nd July.  Nicola Sturgeon suggests third wave infections may have peaked [15].

2nd July.  Contact tracing system “straining” as cases surge [16].

5th July.  Scotland tops Europe hotspot chart [17].

6th July.  Raigmore Hospital at capacity amid rising cases [18].

8th July.  Call to cancel operations to reduce NHS pressure [19].

9th July.  Tayside warning over young patients in intensive care [20].

12th July.  The Lancet publishes an estimate that 85% of the population need to be vaccinated to control the spread of the Delta variant without other lockdown restrictions [21]. The article goes on to state that “The problem now is not severe disease or death, it is Long COVID; we are contributing to chronic disease and the long-term burden on general practitioners and health services”.  At this point 53% of the Scottish population have been fully vaccinated [8].

13th July.  Delay urged over easing Covid curbs in Scotland.  Professor Andrew Watterson, writing in The Times Scotland.

13th July.  Nicola Sturgeon announces that all of Scotland will move to protection level 0 on 19th July [22].

15th July.  Too much and too soon, why level 0 move is a mistake.  Professor Andrew Watterson, writing in The National.

15th July.  Highest daily deaths since March [23].

18th July.  Nearly a third of young adults in Scotland are still unvaccinated [24].

19th July.  Scotland moves to protection level 0 [22].  At this point 55% of the Scottish population has been fully vaccinated [8].  Without lockdown restrictions 85% is the required figure [21].

21st July.  Surgery backlog “could take years” to tackle.  Hospitals are also experiencing demands that they would normally only face in winter months [25].

22nd July.  Deaths at four-month high despite fall in cases [26].

24th July.  The Scottish Government confirms that about 50,000 people stopped using Scotland’s Covid tracking app in July.  Usage has dropped from 970,000 to 920,000 [27].

25th July.  Do not ease restrictions until children are vaccinated.  Dr Jeremy Rossman, writing in the Sunday Post.

27th July.  Humza Yousaf claims, “progress in our continued battle against the virus”.  “Matter of weeks ago 5/10 Covid hotspots in the UK were in Scotland, now no Scottish Local Authorities in top 150” [28].

AUGUST

1st August.  Long Covid Kids generate Freedom of Information (FOI) requests to Scottish Local Authorities, asking them what steps they are taking on school ventilation and CO2 monitoring.

1st August.  Daily new Covid cases in Scotland 1,034 [3].

7th August.  More than 100 cases linked to Glasgow’s Euro fan zone [29].

9th August.  Beyond level 0.  Mask wearing in public spaces and 2 metre spacing in health care settings are the only remaining mitigation.

22nd August.  The results of the Long Covid Kids FOI are published in the Sunday Post.  “Despite the First Minister’s advice and extra millions, some councils fail to buy air monitors to test classrooms.”  Mike Downham, retired NHS paediatrician, said, “The failure of some councils to follow recommendations is part of a wider attitude that the government must be doing the right thing by allowing infection to spread, because governments know best.  Long-term significantly disabling symptoms in children following Covid infection are sufficiently common that we have to do everything we can to protect them from infection. It’s not enough to say they mostly don’t get ill enough to need hospitalisation.”  The Scottish Government responds that it “will request regular updates on progress from all local authorities.” [30].

25th August.  John Swinney reports that Scotland’s record number of Covid cases is partly being fuelled by the return of schools after the summer holidays [31].

29th August.  Record number of cases as NHS faces”’perfect storm”. [32].  Health Secretary Humza Yousaf warned the NHS was facing a “perfect storm” of pressure.

30th August.  Jason Leitch.  “The speed of the surge has surprised us”.  BBC Scotland, The Nine.

31st August.  Daily new Covid cases in Scotland 6,017 [3].

SEPTEMBER

1st September.  Daily new Covid cases in Scotland, 6,163 [3].

2nd September.  Daily new Covid cases in Scotland.  6,392 [3].

2nd September.  Anas Sarwar.  “It’s clear the virus is out of control” [1].

2nd September.  John Swinney announces that the aim is no longer to suppress Covid to the lowest possible level [33].

3rd September.  Daily new Covid cases in Scotland.  6,700 [3].

Analysis

“The speed of the surge has surprised us”.  Jason Leitch, on BBC Scotland, 30th August 2021.

Policy and political structure

The disbanding of the Covid-19 (oversight) committee, the establishment of a Covid-19 recovery committee, and the appointment of John Swinney as the Cabinet Secretary for Covid Recovery, in May 2021, all indicate an underlying assumption that the pandemic was nearly over.

For that to be the case, a suitable level of herd immunity would have to be achieved, either through infection, vaccination, or a combination of both.  Even taking an estimate of 60% for the percentage of the population that would have to have achieved immunity [34], this would only have been achieved by August [8].

The Delta variant was identified by the World Health organisation as a variant of concern on 11th May [35], and the implications of its more infectious nature was clearly understood by July [21], but the Scottish Government committee structure was not changed to reflect this.

In fact, their policy in the face of a more infectious virus variant was to relax mitigation controls [22, 14th May].

This process of relaxation was to continue [22, 19th July] in the face of some well publicised warnings from eminent scientists published several days previously [21], [36], culminating in “beyond level 0” on 9th August.

Schools

Firstly, it is difficult to reconcile the air of surprise shown by Scottish Government officials, John Swinney on 25th August and Jason Leitch on 30th August, re schools and a surge in cases, with what is known from the literature.

The risk of Covid transmission in schools had been highlighted in The Lancet in March [37], The British Medical Journal in June [10] and in The Lancet again in July [36].  The Scottish Government was also aware that it was dealing with a new virus variant by June [38], and the increased infectiousness of the new variant was well established by July [21].

Secondly, if remaining in full alignment with the Joint Committee on Vaccination and Immunisation (JCVI) on vaccination of the 12- to 15-year-old population was the Scottish policy, then work on school ventilation safety was a clear and urgent priority.  Such ventilation work was also the only current method of protecting the under 12s.

The Scottish Government lost the opportunity to tackle this issue by leaving the work in hands that did not appear to have a full understanding of what the problem was or how it should be handled [30].  The Scottish Government response that it “will request regular updates on progress from all local authorities” suggests the future tense, and, coming on 22nd August, 10 days before the new term started, was too little management too late.

Vaccination

The initial vaccination programme was hugely successful and a tribute to the NHS staff involved.

The rise of the Delta variant was a game changer as it raised the required level of vaccination from circa 60% [34] to nearer 85% [21].

This raised the still ongoing issue of the vaccination of the young.  If the policy of the Scottish Government was to be vaccination-led, then it needed 16- and 17-year-olds to be vaccinated in order to approach that 85% figure.  However, its policy of staying in line with the JCVI recommendations meant starting on that work from 4th August [39], even though they had declared their new vaccination led policy on 22nd June.

Despite this delay, relaxations in Covid mitigation continued.

Voices Muted

The advocacy of ending suppression and ‘living with Covid’ has also muted and increasingly silenced the voices of those with, or at risk of, Covid, those working with those with Covid and Long Covid, and those supporting affected and marginalised groups.  This was graphically illustrated at a recent Zero Covid Scotland public hearing where over a dozen different groups and individuals provided testimony on the social, health and economic consequences of getting Covid and the human cost and efforts needed to avoid getting the disease.

Conclusions

“The “end suppression and get everything back to normal” fragmented approach – the big bang theory of pandemic control – simply does not work”.  Professor Andrew Watterson, writing for The National, 9th September 2021.

As of 8th September, the vaccination programme had fully vaccinated 69% of the Scottish population, but the overall reach began to plateau in mid-July, meaning that 75% now had at least one vaccination [8].  However, the more infectious Delta variant requires a full vaccination level of 85% before other mitigations can be reduced [21].  So, clearly, major mitigation is still needed, but the Scottish Government has yet to indicate a willingness to do this.

Between 22nd June 2021 and 8th September there were 225K new Covid cases in Scotland [40].  Of these a significant minority, still to be quantified, will suffer Long Covid and potential future health problems, adding a burden to an already overburdened NHS [18] [19] [20] [25] [32], a service which has also seen 24K NHS staff absence days due to Covid in the same period [40].

There were 502 deaths.

The Scottish Government currently has no real epidemic strategy and is tinkering with the idea of vaccination passports when the idea has been abandoned and discredited elsewhere. Its policies in relation to schools have been inconsistent. It hesitated to vaccinate all 12 to15 year-olds, despite robust evidence that vaccines are effective and safe in this crucial age-group, preferring instead to trail the JCVI. And it has muted the voices of those people most severely impacted by the epidemic.

As Andrew Watterson says:

“The evidence we now already have about the de facto end of the suppression strategy in August and early September by the Scottish Government is clear and it has failed badly.” [41]

Acknowledgements

 

Many thanks to Professor Andrew Watterson and to Mike Downham, MRCP, DCH for their help in writing this article.

References

[1] The SNP Government has no strategy and their tools aren’t working. They have lost control of this virus, Anas Sarwar, Twitter, 2021 https://t.co/Wx8CsmjnNG

[2] Statement given by the First Minister Nicola Sturgeon at the Scottish Parliament, Edinburgh, on Tuesday 22 June 2021 https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-statement-22-june-2021/

[3] JHU CSSE COVID-19 Data, 2021

[4] Scottish Parliament Citizens’ Panel on COVID-19, SP Archive, 2021 https://archive2021.parliament.scot/newsandmediacentre/117115.aspx

[5] Covid in Scotland: Sturgeon objective ‘to eliminate’ virus, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-56347695

[6] Delta coronavirus variant: scientists brace for impact, Nature, 2021 https://www.nature.com/articles/d41586-021-01696-3

[7] NEW COVID VARIANTS DEMAND CONTINUING TRAVEL VIGILANCE, 18th April letter from Zero Covid Scotland to Scottish Government https://docs.google.com/document/d/1t5MWDNd_LedrErZutjc1M8Ue7r_ZPFGr3I0CWuAqwXo/edit?usp=sharing

[8]  Our World in Data, 2021

[9] Scottish Government COVID-19 Advisory Group minutes, SG, 15 April 2021

https://www.gov.scot/publications/scottish-government-covid-19-advisory-group-minutes-15-april-2021/?link_id=4&can_id=afed6afc63f838266b16af9b6e4cc673

[10] Covid-19: Delta variant is now UK’s most dominant strain and spreading through schools.  BMJ 2021;373:n1445 https://www.bmj.com/content/373/bmj.n1445

[11] Suppress the virus to the lowest possible level and keep it there, plus Hampden safety.  Letter from the Scottish Government to Zero Covid Scotland, 16th June 2021

https://docs.google.com/document/d/1WVFd8Y63rcA4qO4QXiiYLa7wBUiLtCmCOydUOUMkHgY/edit?usp=sharing

[12] Covid in Scotland: New cases pass 3,000 to reach new record high, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57638936

[13] Football linked to 2,000 Scottish Covid cases, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57667163

[14] Covid cases in Scotland surpass 4,000 for first time since mass testing, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57684772

[15] Nicola Sturgeon suggests third wave infections may have peaked, Daily Record. 2021 https://www.dailyrecord.co.uk/news/politics/covid-scotland-live-nicola-sturgeon-24418685.amp

[16] Covid in Scotland: Contact tracing system ‘straining’ as cases surge, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-scotland-politics-57668326

[17] Covid: Scotland tops Europe hotspot chart, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57712737

[18] Covid in Scotland: Raigmore Hospital at capacity amid rising cases, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-highlands-islands-57735232.amp?s=03

[19] Covid in Scotland: Call to cancel operations to reduce NHS pressure, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57761409

[20] Covid in Scotland: Tayside warning over young patients in intensive care, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-tayside-central-57776913

[21] Lifting of COVID-19 restrictions in the UK and the Delta variant, The Lancet, 2021 https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(21)00328-3.pdf

[22] Timeline of coronavirus Covid-19 in Scotland, SG, 2021 https://spice-spotlight.scot/2021/09/03/timeline-of-coronavirus-covid-19-in-scotland/

[23] Covid in Scotland: Highest daily deaths since March, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57838071

[24] Covid in Scotland: Nearly a third of young adults still unvaccinated, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57875256

[25] Covid in Scotland: Surgery backlog ‘could take years’ to tackle, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-57903174

[26] Covid in Scotland: Deaths at four-month high despite fall in cases, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57931530

[27] Covid in Scotland: Thousands turn off tracking app, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-57941343

[28] Humza Yousaf, Another indicator of progress in our continued battle against the virus, Twitter, 2021 https://twitter.com/HumzaYousaf/status/1419987880261398530?s=03

[29] Covid: More than 100 cases linked to Glasgow’s Euro fan zone, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-glasgow-west-58118134

[30] Despite first minister’s advice and extra millions, some councils fail to buy air monitors to test classrooms, Sunday Post, 2021 https://www.sundaypost.com/fp/air-monitors-to-test-classrooms/

[31] Covid in Scotland: Return of schools ‘fuelling’ record case numbers, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-scotland-politics-58328945

[32] Covid in Scotland: Record number of cases as NHS faces ‘perfect storm’, BBC, 2021 https://www.bbc.co.uk/news/uk-scotland-58370841

[33] John Swinney announces that the Aim is no longer to suppress Covid to lowest possible level, STV, 2021 https://news.stv.tv/politics/swinney-aim-is-no-longer-to-suppress-covid-to-lowest-possible-level?top

[34] Five reasons why COVID herd immunity is probably impossible, Nature, 2021 https://www.nature.com/articles/d41586-021-00728-2

[35] Tracking SARS-CoV-2 variants, World Health Organisation, 2021 https://www.who.int/en/activities/tracking-SARS-CoV-2-variants/

[36] Mass infection is not an option: we must do more to protect our young, The Lancet, 2021 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01589-0/fulltext

[37] School reopening without robust COVID-19 mitigation risks accelerating the pandemic, The Lancet, 2021 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00622-X/fulltext

[38] Covid: Why has the Delta variant spread so quickly in the UK?, BBC, 2021 https://www.bbc.com/news/health-57489740.amp

[39] JCVI issues updated advice on COVID-19 vaccination of young people aged 16 to 17, UK Gov, 2021 https://www.gov.uk/government/news/jcvi-issues-updated-advice-on-covid-19-vaccination-of-young-people-aged-16-to-17

[40] Coronavirus (COVID-19): trends in daily data, SG, 2021 https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/

[41] Scotland should rethink its Covid strategy as the current one is failing.  The National, Andrew Watterson, 9th September 2021

 

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