Acting fast The Indian variant (B.1.671.2) of COVID-19 is now fairly well entrenched in parts of the UK and is increasing rapidly. Cases in the North West are rising, sharplyamong the young. For detailed analysis of what we know about this variant and how quickly it is spreading (once we exclude carriers who came from ...
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The Indian variant (B.1.671.2) of COVID-19 is now fairly well entrenched in parts of the UK and is increasing rapidly. Cases in the North West are rising, sharplyamong the young. For detailed analysis of what we know about this variant and how quickly it is spreading (once we exclude carriers who came from India) it is best to follow Christina Pagel (@chrischirp) e.g. here. She and other experts think that it is of sufficient concern that we should have stopped today's relaxation of the lockdown.
If there is one thing we should have learnt in dealing with COVID (and some of those dealing with pandemics already knew, like Mike Ryan here) is to act fast. If you wait until you know you are right you will lose, because the virus would have already won. Moving fast is an example of the precautionary principle: you plan for the worst outcome even if you are not sure you need to act at all.
At the moment we have rather poor information on how effective our vaccines will be in stopping this new variant. But if we wait for clear evidence on that question, it will be too late because by then the variant will have spread too much, such that only a lockdown can stop the spread. This is because the Indian variant is more infectious than the other variants of concern.
Living with COVID
Some of those who read this postabout how well the elimination strategy had done compared to the approach in most of the West before vaccines rollout asked how does it apply to a world that is vaccinated? In a post in February I talked about two paths to dealing with COVID once vaccines have been rolled out: elimination and living with COVID. While elimination is clearly superior when we have no vaccine, the issue is more balanced after everyone is vaccinated.
I didn’t get the arguments quite right in the February post, so let me give an amended version. The big negative of the elimination strategy is that it makes it much harder for international travel from or to other countries that follow a living with COVID strategy. That is not a problem if enough other countries follow an elimination strategy, but no Western countries seem likely to do that now that vaccines are here. Turning to the living with COVID strategy that we in the UK are now following, the big negative is the country becomes susceptible to COVID variants.
A question I didn’t address in February, but should have, is whether a compromise between the two strategies would be both possible and desirable. The compromise abandons quarantine for all travellers, but is much stricter in when it does impose quarantine. It does not wait for weeks until it is sure a new variant is a serious concern before putting visitors in hotel quarantine (in the UK the red list). If the UK had followed this compromise solution involving a precautionary approach to variants, the Indian variant would be much less of a threat than it is now. The extent of UK incidence of the Indian variant isn't a consequence of living with COVID, its a consequence of ignoring the precautionary principle in pandemics.
Not controlling our borders
The Indian variant was first identifiedin October. Cases in India started rising rapidly in March, and the Indian authorities expressed concernabout the variant on 24th March. Yet it wasn’t until 23rd April that India was put on the red list.
This delay was particularly odd given that both Pakistan and Bangladesh were put on the red list on 9th April, despite havingless COVID cases per head on that date. The criteria for being put on the red list is long and vague, so it seems highly likely that there were political elements to the delay in putting India on that list. Is it really a coincidence that India was put on the red list within hours after Johnson cancelled his trip? The reason the Prime Minister gave for the delay in putting India on the red list is that the Indian variant had not yet been identified as a variant of concern. However there is plenty of the South African variant in India as well as Bangladesh, and Pakistan has not identified that variant.
It is also unclear why there were days between that announcement (April 19th) and the implementation of that decision (April 23rd). The quarantine system needs to have inbuilt spare capacity to handle passengers who started travelling before the country was put on the red list. At the very least the travellers between those two dates could have been tested at the airport, before they used public transport. We knowthat the red list decision without implementation led to a surge in travel from India.
Why do you need to stop these variants coming into the country sooner than later? Because when numbers are small, the test, trace and isolate (TTI) infrastructure will have more time to deal with them. That assumes, of course, that you have a TTI system that is efficient. That means a system based around those that are trained to do this job (in contrastto this government’s system based on private sector firms with no local knowledge), and incentivesto isolate properly (unlikethe current UK system).
There are three choices for a country where everyone is vaccinated. If a country does not choose elimination for understandable reasons, then they can quarantine visitors in hotels when they are sure that is necessary (as the UK is doing) or they can quarantine visitors in hotels when that might be necessary. The first is making sure you are right before imposing restrictions, and the second is acting fast. If you do the first you will at some point get it wrong and the virus will beat you.
The UK government is waiting to see
At his press conference last Friday the Prime Minister declined to stop the relaxation of lockdown due today.  It was absolutely clear at that conference that this was a government waiting to make sure it was doing the right thing, rather than a government taking precautionary action.  Indeed the Prime Minister talked about only acting if it looked like the NHS was going to be overwhelmed. Such a high bar for action together with a government that waits until it is sure it needs to act is a recipe for disaster during a pandemic, as it was throughout 2020.
SAGE in their latest analysis says “If this variant were to have a 40-50% transmission advantage nationally compared to B.1.1.7, sensitivity analyses in the modelling of the roadmap in England (SAGE 88) indicate that it is likely that progressing with step 3 alone (with no other local, regional, or national changes to measures) would lead to a substantial resurgence of hospitalisations (similar to, or larger than, previous peaks).” It describes that extra transmissibility as a “realistic possibility”. I would be very surprised if SAGE would have done nothing but wait and see if they had been in charge. Once again the UK is not following the science.
Perhaps the Indian variant will turn out to be quite weak against vaccination, and as more people are vaccinated it will die out. I really hope that happens. But the Indian variant will not be the last overseas variant to enter the UK. In putting countries on the red list, if we continue to wait until we are sure they should go on that list we will be open to these variants spreading in the UK. If this variant doesn’t get us, another might.
In addition, a further danger of ‘living with COVID’ is that you produce your own variant which is capable of bypassing the vaccines defences. COVID cases in the UK are still high: according to the testing they have settled down to just over 2,000 a day, although the ONS survey suggests a modest decline. For that reason, it is not clear whether R is above or below 1. It would be much wiser to not relax the lockdown further and try and bring that number down, because the lower the number of cases the lower the chance of producing a home grown variant.
In short, if a country chooses to ‘live with COVID’ because it has vaccinated most people, it has to adopt a precautionary approach. This means putting countries on the red list if there is a small chance of a new dangerous variant, ensuring you have a TTI system that works, getting case numbers as low as you can and keeping them there. Only by doing that can you avoid constant scares about new overseas or home grown variants. If you wait until you know you are right to act you will lose.
The unfortunate truth is that we have a government incapable of applying a precautionary approach. If you have any doubt about this, please read “Failures of State” by two Sunday Times journalists. Johnson has caused tens of thousands of unnecessary deaths by failing to act on scientific advice not once, not twice but three times. It is unfortunately true that most of the UK deaths in this pandemic could have been avoided. 
After my last post on what Labour needs to do, I got some comments along the lines that Johnson’s lying is priced in, and exposing his and his government’s lies will achieve little. This government’s inactions have directly killed tens of thousands of its citizens. The biggest lie of all is that the government did everything they could and followed the science in this pandemic. I refuse to believe that if voters understood the truth of what this government actually did during this pandemic, and is continuing to do, it would still look set to win the next election. This government’s popularity relies on suppressing the truth.
 I thought he might continue to relax the lockdown in most places but have a stricter regime in areas where the Indian variant is concentrated. The lessonsfrom the emergence of the British variant last year show that this doesn’t work. First, many people just don’t know what rules apply to them. Second, people move around whatever the rules say. It is like getting in the fire brigade to fight a fire in one building and covering the neighbouring buildings with petrol. But he didn’t even do that. Instead he just suggested people acted cautiously in travelling to the Bolton area. He is advising caution for individuals but ignoring caution in government.
 The same applies to removingmasks in schools.
 Johnson continues to lie to the public, talking about it’s ‘very tough’ quarantine regime for travellers not from red list countries. Calling a scheme where a virus is easily transmitted to other members of a household very tough is a sick joke. Why does he think the Indian variant has so easily spread to UK residents if his quarantine regime is very tough?!