Thread by @HZiauddeen

🧵COVID-19 : Thinking about the longer-term

Thanks for sending me this 🧵 @timcolbourn. I'm replying here with some thoughts, sorry for the delay in getting back to you.
Anyone else reading this, I've let Tim know I'll be replying via QT to make it easier to 🧵
1/26

https://twitter.com/timcolbourn/status/1473425295319384064

I think there are some additional factors to be considered and I'd put them under 3 categories:
1. The real world complexity of ongoing high transmission.
2. The health economic (& broader economic) costs of ongoing high transmission.
3. Messaging & intervening.
2/26

Real world complexity:
-I think we need to consider this as a complex dynamic problem, with potential for rapid, large magnitude changes at different local-global levels e.g large superspreader events, national oxygen shortages, new variants with significant immune escape.
3/26

-Given this, we will need to be cautious about static assumptions such as 95% reduction in severe illness with vaccines and therapeutics. Even if we assume this holds for a certain period, with ongoing transmission, this is a continuous demand and an ongoing target.
4/26

-We're seeing yet again the impact of a vaccines only approach on controlling new incidences and reinfections. Even drugs will only change this if they are effective if given to everyone who develops the illness, not just those at high risk.
5/26

-Unless we're significantly reducing new cases, getting better at treating those who become severely ill will reduce morbidity & mortality, but will keep up an ongoing demand on health services. COVID may become a less serious health concern but will still take up capacity.
6/26

-The acute healthcare need will continue to take away from other capacity. But there's more.
-Nosocomial infections and preventing & dealing with them will have a significant impact on health care delivery.
-Acute infections will impact on many key pathways e.g imaging
7/26

Imaging is vital for cancer care, to give one example.
-Staff will be impacted by illness and the impact of continuing to deal with COVID, especially in a situation in which no attempt is being made to reduce the number the cases. Some 🧵s included
8/26

https://twitter.com/HZiauddeen/status/1432697677930762246?s=20

-There are also vital healthcare system dynamics to consider. For nearly 2 years the healthcare service has been managing COVID. In terms of resources and human capital, there has been significant depletion with no investment or recovery time.
9/26

https://twitter.com/HZiauddeen/status/1449009117230768133?s=20

-The longer this goes on, the further capacity will reduce, the further it reduces, the more the service becomes a COVID & Emergency care service. This will of course increase the morbidity and mortality from cancer, etc but you'll have reducing capacity to deal with it.
10/26

-I'd also particularly emphasise the cost of losing human capital which is vital & hard to replace (already happening in healthcare & education).
-Not controlling transmission carries the huge risk of repeatedly ending up in situations like now.
11/26

https://twitter.com/HZiauddeen/status/1464938434657755139?s=20

-Finally 2 major areas that I think need particular consideration: children, and LongCOVID. We do need to think about childhood infections, morbidity and mortality as I suspect these can be easily minimised. How are the paediatric health economic costs being factored in?
12/26

-On LongCOVID, I think the combination of the clinical and the mechanistic data is strong enough for us to seriously work to reduce its incidence and I would be cautious about relying on therapeutics in this area, particularly given the already considerable scepticism.
13/26

2. Health economic costs of ongoing transmission:
-I think we need to explicitly consider these alongside the costs of intervention. I do not mean to say we should not bear them but we need to include them.
14/26

-So what are the health economic costs of repeated vaccination, updated vaccines and novel antiviral agents? (leaving aside hospital admissions, & caring for LongCOVID)
-The broader economic cost of sickness and absence in healthcare, education, services, etc.
15/26

-We should also factor in the costs of the conditions we will not be able to treat because we do not have capacity to do so because of COVID.
-The economic cost of people lost from the workforce and disability and sickness payments.
16/26

3. Messaging and intervening:
-I think we need to suppress transmission. Elimination would be ideal but achieving it will require a massive political overhaul and global coordination. But we don't need to work towards elimination, we can work towards suppression.
17/26

-Suppression will reduce a lot of the morbidity, mortality and costs. Masks, ventilation and air cleaning will have a huge impact and if this is not convincing, perhaps do a health economic comparison of the costs of these NPIs vs antivirals?
18/26

-I worry the impossibility of elimination is being used as part of a false dichotomy of elimination vs let-it-rip. elimination is impossible, so don't bother trying (suppression is subsumed under trying). Similarly 'lockdown!' serves to quash any attempt at suppression
19/26

-I agree we need to think about the political factors that have massively impacted our pandemic response and will continue to do so but here again, I think we need a more complex understanding of the various factors and players involved.
20/26

https://twitter.com/HZiauddeen/status/1462547773480312835?s=20

-This includes how they have shaped the narratives around COVID and how they are key in determining 'what is acceptable to the public'. We have never really had clear honest public messaging in the UK (and in lots of other countries).
21/26

We may never have it but we need to bear in mind that it is a major part of the problem and the solution. Civil unrest is a worry but again, I think we need a more sophisticated understanding of this. We've not been in restrictions for much of the time since July 2021.
22/26

Yet we have increasingly vocal and aggressive protects by anti-vaxxers and other groups. What's driving this? It's not just 'grassroots' frustration.
Our current political class is unwilling to do very much to protect the public or control the pandemic.
23/26

We'll have to work with that. But we still need to take the widest set of perspectives on what needs to be done and have and communicate a clear picture. We can acknowledge what bits will never happen and make clear what their consequences will be.
24/26

We shouldn't restrict ourselves to what would be politically feasible because then we get increasingly closer to justifying what is being done.

We need to consider all of the above over the period of at least the next 2 years, minimum, especially if we're not suppressing.
25/26

Finally, I'd really like to see the non-suppression scenarios thought out over at least a 2-year-period. The idea that we'll get 'back to normal' and live with infections and reinfections seems to be a narrative without sufficient consideration of the realities.
26/26