AC 2020: Europe will not return to pre-pandemic life for two years

Europe will not return to pre-pandemic life for at least two years, delegates at CREFC Europe’s virtual Autumn Conference heard. The stark projection, by Alanna Shaikh, Principal Consultant of Tomorrow Global, assumes successful global vaccine roll-out by mid-2021 aligned with widespread improvements in vaccine acceptance and no virus mutation.

Alanna Shaikh is a global health consultant whose firm specialises in individual, organisational and systemic resilience.  In a comprehensive assessment of the worldwide pandemic trajectory, she warned that the ability to bring the second wave of the infectious disease to heel hinges on the nature, timing and compliance to governments’ Covid response policies. But only a vaccine can return life to something close to normal, which will require improvements in the “horrifying vaccine acceptance numbers” around the world, as well as global supply chain co-ordination and consistent behavioural compliance.

“As I see it, we have a choice between two abnormal situations,” Shaikh explains. “One of those abnormal situations entails widespread sickness, death and economic impact. The other situation entails limited sickness and death and economic impact. The next two years in Europe look like constant change. Barring some kind of unforeseen event, we will be looking at a repeating pattern right up until we reach herd immunity. A pattern of government restrictions, in which the viral spread slows, and then spreads again when the restrictions are relaxed. Over and over.”

In her keynote, Shaikh discussed:

• the status of current vaccine candidates; 
• projections of Covid-19’s spread based on current behavioural trends; 
• the role of Covid treatments; 
• how declining fatality rates obscure the severity of the second wave; 
• the danger of low vaccine acceptance; 
• misinformation and complexities related to herd immunity; and 
• advice for individuals.

Simply put, a considerable amount has to be aligned to beat this pandemic. This will be as much about inoculating ourselves against bad ideas and pseudo-science as well as the virus itself. If we do not adapt and learn the lessons of this pandemic, we will remain vulnerable to the next.  

The current picture

Winter across Europe is bringing a devastating resurgence in Covid-19. The daily infection rate is trending above 250,000 cases per day across Europe, according to the European Centre for Disease Prevention and Control. November 8 saw 308,000 new cases. Global cases have spiralled to more than 50 million and deaths top 1.25 million. Lockdowns are sweeping throughout Europe, while President-Elect Joe Biden has indicated his administration will take a more aggressive strategy to combat coronavirus. 

There are currently 11 covid-19 vaccine candidates in third stage trials, as of early November. But three big unknowns which will affect the path of the pandemic in the near and long-term future, Shaikh told delegates. “We do not know which vaccines will end up in widespread distribution; what policy choices will be made by European governments to control the virus spread; or what kind of advancements will be made in Covid-19 treatment. All of those unknowns will affect the path of the pandemic in the near and long-term.”

The University of Washington’s Institute of Health Metrics and Evaluation, one of the world’s foremost developers of reliable Covid-19 models, has estimated that the daily Covid-19 death toll in Europe will increase fourfold by mid-January 2021. Further, most European countries will experience extreme stress on their hospital systems as a result. ECDC data supports this prediction which is based on projections from current trends in which behaviours stay the same. “These projections can be invalidated by different behavioural choices among individuals or as the result of government policies. Mask use is on the rise in Europe. It is now at 60 per cent, and if mask use keeps going up, it will help to slow the spread of Covid-19, as will policies like the UK’s recent lockdown, which imposes restrictions on movement and limits public gatherings.”

Restrictions on movement put the virus on pause, it does not eliminate Covid, but it buys some breathing room, explains Shaikh. “It lets hospitals treat the patients they have without getting overwhelmed, restock supplies and make sure they have enough personal protective equipment (PPE) for staff. It also gives researchers more time to identify effective treatments. Covid will really only be stopped by a vaccine.”

Shaikh explained we are in the forewarned second wave, not because of a viral mutation, but because Europe managed to slow the spread of Covid-19 through strict lockdowns. Key pillars of these lockdowns were the closure of non-essential businesses, restrictions on people’s movement and limiting public gatherings. As soon as those behaviours stopped, and policies were relaxed in the summer, the virus began to spread again. “Now we are in the autumn, and we are seeing the impact of that relaxation.”

Projections from the ECDC suggests hospital and ICU occupancy across Europe is about one-third of where levels during the peak of Covid-10 in the Spring. “That’s not a good sign, but it’s not a terrible sign. Not yet. Hospitals are not overwhelmed. That being said, if daily Covid cases do increase four-fold like the prediction, then that is actually going to be worse than the Spring. I think we all remember the images of Italian hospitals treating cases in hallways,” Shaikh said. 

Declining fatality rates obscures escalating severity of covid-19 

Covid-19 fatality rates – the percentage of infected people who die from the virus – are actually going down across Europe. That is partially due to better treatments, but it’s mostly a statistical effect, explains Shaikh. “More widespread testing means identifying greater numbers of mild Covid. People were never dying from mild Covid, but it used to be undetected. When we bring those people into the statistics, it drives the death rate down on paper, but it doesn’t represent an actual change in the severity of the disease.”

Shaikh continued: “If you want to see the real impact on this pandemic, half measures won’t work. Just implementing a few restrictions doesn’t slow the virus, a moderate response doesn’t mean average viral spread. It means [you are] heading for disaster.”

What will 20201 and beyond look like?

The direction of next year, and after that, will be shaped by the availability and efficacy of vaccines and government covid policy responses. These policies will mediate the future deaths by the virus, rates of spread, as well as the number of people permanently disabled after surviving, Shaikh explained.

By far the most effective anti-covid policies – restrictions to support social distancing, limiting gatherings of people, work-from-home requirements, mandating mask-use, and the closure of non-essential businesses – drive the highest negative economic impact, Shaikh continued. They are inevitably highly unpopular and polarise social attitudes.  “The real decider of our short term and long-term futures is the vaccine. It’s going to be all about which vaccine the EU ends up distributing, how rapidly it’s distributed, how effective the vaccine maybe.”

On Monday 9 November, after CREFC Europe’s conference, Pfizer and Germany’s BioNTech announced its mRNA-based coronavirus vaccine candidate has proved more than 90 per cent effective, in the first-stage efficacy analysis from it phase three clinical study. US regulators are expected to authorise the emergency use of the potential vaccine as early as mid-December. It is a bombshell development, but intuitive declarations that the end of the pandemic is nigh should be tempered.

“We will be giving vaccines to people very likely before the end of this year,” Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, predicted on CNN. “The type of vaccine it is – an mRNA-based vaccine – there is another company, Moderna, has a vaccine candidate very similar if not identical to this; their results will be coming out soon. So, it is likely we will have more than one vaccine that is effective.”  However, we still do not know the durability of this, or any, vaccine candidate. We remain very far from victory and, as Fauci warns, it is wise to not become overconfident and not to assume all necessary variables will neatly align.   

Vaccine effectiveness and public acceptance

Vaccine hesitancy is a significant concern for Europe which has implications for herd immunity. It is achieved when a sufficient proportion of a population is immune, rendering the disease unable to spread beyond the first infected person. In Russia, 59 per cent of citizens would decline a Covid vaccine, the Levada Centre, the domestic pollster reported. In the UK, 20 per cent of British citizens would refuse a vaccine, according to a University College London survey in September. In Europe, only 58 per cent were willing to take an available vaccine. Put another way, four out of 10 Europeans would not. “Even assuming the vaccine is 100 per cent effective, those European numbers would make it very difficult to reach herd immunity,” Shaikh warned, adding that between 60 and 70 per cent of a population needs to be immune to reach herd immunity against the virus. 

The dangers of natural herd immunity hypothesis

Achieving herd immunity is considered our best chance at returning to everyday life but strategies to reach that coveted threshold are riven with complexity. While many suggested that we should let the disease spread until herd immunity is achieved naturally through survivors developing antibodies, the science does support that approach. 

Shaikh offers three reasons. “First, asymptomatic and pre-symptomatic transmission. Transmission of Covid by people who will never develop symptoms or don’t have them yet is a massive part of this pandemic. Not knowing who is infectious makes it very difficult to control the spread. 

“Second, there are way too many false negatives in Covid tests to rely on testing to tell us who is infectious when their lives depend on it. We have also learned that death is not the only bad outcome of Covid-19. Even for people who had mild cases that did not require hospitalisation, can still have the rest of their lives ruined. 

“The last reason that herd immunity through infection is not a good option is that we don’t actually know if it is possible. We still don’t know if recovering from Covid-19 actually makes you immune to future infections. Letting the virus spread can only create herd immunity if surviving the virus makes you immune. And right now, when I look at the data, that is not what it looks like to me. It looks like that some people acquire immunity, but not everyone. And among the people who acquire immunity, it does not look like it is going to last for more than a year, just as immunity works with the common cold.”

Vaccine development and global distribution

The twin challenges of vaccines are development and global distribution. There are currently 11 vaccine candidates in third stage trials, which check for adverse effects.  “No vaccine would be widely available until the middle of next year, based on the time it takes to manufacture. Organising the vaccine campaigns will require human resources and tremendous planning capacity. Just transporting the vaccines will be incredibly challenging. 

“Assuming we have a plentiful supply of vaccine by summer 2021, it will take at least a year to reach national 70 per cent vaccination coverage. This assumes an effective vaccine at the level needed to achieve herd immunity. So, we are not going to see Europe go back to pre-pandemic life until summer, 2022. That is assuming that we are not dealing with widespread vaccine refusal or unexpected obstacles like rapid viral mutation. So overall right now we are about two years away at a minimum from being back to normal. And that is assuming everything lines up.

“There are, however, a couple of bright spots. If we get this right, Covid will help us be ready for the next pandemic. It is pushing us and teaching us how to be safer and better prepared. People are already wearing masks more consistently throughout Europe, attitudes toward mask-wearing are shifting.”

How can people fight Covid?

In part, through communication. Shaikh advises people: “Talk to your friends, family and neighbours about vaccines and why they matter. Talk about why you plan to get the vaccine when it is ready and talk about all the people who are helped when everybody gets vaccinated. 

“Remember the three C’s, avoid: crowded places, close contact situations and confined spaces until we have a vaccine. The virus remains a risk, and the three C’s are the highest risk situations. Remember, your decisions are about more than yourself, your choices about safety and infection prevention benefit, not just you, but everyone around you. You may feel frustrated, or like you’re ready to take your chances, but what about your family, friends and neighbours? Did they want to take a chance too? 

“This isn’t going to be our last pandemic; the circumstances that led Covid to hop from animals into people still exist. Once we get through this, once we have a vaccine, once we have herd immunity, everyone is going to breathe a sigh of relief and want to forget. But if we go back to business as usual and we fail to learn from it, we’ll just be caught unprepared by the next pandemic.”

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