Jim was a panellist during the 10th HIS COVID Challenges webinar on 3 February 2021, which is free to access here alongside other webinars in the COVID-19 challenges and solutions series. This blog captures his thoughts on the extent and impact of new variants of SARS-CoV-2, and how we should respond. Readers are respectfully reminded that as the situation with variants is rapidly evolving, the responses to the questions provided relate to the situation up to 3 February 2021.

Jim McManus

There has been a rapid resurgence of COVID-19 cases in the UK and Ireland since lockdowns ended in early December 2020. Was this because lockdowns were released too soon, before numbers had fallen significantly, or was it driven by the new variant?

I think the short answer is the rapid resurgence was due to a combination of factors.

First, while the vast majority of people had good intentions regarding following the various restrictions, there were equally a number of people who either intentionally ‘bent the rules’ in their favour or extended them beyond the intended principle. A much smaller number of people wilfully disregarded the rules.

Secondly, at the time the lockdowns ended in early December, people had already started their Christmas shopping, planned their family meetups, and were socializing before the rug was pulled out from under them. We know this to be true in my area (Hertfordshire) and others, because the number of public complaints and enforcement activities went up and we were issuing more closure orders and fixed penalty notices. There was more social interaction than there should have been. And that’s understandable, because people had been having a hard time, but it spread the virus.

We also know from modelling from the Judge Business School in Cambridge that the lack of closure of schools added an extra 20 to 40% to the circulation of the virus. So, the November lockdown was never going to be as effective as the first lockdown in spring 2020.

Another factor was that some people became more lax in their behaviours: we eased off too much. I think we can see from common exposure records that a lot of people were visiting shops and various other areas, such as workplaces. And people were genuinely confused – lots of people still think you can get right next to one another if you wear a mask. Messages about the fact we need multiple things to stop people becoming infected got diluted and with this the opportunity for the virus to transmit, especially new and more infectious variants, became clear.

Finally, what was quite clear was that at the very time the numbers should have been coming down (just before we lifted the lockdown on 2 December), they actually started to go back up again.

This started in the southeast of England: the new UK variant, B117, was causing new infections in Kent, then it spread into Broxbourne in Hertfordshire, which neighbours Essex and Enfield in North London. It then spread across London and other areas. We can actually see that those areas that were tier four just before Christmas – quite a lot of southern England – were seeing a sharp rise in infection that should have been going in the other direction. It seems pretty clear that B117 is now likely to become, if it has not already done so, the predominant variant or perhaps effectively the ‘wild type’ for some time, at least until another fitter variant squeezes it out.

There was also a significant amount of additional testing behaviour that went on. I think lots of people were getting tested early for Christmas in the hope that they would be able to socialise if they tested negative.

There was almost an epidemiological perfect storm, if I can put it like that.

How many COVID-19 variants have been identified worldwide, and have they resulted in increased transmission or more severe symptoms?

To say that’s a movable feast is probably an understatement. We should expect variations, and we should expect recombination events, because this is what the virus does. To some extent we only know about the variants we know about because of genomic sequencing and other surveillance – there could be more variants than we are aware of.

There's also the South African variant 501YV2, which was detected in October 2020 in South Africa, and which was detected in the EU on 28 December - I'll come back to that. Then there is P1 which is the Brazilian and Japanese variant. We also have, it seems, an E484K mutation, which has potentially been independently acquired by B117 in the UK, another worrying factor.

All of these variants seem to show increased transmissibility. The South African variant seems to show reduction of vaccine effectiveness. But we don't know. There are questions remaining about the Brazilian and the Japanese variants as well.

In early February this year there were six local authorities in England that were being asked to test, and to do more genomic analysis on the South African variant of interest in a cluster of cases that were not linked to travel. And Hertfordshire was one of them. The number of authorities grew, as did the number of variants being tested. We are writing the playbook for these as we speak.

We are currently offering PCR testing to 10,000 households to be able to do genomic analysis on positive samples. This kind of exercise will be important for surveillance epidemiology. But we also have to work out how, in public health terms, we handle multiple emerging variants in future, because SARS-CoV-2 isn’t going away any time soon: we have to learn to live with it.

How might we adapt our approach to tackling COVID-19 in light of these new variants?

Virologists warned of variants and recombinants early in the pandemic, but this message perhaps got drowned out by other debates and so has understandably come as a surprise to some people. We know that coronaviruses do develop variants, and that recombination events happen. (Influenza viruses show variation and recombination, for example, though the recombination mechanism is somewhat different.)

So it is highly likely this will need to be part of our virus suppression playbook. Co-infection will be possible, and this has public health implications not just for the creation of more recombinants but for the spread of infection. As more genetically distinct variants of SARS-CoV-2 arise and circulate, so the risk of more variants, and of recombinant variants, rises.

In our playbook for suppressing the virus we must prioritise the need to explain and reinforce combination prevention. This is not yet a vaccine-eradicable disease, so reducing transmission through physical distancing, hygiene, self-isolation of infected and symptomatic people needs to continue alongside vaccinations.

We need to have a strategy that expects the virus to mutate, and that tracks symptoms because there is certainly anecdotal evidence that the new variant is causing more cases of hypoxia in the community. And there are some fears around symptoms. And some reports of increased acuity in our hospitals. A public health strategy from my perspective would mean welcoming much more genomic sequencing, and of course understanding what this means for tweaking vaccines.

Control measures are key too. We must remember that basic tools for controlling spread – whether individual or communal interventions – remain pretty constant and unchanging and they are the best bets for controlling spread, variants or not. Combination prevention wins.

But there is no single ‘thing’ to do, there are multiple ‘things’. We have to expect variants as part of the playbook going forward. Let's get a very clear strategy for what we do with variants and recombinants. The existing variants are not the only variants which will emerge.

---

If you have any questions for the author, please email them to admin@his.org.uk