Dr Jonathan Cylus reflects on recent discussions organised by the APPG on Coronavirus, to compare England’s COVID-19 Winter Plan with the plans in other countries. England has differed with many other countries in terms of lifting restrictions, not imposing masks mandates and vaccination rates, and this may provide some insight of what to expect over the winter months. 

On Tuesday 5th October, I participated in an oral evidence session organised by the All Party Parliamentary Group (APPG) on Coronavirus (COVID-19). APPGs are informal groups of Members of the House of Commons and the House of Lords with a common interest in particular issues, in this case, the COVID-19 pandemic. The purpose of these groups is to examine policy issues, where stakeholders and government ministers are invited to speak at the sessions. This session’s aim was to compare England’s COVID-19 Winter Plan with the plans in other countries and to gain a sense of what we might expect will happen over the winter months.

Below I consider the Members’ main question of the day: What measures are countries across Europe and beyond doing to prepare for winter, and how does this compare to England’s ‘Winter Plan’?   (for video of the full session, please visit here). Where possible I made use of the COVID-19 Health Systems Response Monitor, which is an initiative begun in March 2020 and led by the European Observatory on Health Systems and Policies together with the World Health Organization (WHO) European Regional Office and European Commission to collect, organise, and analyse information on how European countries have been responding to the COVID-19 pandemic.

Other countries have waited until a much higher share of their population is vaccinated before lifting COVID-19 restrictions

Countries around the world, including England, are counting on vaccinations to weaken the link between COVID-19 cases and severity. As of 11^th October 2021, nearly 37.9 million people in England had received 2 doses of the vaccine: about 67% of the population. This is comparable to much of Western Europe, including France (71%), Spain (73%), Italy (69%), and Ireland (75%), though lower than many others.

However, unlike England, which lifted all restrictions on 19^th July – aka ‘Freedom Day’ – at a time when around half of the total population was fully vaccinated, most other countries have waited to do so until a much higher share of their population is vaccinated. There are several reasons for leaving restrictions in place: to wait until a critical mass of people is vaccinated; because of uncertainty about how long vaccines will remain effective for; and uncertainty about the effectiveness of vaccines in the presence of high rates of community transmission. Indeed, many countries remain under restrictions even still despite vaccination rates that are currently higher than England’s. While there is variation in terms of whether thresholds to re-open are based on the total population or the total adult population, Ireland has been waiting to lift restrictions until 90% of those 18+ are vaccinated (tentatively 22^nd October 2021), Finland is waiting until 80% of the 12+ population is fully vaccinated, and Spain has been waiting until 75% of the population is fully vaccinated. Notably, even Portugal, the most vaccinated country in the European Union (EU) (80% of the population is currently fully vaccinated), waited until 85% of the population had at least one dose.

Re-opening the economy in other countries has often included mask mandates and COVID passes

Of course, ‘lifting restrictions’ can mean different things in different countries. For example, the majority of countries in Western Europe have largely re-opened their economies but continue to require masks indoors. In countries like Germany where mask mandates persist, the use of cloth masks is widely seen as unacceptable, with medical grade or FFP2 masks often required to enter shops. Many countries are also using COVID passes to ensure people are either vaccinated, recovered, or tested before being admitted to certain events. Italy requires the COVID pass for domestic travel and even to go to work. Portugal is continuing to require the use of COVID passes for bars and clubs going forward. In England COVID passes are rarely used and mask usage is patchy even in some locations where it remains officially mandatory, such as on Transport for London.

Additionally, other countries are ahead of England in vaccinating 12-to-15-year olds. Although younger people typically experience only mild symptoms, little is understood about long-term effects of COVID-19 infection and younger people can be reservoirs for the virus to evolve further. England just began to vaccinate 12-15-year olds and had made negligible progress thus far, while Finland and Portugal began in August before schools reopened and Spain began in July.

However, unlike England, which lifted all restrictions on 19^th July – aka ‘Freedom Day’ – at a time when around half of the total population was fully vaccinated, most other countries have waited to do so until a much higher share of their population is vaccinated

The experiences of Israel and Vermont suggest vaccination rates comparable to England’s are not high enough to allow an end to all restrictions

The experiences of others give reason to be worried about England’s decision to remove all restrictions before vaccinating a larger share of the population. Israel was lauded early on for its rapid vaccine rollout however it subsequently experienced a fourth wave towards the end of the summer, largely driven by the unvaccinated (who remained a share of the population as in England) and also potentially due to waning immunity of vaccines. Vermont, the most vaccinated State in the United States (US) has had a similar experience, with its highest cases and hospitalisations of the whole pandemic in the past few weeks. Given these experiences, England should not be surprised if it also sees further growth in case rates and pressures on the National Health Service (NHS), particularly over the winter months.

There are nevertheless a few success stories. One of these is Denmark, where there have been no domestic restrictions for over a month (since 10^th September). However, vaccination rates are higher than in England (upwards of 80% of the total population) and Denmark has arguably earned its freedom after locking down early, and it continues to maintain restrictions on travel. England on the other hand locked down comparatively late, after relatively high levels of cases and death rates (see Figure 12.3 in the linked chapter). Positivity rates in Denmark also remain below 1% according to the European Centre for Disease Prevention and Control (ECDC), although time will tell whether this remains the case as we move into the winter.

What now?

Compared to most European countries with similar or higher vaccination rates, England’s approach to managing the pandemic this Winter could be considered among the least risk averse. Indeed, England’s Plan B for the Winter looks like much of Europe’s implicit Plan A. Will England manage to keep the economy open without experiencing surges in cases, hospitalisations, and deaths? Early evidence gives cause for concern. England has had a PCR positivity rate over 5% since the end of June, 7.4% PCR positivity in the last 7 days (as of 5^th October), and around 4% positivity rates if one counts all 900,000 or so tests conducted daily (including rapid lateral flow tests).Compared to European countries with high vaccination rates and few restrictions in place (e.g. Denmark), this is quite high. Hospitals are already under considerable pressure, with an average critical care bed occupancy rate of 78% in the 7 days between 6^th October and 12^th October, and more than 1/5^th of those beds occupied by COVID-19 patients. While the government publicly seems reluctant to reinstate restrictions, it may be that the best thing the government can do now to bring the pandemic under control is to remind people that the pandemic has not ended and prepare for an eventual move to Plan B.

The views expressed in this post are those of the author and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.

Photo by Andrei Ianovskii on Unsplash