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Herd Immunity

Not in mandatory lockdown; Iceland, Sweden, Portugal, Israel, Japan, The Netherlands, Hong Kong, Singapore, Taiwan, The UK (lose lockdown), South Korea (soon), Indonesia & Turkey. Libertarian or Authoritarian; which do you prefer? 

Obviously the information in this article is rapidly changing. For example Denmark on Monday 6th April 2020 announced plans to open kindergartens and schools next week and a staggered return to work, Austria's plans for lifting Covid-19 restrictions, Germany may reopen schools if infection rate stays low. The point of this article is to compare libertarian and authoritarian suppression measures only and to discuss the legitimacy of herd immunity.

A vaccine will take a minimum of 12-18 months and this time frame carries risks and there is no guarantee. Humanity needs to accept that a vaccine will be not available in time for this current wave of COVID-19 and that herd immunity is not an option; it is the only option. No one supporting herd immunity supports a rapid spread of COVID-19 in vulnerable populations. Herd immunity does not mean no restrictions. Herd immunity is a controlled distribution of COVID-19 among groups that are least at risk. It is expected that in countries where greater herd immunity is achieved, the better prepared that country will be to reduce the curve in the suspected second and third waves, thus requiring less restrictions on personal liberty. Dismissing other countries approaches without having all the data is premature.The truth is the outcomes of any measures will only be known once the pandemic plays out in full. In a bid to save lives we should continue to prepare as best we can for the inevitability of this pandemic to overwhelm healthcare systems, whilst recognising in turn the need to protect livelihoods and personal liberty. Herd immunity, through either vaccine induced artificial immunity, natural immunity, or a combination of both, will eventually be achieved everywhere, it is a matter of which strategy your government adopts; nanny state or night watchmen. 

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What is herd immunity?
Herd immunity is a term applied to natural immunity that has been commandeered by the pharmaceutical industry. Herd immunity can be achieved by either exposure to a disease or vaccination. A good example of herd immunity is when adults get exposed to chicken pox in children and this strengthens their immunity against shingles. We now see dramatic rises globally in shingles because the chicken pox vaccine has suppressed natural herd immunity to shingles which is a far more serious and painful condition than chicken pox. Immune people act as a barrier to the spread of disease, and slow and preventing the transmission of disease to others. An individual's immunity can be acquired through artificial immunity via vaccination or through natural infection (1). The herd immunity level (HIL), is the percentage at which the disease may no longer persist in the population, putting an end to the pandemic. The HIL for SARs coronavirus is 50%-80% (2). Dr. Gabriel Leung an infectious disease epidemiologist and the dean of medicine at The University of Hong Kong and founding director of the WHO's Collaborating Centre for Infectious Disease Epidemiology and Control says the herd immunity level may be between 50-60%. See below.

Natural herd immunity; there may be no other choice
The Imperial College London concluded on March 16th that that even a mitigated epidemic is still going to overwhelm healthcare systems and cause at least 250,000 deaths in the UK and more than 1.1 million in the US. Suppressing the virus by combining all available measures, including school closings and social distancing of the entire population has been described by the Imperial College London team as “only viable strategy at the current time.” , The team concluded that draconian measures could be relaxed once in a while and then re-imposed when case numbers remerge. In that scenario, the population would still build up immunity. Chief epidemiologist and vaccine expert Seth Berkley, CEO of GAVI, the Vaccine Alliance says “You cannot say the Earth has to stop for a year or 2 years" (3).

What the WHO says about when the COVID-19 pandemic will end
In short the pandemic will end when we achieve herd immunity, which will be either natural through acquiring the infection or artificial through vaccine induced immunity or a combnation of both. Essentially what is no playing out is a race between Mother Earth and the scientists as to who will protect the herd first. Dr. Gabriel Leung is an infectious disease epidemiologist and the dean of medicine at The University of Hong Kong and founding director of the WHO's Collaborating Center for Infectious Disease Epidemiology and Control in a radio interview spoke to “The World's” host Marco Werman about how the pandemic might end. Leung described needing at least 50%, perhaps 60% of the world's population to acquire immunity before this would settle down. Dr Leung discussed the new antibody titers (test) and how this will allow us to understand how infectious the disease is and how much of the population already has natural immunity and that this relates to gauging the vaccine availability timeline. He then goes on to discuss the problems with past coronaviruses vaccines making the disease worse by creating an enhanced response (4).

I explained vaccine enhancement and other past issues of coronavirus vaccine production in my article; Coronavirus (COVID-19) Lockdown: How Long will is Last?

The antibody test
An antibody test is going to be available soon which will reveal whether someone has had the virus and is therefore will have immunity to the disease . It is a home finger prick test that looks like a pregnancy test. This will be distributed by Amazon and in Boots stores soon. The UK coronavirus home testing is going to be made available to millions. Tests are being ordered across Europe and in South East Asia. NHS workers or anyone else will be able to know if they have had the virus and are therefore immune, which means they could resume their normal lives, no longer having to work from home or keep their distance from other people (5). This test will allow an army of immune healthcare workers to be able to return to the frontline knowing they have cannot get or give the virus and this is particularly important in light of deficient personal protective equipment (6). Natural immunity to COVID-19 is being described by medics on the BBC as a like having a “Super Hero Power”. On April 2nd 2020, the FDA approved the first COVID-19 antibody test, this tests will answers questions such as how many people are asymptomatic, better estimate the death rates and teach us how long natural immunity lasts. An Irish company Assay Genie, is going one step further and has created a coronavirus testing kit which can detect both the virus and antibodies in one drop of blood.

Countries Adopting Herd Immunity
Infectious disease expert Dale Fisher, chair of the World Health Organisation (WHO) Global Outbreak Alert and Response Network just announced countries under lockdown should look to Singapore’s actions and efforts. “At the end of the day, I believe you have to do what’s happening in Singapore now” (7). What is Singapore doing?

Singapore
In a ministerial statement Health Minister Gan Kim Yong In laid out two strategies drawn up by academics to tackle the pandemic; establishing herd immunity, and flattening the curve. Singapore aims to get through the coronavirus outbreak by attempting to avoid a sharp spike in cases, while ensuring that the epidemic does not last too long. Singapore is taking, as Public Health law should, a considered, proportionate and necessary approach. Singapore has implemented restrictive measures however has not gone into a total lockdown. Schools remain open, businesses are encouraged to work from home but some remain open and precautionary measures such as regular temperature checks at work occur (8).

Israel
Israel is “winning the war on coronavirus” not by imprisoning the healthy but by actively promoting herd immunity. The elderly and sick must be isolate while the low risk group of young healthy infected people with COVID-19 are told to get back to work in order to make the population immune to the virus (9).

Iceland
Iceland is taking a sensible approach to containing and ending the coronavirus pandemic. No mandatory lockdown, no mass surveillance, no infringements on civil liberty; instead a considered, proportionate and necessary approach. Iceland is randomly sampling their population, testing those with symptoms and without. Random sampling will allow Iceland to have the clearest picture of death rates. This is why we know that 50% of people with COVID-19 have no symptoms. In Iceland measures are aimed at finding and isolating infected individuals and placing those who have been in close contact with infected individuals in quarantine and encouraging social distancing to reduce the likelihood of infection and lower the value of R0. R0 refers to the average number of people that one infected person goes on to infect. In Iceland it is noted that understanding the correlation between R0 and herd immunity (H) is key (H=1-1/R0). If R0=2.5, then 60 percent of the population needs to develop immunity to stop an epidemic. If the value of R0 can be successfully reduced, a substantially lower proportion of the population needs to develop immunity in society for the epidemic to end (10). 

Portugal
Spain’s neighbouring Portugal is not under mandatory shut down. Portugal did go into lockdown and is keeping schools closed during April however the government imposed lockdown is not mandatory. The government isaid said it would be “disrespectful” to the Portuguese. Portugal’s government has advised people to self-isolate if they have symptoms. Some beaches around Porto are closed although the Portuguese can still go for a solitary swim. Their  motto is “save lives, while ensuring that life continues” (11).

Netherlands
The Netherlands just announced it will adopt a herd immunity strategy to combat the coronavirus pandemic. Dutch Prime Minister Mark Rutte is the first world leader to publicly back the herd immunity theory. Mark Rutte said a mass lockdown was not feasible and the country had instead opted for a plan that included "controlled distribution" of COVID-19 "among groups that are least at risk" (12). Countries adopting stricter measures as the curve dictates are still adopting a herd immunity approach by controlling the spread of COVID-19 in the population.

Sweden
Sweden has also adopted a herd immunity strategy aimed at contained release of COVID-19 among not at risk population. Sweden's chief epidemiologist Anders Tegnell says strategy ensures “a slow spread of infection, and that the health services have reasonable workload”. Tegnell says Coronavirus could be stopped either by “herd immunity, or a combination of immunity and vaccination”, he said. “It’s basically the same thing (13). Yes there are reports of the Netherlands backing off herd immunity however a herd immunity policy is one of applying stricter control measures to reduce the pressure on the healthcare system as and when necessary. Sweden's lockdown policy is not mandatory. Sweden describes their citizens are mature, grown-up and responsible and asks them to do the right thing.

UK
This concept of promoting natural herd immunity was expressed by Sir Patrick Vallance FRS FMedSci FRCP and Chief Scientific Officer (CSO), who says coronavirus may become an annual event and that Britain needs herd immunity to combat the spread of Covid-19 (3). Professor of Infectious Disease Modelling Graham Medley at the London School of Hygiene and Tropical Medicine also agreed and explained why the Government is trying to actively promote herd immunity by initially allowing schools to stay open longer than other countries (4). Because the UK has moved into from the social distancing to the stay at home order does not mean they are not adopting a herd immunity approach. The herd immunity approach involves a controlled distribution of COVID-19 among groups that are least at risk.. Schools, nurseries and childminders are still providing care to vulnerable including children under social worker care and children with special educational needs. Schools are also open to children whose parents are key workers "critical to the Covid-19 response". Given that the NHS alone is one of the largest employers in the UK there are many children still at school developing herd immunity. Whilst the papers report that the UK has backed off herd immunity, the reality remains that CSO Sr Patrick Vallance never denounced his herd immunity approach and the fact that so many children are in school confirms it. The Tube is crowded with many key workers and people are not wearing masks. Britain has instead adopted the approach to enforce self-isolation of pinpointed vulnerable for 12 weeks. Britain has a very respected police force that continues in the majority to police by consent and not by handing out disproportionate fines. 

Hong Kong
Hong Kong has chosen to leave the city open. A University of Hong Kong epidemiologist says there's no need for a lockdown of the city despite an increase in the number of local Covid-19 outbreaks instead the focus is on the top clusters of cases (14).

Japan
Since the Diamond Princess debacle, nothing has been said in the news about Japan. Japan has one of the lowest infection rates of all developed countries. In sharp contrast to the likes of China and South Korea, which put in place heavy-handed isolation measures, and in the case of the latter set about mass testing, Japan did not mandate a stay at home. Japan did take the crucial steps to closing schools, stagger commute times on public transport during peak hour times, and limit crowd sizes at public gatherings and at some entertainment venues. But Japan did not shut down its nation, with most of its clubs and restaurants still busy and bustling. Japan's main airports, which have stayed open, took basic precautions such as thermal scanning international passengers for elevated temperatures as they walked by and having new arrivals pledge to self-isolate for 14 days, although this was not enforced. Rather than adopting draconian suppression methods to stop the spread of coronavirus, Japan have relied on a strategy of quickly identifying clusters of new cases and then imposing containment measures to prevent a larger outbreaks. Japanese culture has played a part in slowing the spread. Japanese greeting etiquette is a bow instead of a handshake or a kiss on the cheek and basic hygiene education is taught from an early age. Washing hands and wearing masks was already a part of their everyday lives. The face masks may have played an important role in slowing down the spread of the virus (15).

South Korea
A lot has been said about South Korea which has been adopting the WHO guidelines and testing and isolating cases. This approach has been successful to date but is going to change soon as South Korea are expecting a new wave as they have not achieved herd immunity. The National Medical Committee, Dr Oh Myoung-don, told reporters there could be another spike in infections once schools re-opened and also expected a possible resurgence of the virus this winter because the suppression techniques used means people will not be immune to this virus. He raised the possibility that it may be time to allow part of the population to get sick and encourage herd immunity (16).

Indonesia
The Indonesian government has been reluctant to declare lockdowns, though the president has called for people to “work, study and pray at home." People are free to travel. The Transportation Ministry has asked the public to cancel trips back to hometowns for the Eid al-Fitr holiday at the end of Ramadan, but it is thought many will ignore requests. Nine provincial governments have declared emergencies and ordered bars, spas, cinemas and other entertainment venues to be closed from March 23, and public transportation is limited. Shopping malls in Jakarta however are open only closing earlier than usual (17).

Taiwan
In Taiwan meticulous early infection control measures have helped to contain Covid-19. Taiwan is using phone tracking to enforce mandatory quarantine. Most residents in Taiwan however carry on as normal, with offices, schools, restaurants, gyms, and cafes in Taipei open. Most premises will take temperatures and spray hands with sanitiser before allowing customers in (18).

Turkey
The Turkish  government has gradually increased measures to combat the virus, including the suspension of international flights, border crossings and travel between cities, a ban on public gatherings and communal prayer, and the closing of schools and most shops however order people to stop going to work and stay home, but President Erdoğan insists that the “wheels of the economy must keep turning”. Reported fatalities remain much lower than other badly hit countries however case numbers are rising. Two theories exist.; The first is that he says that the Turkish economy cannot manage a lockdown. The other theory is herd immunity, with people over sixty-five or with chronic diseases being told to self-isolate. Turkey's apporach is described as "the hidden herd immunity theory".  

1. Merrill RM. Introduction to Epidemiology2013.
2. Wallinga J, Teunis P. Different Epidemic Curves for Severe Acute Respiratory Syndrome Reveal Similar Impacts of Control Measures. American Journal of Epidemiology. 2004;160(6):509-16.
3. Cohen J. Mass testing, school closings, lockdowns: Countries pick tactics in ‘war’ against coronavirus. American Association for the Advancement of Science. 2020 Mar 18.
4. Hills C. Hong Kong epidemiologist warns pandemic's end may not be straightforward: Public Radio International PRI; 2020 Mar 26
5. Boseley S. UK coronavirus home testing to be made available to millions. The Gardian. 2020 Mar 26.
6. Daly M. Can New Test Help Build an Army of Immune Medical Workers? Daily Beast. 2020 March.
7. Chair A. Countries in lockdown should do what Singapore has done, says coronavirus expert: CNBC; 2020
8. Lai L. Coronavirus: Singapore has chance to slow down spread of virus, says Gan Kim Yong. The Strait Times. 2020.
9. Yeheskeli DY. Israel must turn to herd immunity to combat coronavirus. Y Net News. 2020 Mar 31.
10. Hafstað V. Herd Immunity Threshold Could Be Lowered in Iceland. Iceland Monitor. 2020.
11. Catarina Demony VW. Portugal restricts movement to stem coronavirus, rules out rationing. 20202 Mar 19.
12. Shields B. Dutch embrace 'herd immunity' as dire death warning prompts UK to change course. Sydney Morning herald. 2020 Mar 17
13. Henley J. Swedish PM warned over 'Russian roulette-style' Covid-19 strategy. The Gardian. 2020.
14. News RE. Full lockdown not needed in Hong Kong: HKU professor 2020 Mar 27
15. News F. Coronavirus: How Japan keeps COVID-19 under control 2020
16. News B. Coronavirus: South Korea reports lowest number of new cases in four weeks 2020 Mar 23
17. writers Ns. From light touch to total lockdown: How Asia is fighting coronavirus. Asian Review. 2020 Mar
18. Yun M. How Taiwan is containing coronavirus – despite diplomatic isolation by China. The Gardian. 2020 Mar 13.
19. Chotiner I. The Coronavirus Meets Authoritarianism in Turkey. The New Yorker. 2020.

 

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