Intended for healthcare professionals

Rapid response to:

Letters Aiming for “zero covid”

To achieve “zero covid” we need to include the controlled, careful acquisition of population (herd) immunity

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3487 (Published 09 September 2020) Cite this as: BMJ 2020;370:m3487

Rapid Response:

Zero COVID-19 and population immunity: clarification of views and brief response to objections on grounds of immunity and morbidity

Dear Editor,

Zero COVID-19 and population immunity: clarification of views and brief response to objections on grounds of immunity and morbidity

In my earlier rapid response and now published letter,(1) I set out the background to my ‘COVID-19 zugzwang’ paper including an email dialogue with Professor Martin McKee in April 2020. In our dialogue I had included the suggestion that young people might voluntarily get the infection. However, I was fully persuaded by senior public health colleagues that this was not workable. I agreed and changed my mind then (although I might revisit the idea should there not be an effective and safe vaccine within the next year). Rather, as I have emphasised in my COVID-19 zugzwang paper,(2) and even more strongly in my interviews, young people will acquire the infection in their day-to-day lives and should be allowed to do so without stringent, authoritarian measures being imposed upon them. I have argued strongly for this to be done carefully and within a broad public health strategy of containment. Young people have the most to lose from restrictions, and the least to lose from the infection, while the opposite is true for people like me (67 years of age and Indian and therefore at high risk).

Although more than 90% of people, professionals and public alike, support my views there have been some important objections.

Firstly, one response is that we know little about immunity following infection. That is incorrect. We have now nine months of experience of this pandemic. Perhaps, 10% of the world’s population has had the infection, and much more in some places. That means up to 700 million people (about 3-6 million in the UK) and possibly much more. Currently, the possibility of re-infection, even without hospitalisation or intensive care, is making the global headlines so we can say that immunity is surprisingly strong. As I have emphasised immunity is unlikely to be lifelong, especially if the virus evolves genetically as it is doing.(2, 3)

The second objection is that a focus on mortality misses out morbidity. We have worked hard on providing population perspectives on mortality and set out the statistics on hundreds of millions of people.(4-6) When we have the data we will apply the same approach to morbidity when data are available. In the meantime, an estimate of 60,000 people with long-term morbidity following COVID-19 in the UK is being discussed. If 6 million people in the UK have had the infection that is 1% of people becoming ill (so-called long-COVID). Morbidity is extremely common after all virus infections and it remains to be seen whether COVID-19 is exceptional in this regard.

Finally, I would like to emphasise that strategy puts a heavy emphasis on individual autonomy and individual responsibility. I oppose any fines or, worse, jail sentences as part of a public health strategy against COVID-19. The public needs to be participating in controlling this pandemic and coercion will be counter-productive as the problem, with or without vaccines, will take many years, possibly even decades, to resolve.

References
1. Bhopal RS. To achieve “zero covid” we need to include the controlled, careful acquisition of population (herd) immunity. BMJ 2020;370:m3487.
2. Bhopal RS. COVID-19 zugzwang: Potential public health moves towards population (herd) immunity. Public Health in Practice 2020;1:100031.
3. Bhopal R. Patients who have recovered from covid-19: issuing certificates and offering voluntary registration. BMJ 2020;369:m2590.
4. Bhopal S, Bagaria J, Bhopal R. Children's mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers. Public Health 2020;185:19-20.
5. Bhopal S, Olabi B, Bagaria J, Bhopal R. COVID-19 deaths in children: comparison with all- and other causes and trends in incidence of mortality Public Health 2020; https://doi.org/10.1016/j.puhe.2020.08.022
6. Olabi B, Bagaria J, Bhopal S, Curry G, Villarroel N, Bhopal R. Population perspective comparing COVID-19 to all and common causes of death in seven European countries. 2020.08.07.20170225. https://www.medrxiv.org/content/10.1101/2020.08.07.20170225v1 (preprint not peer-reviewed)

Competing interests: No competing interests

14 September 2020
Raj Bhopal
Emeritus Professor of Public Health
The University of Edinburgh
Usher Institute, Teviot Place, EH8 9AG