Winter is coming—but will the gloomiest forecasts come to pass?BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2357 (Published 24 September 2021) Cite this as: BMJ 2021;374:n2357
What is the likely effect of flu this winter?
The latest report from Public Health England, based on data for 13 to 19 September, shows that influenza activity is currently very low.1 However, Sharon Peacock, head of the Covid-19 UK Genomics Consortium, warned the webinar, “I think there is reason to be concerned about influenza. We had very little influenza last year so our natural immunity will have waned somewhat during that time.” She said that it was difficult to know how much flu we will get this year but that modellers at Warwick University had predicted we may see high numbers of cases. On the other hand, she said that we are still not at pre-pandemic levels of social mixing and that people also had more awareness of the importance of not going into work with a cough or cold-like symptoms. This, combined with other measures such as social distancing and handwashing, may offer some protection from flu.
Preventing nosocomial coinfections within hospitals will be an issue this winter, the webinar heard. Charlotte Summers, an intensive care consultant and council member of the Intensive Care Society, said, “It’s going to be incredibly challenging from an infection control point of view this winter to separate out those patients with RSV [respiratory syncytial virus] from those with flu and those with covid. Unless we have rapid multiplex testing we are going to be in trouble.” She added, “The absence of infrastructure and side rooms was a challenge when pretty much the only bug we had was covid, and it’s not going to get any easier when we have to separate those with covid from those with flu or RSV.” She pointed out that last year saw almost no RSV, so paediatric intensive care was almost empty and these clinicians could help out, whereas “now they are teeming with RSV.”
What has been the effect of schools returning?
Schools went back two weeks ago in England and over a month ago in Scotland. Sarah Walker, professor of medical statistics and epidemiology and chief investigator for the national covid-19 infection survey, told the meeting, “If you look at Scotland, rates went up very quickly after schools went back. At the moment in England positive PCR tests have been more level over recent weeks. But one in 80 people have covid. So rates are at a level that has the potential to cause severe problems this winter.”
The most recent data in England shows that, while cases in older people are typically going down, in school age children they are rising.1 New cases among 5-14 year olds rose by 80% week on week, to 811 per 100 000, in the period ending 19 September. Cases also seem to be starting to rise in their parents’ age groups.2
Leicester’s schools went back a week earlier than other council areas in England. Case rates among school age children rose to 979 per 100 000 by 13 September, but the surge may have peaked. Ivan Browne, the city’s public health director, told the webinar, “We started to see really sharp spikes in 11-15 year olds. At the moment we seem to be at a tipping point.” He said that this was encouraging but that he was not fully convinced this will be the end of the story.
Could we see another covid variant cause a problem?
Peacock told the webinar that the four SARS-CoV-2 variants of concern all emerged before the vaccination programme started and that it has been pretty quiet since delta emerged. But she added, “I think there will be new variants emerging over time. It’s inevitable and there is still quite a lot of road to travel down with this virus.”
Sarah Gilbert, lead professor behind the Oxford-AstraZeneca vaccine, presented a more optimistic viewpoint. “We normally see that viruses become less virulent as they circulate more widely. [We’ve seen] that with pandemic flu viruses, and there is no reason to think we will have a more virulent version of SARS-CoV-2. We tend to see slow genetic drift in viruses. There will be gradual immunity developing, as there is with the other coronaviruses. We already live with four other coronaviruses, and eventually SARS-CoV-2 will become one of those.” She argued that the spike protein targeted by vaccines had only limited ability to mutate while still allowing the virus to get inside human cells.
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