As vaccination campaigns ramp up around the world, the countries furthest ahead are beginning to debate at what point coronavirus restrictions can begin to be eased, even before full coverage of the adult population has necessarily been reached. In particular, some are asking which restrictions can be lifted while only the elderly and most vulnerable are vaccinated.
In this debate, there are four main considerations. The first issue is where to draw the line. The lethality of Covid-19 increases exponentially by age. Over 80s are dozens of times more likely to die from coronavirus than people under 50. All else being equal, this should mean that fatalities will drop drastically once over 50s and vulnerable groups are vaccinated, perhaps by 90 per cent or more, a New Statesman analysis from the UK shows. Yet some governments will be tempted to ease restrictions when over-60s or over-70s are vaccinated – potentially risking the health of millions at higher risk.
The second is hospital capacity. Throughout the pandemic, the hard limit for many governments has been avoiding healthcare systems being overwhelmed by the sheer numbers of patients, in the worst case forcing doctors to conduct emergency triage of patients and in the best not being able to offer the optimal quality of care. As most coronavirus patients are elderly and vulnerable, vaccinating those groups is likely to significantly reduce the pressure on hospitals, even if the virus continues circulating among younger people.
However, not all coronavirus patients are elderly or with comorbidities. Some are young and apparently healthy, who nonetheless get struck down with the virus badly enough to require hospitalisation. Lifting restrictions if only a proportion of the population are immunised could still result in significant pressure on the medical system. Some non-essential operations could continue to be delayed, for instance, which would have knock-on costs for patients and healthcare further down the line. It could also require yet more lockdowns if the pressure on the hospital system were to become too acute.
The third is the risk of so-called “long Covid” and any long-term effects of coronavirus. Long Covid is an extended form of the disease thought to affect up to a fifth of patients for weeks or months, with symptoms including extreme fatigue, breathlessness and headaches. Furthermore, because Covid-19 is only a year old, its long-term effects are not yet well understood. There is some evidence of lasting heart or lung damage among some patients who recover from coronavirus. This would have significant long-term costs for individuals and health systems.
The fourth is the effect on elderly and vulnerable people who do not take the vaccine. Even in less vaccine-sceptical countries, there will be some people in vulnerable groups who do not take the vaccine and others missed by imperfect government lists. Others will have weaker protection because they will only have received a single dose of what are generally two-jab treatments. If the virus continues circulating in some parts of the population, in the absence of herd immunity – the term epidemiologists use for immunity to a disease in a group as a whole, achieved through infection or vaccination – it is possible that Covid-19 could still be spread to vulnerable people who are not immunised, resulting in more deaths.
So how can reducing the spread of coronavirus be balanced with the need to reopen economies? The safest option, according to the doctors and epidemiologists I spoke to, is to err on the side of caution and maintain social distancing regulations for longer. Coronavirus is a crisis which has consistently shown tougher measures to be more successful in limiting the short and long-term effects of the disease. Covid can over time be reduced to a manageable risk perhaps on par with seasonal flu – but it could easily surge if restrictions are lifted while the virus continues to spread widely in the absence of full vaccination of entire populations, Chris Smith, a public understanding of science fellow at the University of Cambridge, told me.
On this issue, Israel’s experience will be instrumental. The country is on track to be one of the first to reach full coverage of the adult population by March or April, according to officials. Around a fifth of the population has already received at least one dose of the vaccine.
How and when Israel chooses to lift restrictions will be closely watched by the rest of the world. The country plans to issue “vaccine passports” which will exempt bearers from some social distancing rules, but the Ministry of Health said in a statement that it expects to keep a number of regulations, such as mask-wearing, in place for some time. It also says that it is considering easing regulations with only over-50s vaccinated, though that would depend on receiving more data on whether vaccinations prevent transmission of the virus, or merely protect against disease.
However, Yoav Yehezkelli, an expert in disaster management at Tel Aviv University, told me that because Israel’s immunisation campaign is advancing so fast towards full coverage, vaccinating close to 1 per cent of its population a day, there may not be any need to debate whether to significantly reopen with only partial coverage of the population. The difference between doing so and not would be only a matter of weeks, which may prompt Prime Minister Benjamin Netanyahu, who is running for re-election in elections due on 23 March, to err on the side of caution in lifting restrictions.
For rich countries which can secure enough vaccines for their entire populations and have the capacity to administer them, efforts should be focused on ramping up distribution to a point when questions of reopening before full coverage is reached become close to immaterial. Governments overeager to reopen risk making the same mistakes as earlier in the pandemic – and now that the end of the pandemic is within touching distance, they would be unlikely to be forgiven.