“One can understand the BBC, as part of the state apparatus, would be putting out the messages that the Government wants the public to hear – and propaganda is very important to get the message right – but some of the media hasn’t been at all helpful in that they’ve increased the political polarisation”, says Professor Pollock.  Similar problems have occurred with scientific discussions.  It would have been more helpful had the media taken the time to explore the uncertainties and unknowns and said, “Well, these are the uncertainties [and] unknowns and this is what we’re doing and why we’re doing it. We don’t quite know, but this is why we think it might be beneficial”, as was done in Sweden, Norway and Denmark.  Such an approach wins a lot of trust, she notes.

On the other hand, “If you don’t declare the unknowns and uncertainties – as the Government has often done, and even the Chief Medical Officers – then actually you break trust, especially with people who are questioning or sceptical”, says Professor Pollock. Everyone has a lot of questions about pandemic control measures, especially if what they see around them suggests that they don’t appear to be working or they appear to be ridiculous. This was a particular problem with vaccination, “especially when we were told that one vaccine then two vaccines would work and then we suddenly into a third one and then a fourth one. People were saying, “Hang on, never in the history of vaccination have we done this sort of boosting and what are we doing to ourselves and our immune system?” so they’re raising very genuine questions and yet they’re constantly being shut down”, she says.

Had the Government simply declared the uncertainties and unknowns and taken a lot more of the expert advice that was available there could have been less political polarisation and perhaps a lot less wasted expenditure. It was this kind of thinking that prompted Professor Pollock, together with Professor Davey-Smith and the BMJ to run a series of webinars dedicated to discussions by experts of the unknowns and the uncertainties from school closures to variants to vaccinations.

Professor Pollock has two messages for health care workers in primary care. First, knee-jerk reactions should be avoided if possible and time should be taken to weigh up the available options and when measures are rolled out, studies should be put in place at the same time to evaluate the benefits and harms. Second, “it’s equally important as a health professional to express uncertainties and unknowns in your own profession, and to be very honest at the individual patient level as well as the public level – and that way you build trust”.

Read and watch the full series on our website.

“I think the most extraordinary thing in the UK is the way natural immunity has been ignored especially for those healthcare workers that were exposed early on and had it ……..  What we know is that your antibodies may wane very, very fast and we really don’t know what the antibodies actually mean ….  but we do know that once you’ve been exposed to the whole virus you will raise your B cells and T cells, your memory cells will be there, ready to launch antibodies when you need them” explains Professor Pollock. It is not known how long this immune memory will persist or whether it will protect against all variants. “Actually, one of the things about the virus being endemic is that by having re-infections you’re constantly topping-up that immunity so re-infections tend to be very mild”, she adds.

‘Topping-up immunity’ is an important concept for community health. Professor Pollock explains that when children were excluded from education in schools for long periods over the past two years an unusual phenomenon emerged. “What we saw in the summer time was something quite extraordinary – we saw respiratory syncytial virus (RSV), which is a seasonal virus, coming back in the summer. Children are much more at risk of serious outcomes from RSV than they are from covid”, she says.  Effectively, children who had not been exposed to viruses routinely in play and in school experienced ‘immune depletion’ “so when they came back, they came back with a vengeance”. Topping-up immunity through frequent, low-level exposure is what happens with the common cold viruses.  “I think the average is one or two corona viruses in the year and you’re constantly topping-up so you’re no longer naïve and the whole problem with covid was [that] it was hitting a population that was completely naïve, that had never been exposed to this virus before”, she says.

Vaccination of children

Several groups have expressed concern about the wisdom of vaccinating children against covid-19. In January 2022 a group of senior doctors, public health specialists and members of parliament set out their concerns in an open letter to the Joint Committee on Vaccination and Immunity (JCVI).

Covid is far less serious for children and although there was some concern that long-covid might be a problem this has turned out not to be the case. However, “there are many, many uncertainties around the benefits for children especially since we know [that] over the summer a lot of children had been exposed to the virus and had established immunity. Indeed, one could hypothesise that it’s in children’s interest to have this virus and prime their immune system when they’re young and less at risk”, says Professor Pollock.   The absence of good data on the medium and long-term harms and the benefits of vaccination make the decision difficult. One possible harm is being exposed to the virus later on in life when the immune system has not been primed by the whole virus. “There are many people who have raised really serious concerns because for children it’s really important, because they have to live with those harms for the rest of their lives. I think it’s really important that that evidence is reviewed especially [given that] we know that children have a lot of natural immunity through infection ….and if there’s a lot of reinfection occurring that they’re constantly being primed. I know that yesterday Denmark said it won’t be doing any boosters for people under 18 and it even seems to be saying that they’re not going to be doing fourth boosters, except those who are most at risk. So, I think it’s really time we began to question whether we should be carrying on with boosters and vaccines and if we should, which groups should be having them but certainly children are least at risk and it’s where the greatest uncertainties about any benefits are and where there are very many unknowns about the harms long term”, she says.

The main reason for the introduction of vaccine passports is to increase vaccination uptake. When vaccine uptake is low – 10-20 percent – this can be an important consideration but, in the UK, there is already 90 percent uptake of covid vaccination and so there is little to be gained.  “There wasn’t good evidence that we needed to do that and, in this country, we’ve always used trust and education. Vaccination has not been mandatory for over 120 years and for very good reason – so that’s quite extraordinary – it’s a coercive measure which is completely against all ethical principles”, says Professor Pollock.

Another reason for vaccine passports is to stop transmission of the disease. During December (2021) and January, despite high vaccination rates in the UK, the vaccine failed to provide sterilising immunity and transmission has turned out to be very high in the vaccinated population – so this could not be an argument in favour of vaccine passports in this instance.

A third reason for vaccine passports is that vaccination protects the individual but we now know that there are only certain groups for which the risks of covid infection are high. Furthermore, “What we now know is that there’s a complete decoupling of the cases – you can have very high numbers of cases but a very low number of hospital admissions, very low number of ICU cases, ……  and actually, deaths are now falling below the seasonal average for covid ……  So, there isn’t a case around the individual because we’ve got good, well-established population immunity  – or even for protecting the health service – so it’s very difficult to understand what the rationale is for covid vaccine mandates”, says Professor Pollock.

The Government would probably have found it very difficult to prove that it had provided enough evidence and that it was a proportionate measure and this may have influenced the recent revocation of the vaccine regulations (see Editor’s note below) for health and social care staff.  However, the Chief Medical Officer has now written to professional regulatory bodies such as the General Medical Council, urging them to make vaccination a professional responsibility. “Now that is very worrying because it’s another coercive measure”, says Professor Pollock.

At present we do not know enough about the short, medium and long-term harms associated with covid vaccination. Suitable trials have either not been undertaken or they have not continued for long enough to provide the information that is needed. In this situation the only information comes from ‘yellow card’ (voluntary) reporting that tends to under-report. “What we do know is that the risks are greater than the benefits for some groups of people so it’s very important that we weigh that up – but the Government has not addressed these questions on prevention. …. Why they’re targeting healthcare workers [whose] average age is 43 or 45 years, so they’re in a low-risk group – much lower risk than [participants in] the trials and whether there would be any benefits from vaccination, either in preventing pressures on the health service or preventing transmission, and those questions have not been addressed”, says Professor Pollock.

PCR testing

Many people believe that a positive PCR test indicates infectiousness. Professor Pollock explains that a recent report by Professor Carl Heneghan and colleagues has shown “some of the very many issues with PCR tests”.  There may be as many as 400 different tests in use in Europe and this coupled with a lack of standardisation and quality control confuses the picture. “What we know about the PCR test is it can test viral fragments and relics of the remnants of the virus for as long as 90 days post infection”, she adds.

Editor’s note

Since this interview was recorded the UK Government announced that the vaccine mandate for health and social care workers will be revoked from 15^th March 2022.

Read and watch the full series on our website.

“These vaccines were rolled out at speed, well in advance of us having access to all the data”, says Professor Pollock. Not only were there problems of transparency and insufficient trial data but also the roll-out preceded the completion of trials, which can take five or ten years for vaccines. “Like tests, you have to remember all tests do harm – you’re hoping the benefits outweigh the harms – but all medicines and vaccines also do harm and the only way you can really establish the benefits and the harms are through trials which are large enough but also go on for long enough – because you’re trying to make sure you detect the signals for harm as well”, she says.

It is now known that while the vaccines may appear to have been very effective in preventing severe illness, hospitalization and death, their effectiveness wanes very rapidly over time. By about 20 weeks their effectiveness has fallen and it is uncertain how much immunity has been established in the population by then. However, there has been a lot of infection and re-infection, mainly occurring now in the vaccinated population.

An important issue now is that studies of vaccines tend to be observational studies, such as those comparing vaccinated and unvaccinated people in intensive care units – and all observational studies are subject to confounding.  Professor Pollock explains, “What we know about people admitted to ITU is, whether they’re vaccinated or unvaccinated, a higher proportion are poorer and also have co-morbidities.  We know that these are the risk factors in both the vaccinated and unvaccinated groups but that is as far as you really can go because the unvaccinated are not at all like the vaccinated for many reasons. We know they tend to be much poorer and also, they [tend to belong to] certain ethnic groups. So, you are not comparing like with like when you compare the outcomes of vaccinated and unvaccinated because the denominators from which they’re drawn are so different.” She also notes that reports from the Office for National Statistics (ONS) say “tucked away in the small print” that comparisons between these groups are not measures of vaccine effectiveness.

“The only good measure you’re going to have [of] vaccine effectiveness will be from the long-term, phase four studies, but ….. if you start to vaccinate your whole population you are never going to know”, she says.  A number of factors could be contributing to the current picture. These include ‘survivor bias’ (the situation where vulnerable individuals have already died leaving a healthier population behind), established immunity for previous covid-19 infections, the effectiveness of the vaccine and the behaviour of the omicron variant. “So, you’ve got all these factors playing out and huge amounts of unknowns, which really raises questions about why we’re …. giving vaccine boosters to everybody and why we’re targeting young people; some countries now like Denmark are moving to only boosting very vulnerable people say in nursing home or care settings”, she adds.

Asking questions about vaccines and vaccine policies does not make you an ‘anti-vaxxer’, emphasises Professor Pollock. “I think there are still huge uncertainties about vaccines, their effectiveness, whether we should be continuing to use them and whether they are appropriate [for use] in the way that we’ve done for mass testing – to blanket target the whole population. And then that raises questions in turn about the other measures such as vaccine mandates for social care workers and healthcare workers most of whom ……  have been vaccinated anyway, but they’ve been vaccinated with a vaccine which has been shown to diminish in its effectiveness and we have a lot of reinfection now amongst the vaccinated group that is less serious with less serious outcomes”, she says.

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“Mass testing – if you’re testing healthy or asymptomatic people – this is known as screening. Way back in the 70s and 80s, as more and more tests were being launched in the market,  …… the WHO (World Health Organisation) realised they were going to have a problem [in] that they had an unwitting public who were going to be exposed to a lot of  tests in the belief that it would help early diagnosis and [disease] prevention”, says Professor Pollock.  The WHO commissioned James Wilson and Gunnar Jungner to look into the issue and in 1968, The Principles and Practice of Screening for Disease¹ was published. “The test is only the beginning of the story – you have to have a safe test, it has to be effective, it also has to be acceptable to people before you roll it out – but a test is always followed by an intervention”, explains Professor Pollock.  In the case of covid-19 the intervention was not treatment but quarantine of the individual case, then contact tracing and isolation of those contacts for a period of 10 to 14 days. “The thing to remember is that all tests do harm and the important thing about the test is [that] it’s not only got to be safe but the benefits and the costs of the test should outweigh the harms and the costs of the test – and that’s really important”, she says.

In fact, “the government decided to roll out mass testing without doing prior evaluations or putting in place good trials to see whether these tests were going to be effective and beneficial”, says Professor Pollock. This approach has not been used in the past. Usually, the approach would be to work out which population group would benefit most from the test and then carefully target the test at that group.  The risks of testing were understood and for this reason the government set up the UK National Screening Committee (in 1996) under the leadership of Professor Sir Muir Gray.

Professor Pollock says, “The extraordinary thing about mass testing for covid was [that] it did not go through the UK National Screening Committee and if it had, the UK National Screening Committee would have said ‘Now, you need to remember that all tests do harm. We need to make sure these tests actually work – they do what they say they do – but also that the interventions are not creating more harm than good.’”

Furthermore, all tests create false positives which means that there is unnecessary isolation of all the contacts. There are also false negatives “which means you get false reassurance and people going into the workplace ….. when they think that they’re negative [and] they feel they have a green light to go”, she says.  “These are very important considerations. Now, of course, covid is very common we’re getting a lot of reinfection ……… so now, definitely, for sure, all mass testing should cease”, says Professor Pollock.

Testing should now be carefully targeted and evaluated as part of local public health outbreak control in order to avoid the situation where people who are well and healthy are forced to isolate unnecessarily – a situation that has a major impact on public services, including hospital services, nursing homes and transport services.  “This is why you have to be very careful when you’re proposing doing mass testing – and as you can see many countries now are rolling back and stopping mass testing completely – Sweden, Norway [and] Denmark for example”, she says.

“The whole object of doing a test is to intervene early in order to break the chains of transmission – so that’s the whole principle behind contact tracing. You isolate the case and their contacts because you’re trying to stop transmission but now that the virus is endemic, you’re not going to be able to stop transmission. You may try and suppress it, especially in certain vulnerable groups, but the very big problem now is because we’ve got a mass testing measure that’s being targeted indiscriminately at the whole population and we have very little evidence that mass testing has actually broken the chains of transmission and actually prevented disease from occurring. ….  Throughout January we had a lot of mass testing and isolation, we also had huge numbers of cases so clearly something wasn’t working. The Public Accounts Committee, earlier this year in October, also published a report saying that despite the billions and billions of pounds spent on Test and Trace, ……. there was really no evidence that it had stopped or prevented the transmission of the disease”, concludes Professor Pollock.

Reference

Wilson JM, Jungner G, World Health Organization. Principles and practice of screening for disease. 1968

Read and watch the full series on our website.

https://vimeo.com/685689252

The important thing to understand about endemicity is the virus never goes away – doesn’t ever disappear completely”, says Professor Pollock. There will continue to be   outbreaks of disease and the severity and frequency will depend on how much population immunity has been established. The common cold and influenza are seasonal viruses that circulate more commonly in wintertime, causing intermittent outbreaks. “Sometimes the ‘flu outbreaks will be less serious and sometimes they’ll become epidemic because there’s not enough population immunity”, she says.  Covid-19, which is a coronavirus like the common cold, can be expected to behave in a similar way.

Some people are more susceptible to covid-19 than others. “We knew right away from the Chinese experience that those who were most at risk were those in the older age groups,  ….  with risk …. increasing or doubling every decade over the age of 60.  We also knew that children were far less at risk – it was a far less severe disease in children – so we knew this very early on”, says Professor Pollock. “What we now know from the data in hospitals is that ….  poverty is a very bad indicator for bad outcome and of course poverty is associated with co-morbidities”, she continues.  Obesity is another independent risk factor, although it can also be linked to poverty. “So, we know that poverty is a major risk factor – whether you’re vaccinated or unvaccinated – for worse outcomes and that’s associated also with comorbidities such as asthma, diabetes and also obesity in its own right”, she says.

Professor Pollock says we may never know how effective the control measures – non-pharmaceutical interventions – for pandemic control are. Hand hygiene remains important but “what we still have is very weak, uncertain, unknown evidence around … the effect of the isolation, social distancing – the two-meter rule – but also masking in community and especially in school settings”, she says. The necessary studies have not been performed and we have been left with strong beliefs and opinions “in both directions around masks but very, very weak and uncertain evidence both for and against”.

“If we look at masking, one of the reasons, of course, is [that] the theory may be very different from the practice. So, in theory you may think that masks would be a good thing but actually if you look at the practice …… most of us, unless you have quite obsessive-compulsive tendencies – don’t actually wear our masks terribly well. … We really still have a huge amount of uncertainty and unknowns but there’s been an enormously strong lobby, lobbying for masks and the Government adopted it probably because they needed to be seen to be doing things”, says Professor Pollock

Moreover, “once you start to adopt these mass interventions you are distracting from the real issues that we know are important. So, we knew that the most at-risk group were people who were older, people in vulnerable settings, vulnerable people in nursing homes, residential care homes but also people who were poor. So, what’s happened is we’ve spent billions of pounds on masks and PPE in community settings and school settings and workplaces, creating huge waste environmentally. But actually, if we had really thought about it hard, we might well have diverted those resources into what we do know works, which is alleviating poverty, alleviating stress of illness and also increasing the capacity in social care, residential homes and nursing homes”. The real problem in these settings was not the lack of non-pharmaceutical interventions, but lack of staffing and lack of health care input. Understaffing and poor pay remains a problem in our nursing homes, in residential care and social care. The billions of pounds that were spent on PPE and other measures could have been diverted into funding for this sector, she suggests. “The quality and outcomes of care are directly related to the quality and number of staff that you have in nursing homes, social care and environments where [there are] vulnerable groups in institutional settings”, she says.

Read and watch the full series on our website.