The remaining COVID-19 restrictions in England will end on July 19, the UK prime minister, Boris Johnson, has announced. Businesses currently closed will be allowed to reopen, attendance limits at events and indoor gatherings will be lifted, and using social distancing and mask wearing to control the spread of the virus will become discretionary. This will be the beginning of a new way of living with the virus, the government has said.
Critics have called the decision highly risky, noting that it could have significant health consequences. Ultimately, though, the decision of when to lift restrictions is a political one that has to consider many competing views and interests, of which public health concerns are just one. Balancing the harms and benefits of lifting sooner rather than later is difficult. There will always be trade-offs.
By disrupting education, employment, healthcare and social activity, lockdowns and other limits on behaviour themselves have negative health effects. Further delays to hospital treatments, the psychological impact of restrictions, and the pervasive consequences of unemployment all need to be factored in.
But equally, there are concerns that now is not right time. Infections are currently rising fast, with more than 27,000 new cases being reported each day. And lifting restrictions will certainly lead to further rises in cases – the health secretary has said they could exceed 100,000 a day over the summer.
Yet thanks to the protection provided by vaccination, the risk of severe disease in fully vaccinated adults has fallen by more than 90%. The relationship between infection and hospitalisation has been substantially weakened. COVID-19 hospitalisations and deaths are rising, but they are doing so at a lesser rate. Numbers remain low.
Indeed, the UK has one of the highest vaccine coverage rates for COVID-19 in the world, with more than 60% of adults having been fully vaccinated and over 80% having had at least one dose. For the vaccinated, infections are likely to be mild. Most infections now tend to occur in unvaccinated younger people, where the risk of severe disease or death from COVID-19 is very low. Vaccination efforts are ongoing, so the level of vaccine protection in the population continues to rise.
But full reopening may give the public the erroneous impression that the risks that come with getting infected are now zero. They’re not. Even if science has made COVID-19 less lethal, the disease can still have considerable long-term health consequences. Many people may develop long COVID, which is still not well understood and for which health services are underdeveloped.
Taken all together, these factors make the decision of whether to fully remove restrictions or not a difficult one to balance. But in reality the question may not be whether now is the best time to lift restrictions, but whether now is the least bad time to open up.
Looking at the current trajectory of the third wave and modelling studies, it’s likely there will be many infections following full reopening, whenever it happens, and that cases may even exceed those seen in the second wave – although hospital numbers and deaths are anticipated to be much lower. Delaying lifting restrictions would reduce infections and hospitalisations somewhat as a result of increasing vaccine coverage – but not completely.
It would also likely extend the current third wave into the autumn – rather than having it peak now – raising the risk of a further peak at this later point in the year. Lifting restrictions later may therefore add pressure on the NHS at a time when its workload is mounting due to the usual winter pressures. Given there will be an inevitable rise in cases when final restrictions are removed, there’s a logic to reopening now.
What happens next?
Allowing more infections to occur in the UK, especially in people not fully vaccinated, runs the risk of potentially dangerous variants emerging. However, it’s not easy to predict when and where the next variant will emerge. Many countries around the world have high levels of infection as well as circulating variants that we don’t yet fully understand.
There’s therefore a need for ongoing surveillance of variants both in the UK and around the world. If a new variant of concern were to emerge and spread rapidly, especially one capable of evading vaccine protection or causing more severe disease, then the government may have to consider reintroducing some public health measures. This could include lockdown. If the pandemic has taught us anything, it’s the need to be flexible and to act fast against this evolving virus.
The likelihood is that the virus will become endemic in time and is here to stay. It will probably follow a similar path to its cousins, other human coronaviruses, that circulate constantly and cause the common cold each year. As such, it’s true that we will have to learn to live with the virus, as the government has suggested.
This will mean accepting the risk that every year some people will get infected and some will die, as happens with other respiratory infections. But what we can do to mitigate these risks hasn’t changed. Ensuring buildings have good ventilation, using face masks in high-risk situations, avoiding crowds and confined spaces, and self-isolating when ill are things we should be prepared to do when it’s smart to – even if they’re not mandatory.
We also need to be mindful that some people will remain at higher risk, even if vaccinated, due to their underlying health conditions or age. Maintaining some of these protective behaviours is therefore not just a case of self-protection, but also part of our collective responsibility to protect the vulnerable.
Finally, we’re unlikely to achieve population immunity unless children become immune to COVID-19 too. Non-immune children could become reservoirs for infection, and outbreaks in children can be disruptive and harmful. Consequently, childhood immunisation against COVID-19 is a desirable future step, but this will depend on there being safe and effective vaccines available.
Andrew Lee has previously received research funding from the UK's National Institute for Health Research. He is a member of the UK Faculty of Public Health and the Royal Society for Public Health.