comment “It’s hard to challenge our own practice when we feel so challenged” DAVID OLIVER “Disagreeing with those in charge becomes easier with experience” HELEN SALISBURY PLUS The NHS is already overwhelmed; health workers need a fair vaccination deal

TAKING STOCK Rammya Mathew This crisis could help us improve vaccine uptake he recent approval of the Oxford- of the most common reasons for people rejecting AstraZeneca and Moderna covid-19 vaccines in general is that they believe the vaccine vaccines in the UK has felt like much itself gave them or their loved ones an illness— needed good news. We’re facing and, with covid, they may even have the positive Tmutations of the virus with increased test result to “prove” it. If we don’t roll out the transmissibility, rapidly rising cases, and many programme quickly enough, conspiracies around hospitals overwhelmed with covid related vaccine safety and eff ectiveness could well multiply, admissions. Vaccines seem to be the only way out, making it harder still to achieve the desired uptake. but, as they need to be administered to have the The human factors infl uencing vaccine uptake are desired eff ect, alongside their effi cacy we must complex, especially in this pandemic. Tough calls consider factors infl uencing vaccine uptake. and compromises are needed to escape the current The Joint Committee on Vaccination and crisis—but it may be that we can ride on the back of Immunisation’s decision to delay booster doses this wave of devastation to make signifi cant gains in by as much as 12 weeks will have dented public vaccine uptake. If our government can pull the levers trust in vaccine rollout, when we can ill aff ord to maximise supply now, I’m confi dent we can rise this. The scientifi c community is divided, many to the challenge of accelerating the programme. I’m fi ercely opposing the implementation of an untested also hopeful that, by doing so, we can defi nitively regimen outside a trial setting. Meanwhile, health change the course of this pandemic. professionals are having to try to convince the public Rammya Mathew, GP, London that, although two doses in close succession might [email protected] have provided greater immediate protection to the Twitter @RammyaMathew individual, society will continue to suff er for longer Cite this as: BMJ 2021;372:n66 without us distributing the vaccines more widely. As we grapple with the impact of a third lockdown, the societal benefi ts of a rapid vaccination programme If we don’t roll out with broad coverage could not be clearer. People the programme recognise the need to protect themselves, but they can quickly enough, also see that a return to “normal” depends on wider, conspiracies around population level protection. However, if the rollout vaccine safety and continues through spring and summer, things could effectiveness could be diff erent. As the weather changes and society well multiply potentially starts to reopen, the need for vaccination may become less apparent—a strong argument for doing all we can to accelerate the programme now. We should also be mindful that we’re rolling out vaccination when the R rate is over 1, so a considerable number of people will go on to test positive for covid-19 after receiving the vaccine. This will be either because they were already incubating the virus before vaccine protection kicked in or because the vaccines aren’t 100% eff ective. One the bmj | 16 January 2021 63 ETHICS MAN Daniel Sokol The NHS is not at risk of being overwhelmed ...... it already is—as patients whose conditions worsen as they wait for cancelled procedures and treatment know to their cost ases of covid-19 are surging and predicted within the next 10 years because Public tolerance is greater for a slow doctors warn of the NHS being of delays in diagnosis. In the UK, a study death than for a quick death arising overwhelmed. On 2 January, in Lancet Oncology has predicted more from a lack of intensive care facilities C there were 57 725 daily cases of than 3000 excess deaths from breast, lung, covid in the UK, a new record. oesophageal, and colorectal cancer within manner of death plays an important part in Hospital admissions have also risen and fi ve years. its perceived moral acceptability. many hospitals are struggling to meet the The government will be aware of the Moreover, the death of the patient with high demand. The government is petrifi ed at collateral damage that pooling resources for covid-19 is arguably more distressing for the prospect of the NHS being overwhelmed. the covid-19 eff ort will have on non-covid healthcare staff than the slow passing of Yet, it already is. patients. The reality is that it, and probably the cancer patient. Clinicians may feel a Elective operations have all but stopped the public, is more willing to tolerate a slow greater sense of distress and helplessness in many hospitals and resources reallocated death from an underlying condition or a at the sight of a patient dying rapidly from towards the covid-19 eff ort. What this prolonged period of suff ering, outside the a condition that in normal times would be means is that patients with, say, a brain glare of the media, than a quick death arising treatable. The morale of healthcare staff tumour might have their operation delayed. from a lack of intensive care facilities. and the risk of burnout are all the more The patient will continue to suff er from important when human resources are low. symptoms until the rescheduled operation Less public outrage When the government talks of an and, by the time of surgery, the tumour may The cancer patient’s life is not worth any overwhelmed NHS, it refers to a situation be inoperable. The delay, therefore, could less than that of the patient with covid-19, where patients with covid-19 are deprived lead to a premature death or life changing but a patient who dies over a period of of potentially lifesaving intensive care symptoms that could have been avoided months or years because of tumour spread is treatment. It wants to avoid this scenario with timely intervention. less likely to cause a fuss or generate public at all costs because it would attract In the US, about 10 000 excess deaths outrage than the dramatic death of a patient opprobrium and, at worst, may lead from colorectal and breast cancer are with covid-19 in need of intensive care. The to complaints and aggression towards

BMJ OPINION Clara Munro

Vaccine priorities I have worked in a non-clinical role at The BMJ If we want staff to dig deep we need since October, so I’ve been privy to a unique to give them the vaccine in a fair way risk destroying a perspective on my return to clinical work. When covering an on-call rota over the with vaccine rollout to healthcare workers is fatigued workforce festive period it saddened me to notice the driving morale down further. stark difference in morale since the first covid- Listening to the news, we are led to believe 19 wave. Why was morale so low? Like many, there is a neat queue in every hospital where staff feel undervalued and overlooked. The risk stratification is ubiquitously performed nervous energy and anxious anticipation of and that healthcare workers are receiving the spring and early summer, when we were their vaccines in a timely and organised primed for a short but terrible pandemic, has manner. This is not the case. I’ve heard stories gone. Replacing it is chronic exhaustion and a of management being vaccinated before downtrodden lack of enthusiasm. intensive care or emergency department I’ve watched colleagues pour energy into staff and, perhaps worse, emails sent to an remaining upbeat every day, but this energy apparently indiscriminate selection of staff is not limitless. Cynicism has grown—not only advising them of “first come, first served” from working through a pandemic, but from slots, resulting in scenes of doctors running all the tiny fights that come with attempting through corridors to receive their vaccine. to care for patients and the precious little The delegation of the distribution of space left for self-care. A small gesture that vaccinations to trusts and hospitals has led would go a long way to remedy this would to a lack of consistency across the UK. You be the equitable distribution of the vaccine. could be excused for thinking there might be

OWEN HUMPHREYS/PA OWEN Instead, the “postcode lottery” associated one or even two ways of risk stratifying and

64 16 January 2021 | the bmj ACUTE PERSPECTIVE David Oliver Hospital acquired covid: can we do better? ospitals are in the eye of a one in three in some hospitals and had covid-19 storm, driven by risen by 35% in a week. a rapid rise in community Worryingly, on 16 December the HSJ also Hinfection rates and more new reported a study by doctors in northwest emergency cases presenting England, showing “major defi ciencies” in NEIL HALL/PA daily. But before the current surge there compliance with Public Health England’s clinicians, litigation, civil unrest, and staff were concerns about covid infection good practice guidance. Failings included absences. Last April, frustrated by the acquired or identifi ed during a hospital stay. routine allocation of patients to beds lack of practical guidance for clinicians, In October the Healthcare Safety before negative tests were confi rmed, not I created a triage protocol to help hospitals Investigation Branch (HSIB) issued a testing clinical staff regularly, and not with their decision making in the event of report on the factors behind hospital using protective screens between patients. a covid-19 emergency. Despite calls to do acquired covid infections in England last My intuitive reaction as a doctor so, the government has refused to release spring. We now have better knowledge working on all-covid wards was, “What similar guidance. No doubt politicians and better access to testing and PPE, do you expect in a service with endemic worry that disclosing such a document but the rates of infection classifi ed as structural defi ciencies, in the middle of would lead to public panic, criticism, and “hospital acquired” have yet to fall. a pandemic, and with a virus that people legal challenge. Hospitals are fi elding formal complaints often test negative for to begin with? Get Prioritising patients with covid-19 from people distressed that they, or a family off our backs.” However, I did start to read over others may be justifi able but it is member, may have contracted infection more stories from other health systems. important for all to appreciate that the in what they expect to be a place of safety. A JAMA editorial on “Hospital acquired costs of this, although less visible, are Teams battling to deliver clinical care will infection: lessons for public health,” which nonetheless very real for thousands of be sent down a distracting, demoralising summarised data from several nations on patients whose suff ering goes unrelieved warren of complaint handling and root prevalence and successful interventions, or whose conditions worsen as they wait cause analysis, for something that can also found that around one in seven of in line. For those patients, who are paying seem inevitable and out of our control. all cases worldwide was in hospital staff . the heaviest price, the NHS has already Besides which, the HSIB made it clear Often, simple measures to prevent infection been overwhelmed. that many of those root causes lay in in patients could protect staff and vice Daniel Sokol , medical ethicist and barrister, 12 King’s building design, ventilation, overcrowded versa. The key was rigorous, sustained, and Bench Walk, London [email protected] beds, short staff ed and overwhelmed consistent vigilance and implementation. Cite this as: BMJ 2021;372:n62 clinical teams, and a lack of testing and It’s hard to challenge our own practice PPE in those early months. Hardly our when we feel so challenged. And right now fault—and there hasn’t been much time to is not the time. But when we’re through implement the recommendations as we the worst, we need to think about how to vaccinating healthcare staff, but the reality near the peak of the winter surge. improve prevention of nosocomial viral is that there are innumerable methods, and Still, the numbers are alarming. transmission for all infections, to those often lack transparency or rigour. On 18 December a Health Service stand us in better stead next time. What healthcare workers need is to feel Journal analysis of NHS England David Oliver, consultant in geriatrics and adequately protected against the virus that data found that around one in four acute general medicine , Berkshire they have relentlessly faced, while others covid cases was probably caught [email protected] were forced to stay at home. This past year by hospital inpatients admitted for Twitter @mancunianmedic has not only been defined by a fight against other reasons. The rates were over Cite this as: BMJ 2021;372:n70 a virus, it has been characterised by a series of fights against a lack of PPE, inconsistent testing, corona sceptics, an evidence Simple vacuum, and now a seemingly inequitable measures distribution of vaccine that was pledged to to prevent protect our “frontline heroes.” If we want infection in healthcare workers to dig deep to get through the coming months we need to provide them patients could with the vaccine in a fair and just way. A protect staff random vaccine rollout that undervalues those and vice versa who have placed their own safety second to that of their patients, threatens to bring an already exhausted workforce to its knees. Clara Munro, editorial registrar and clinical fellow, The BMJ; general surgical trainee, northeast England the bmj | 16 January 2021 65 PRIMARY COLOUR Helen Salisbury LATEST PODCAST S Respectful disagreement ll GPs will have experienced Christmas, the “Eat Out to Spread the that uncomfortable feeling Virus” scheme, and the decision to open when they’ve referred schools for a single day. In these examples, a patient for an expert it took no expertise in public health or Aopinion but the response epidemiology to predict rises in infection. doesn’t seem quite right. You wonder if Other decisions have been more fi nely important details were missing from the balanced, including the proposal to referral letter, or if maybe the patient postpone the second doses of the Pfi zer became miraculously, but temporarily, vaccine for as long as 12 weeks to help better in Outpatients. Whatever the cause, spread vaccinations more widely. In it leaves you with a dilemma: do you arguing against this, I was conscious of follow the specialist’s advice because this my lack of expertise in vaccinology and Supporting food aid providers is their area of expertise (and, frankly, it’s pandemic modelling. However, I was disrespectful to do otherwise), or do you extremely confi dent of my knowledge of As the pandemic grips the country, food contact them again for further discussion, my older patients, the ethics of shared insecurity is an increasing problem. This year to check that nothing was missed and to decision making, and the mechanics of The BMJ’s appeal is for the Independent Food reassure yourself and the patient? organising a vaccination clinic. Aid Network (IFAN), a charity that supports a How you handle such cases depends Discussion, professional engagement, network of independent food aid providers on many things, including the possible and transparency about the data used, while also campaigning for an end to the clinical consequences of a mistake and including information about supply, might need for food aid. Isabel Rice, senior dietitian your confi dence in your own knowledge. have avoided open disagreement. The at Centrepoint, a charity supporting young You’ll probably weigh up the patient’s government has now said GPs can use homeless people, and a member of IFAN, needs against your desire not to appear their discretion and honour appointments explains why the charity is working on providing arrogant or troublesome to your hospital for a second dose for older patients. people with nutritional advice: colleagues. This becomes easier as you Working out when it’s more important “If you’re using a food bank again and again, gain experience and worry less about to speak out because you think mistakes it can exacerbate any health problems you have. being thought foolish. If you’re lucky, you are being made, or when it’s better to You’re more likely to use a food bank or be in also come to know the consultants, so quash your doubts so public trust in a food poverty if you’ve got health problems; and what could be perceived as an awkward united medical profession is maintained, if you’re food insecure, you’re more likely to challenge will instead become a friendly is not easy. We all need the humility to end up with health problems. We shouldn’t be discussion that increases your knowledge. accept we may be mistaken—but also the needing to use food banks but, pragmatically, In this pandemic it has often looked as if courage to raise our voices in defence of the fact is people are having to use them long those in charge have been in error over the our patients. term, and if we can try and give them better quality food while they’re having to do that, decisions they’ve made. Some mistakes Helen Salisbury , GP, Oxford that’s the aim.” were obvious, such as the delays to [email protected] lockdown in March and October, Twitter @HelenRSalisbury the relaxation of restrictions at Cite this as: BMJ 2021;372:n78 Another lockdown for the UK As the UK weathers another national lockdown, schools are closed, the NHS struggles under the surge of cases, and vaccination programmes I was extremely make a faltering start. The latest episode of the confident of Second Wave podcast tries to make sense of my knowledge these events, with intensive care doctor and BMJ columnist Matt Morgan speaking here: of my older “A lot of clinicians and nursing staff and patients healthcare providers are also fighting this war of disinformation and responding to sometimes quite upsetting criticism. So it sometimes feels like we are fighting two wars: one in hospital and one at home from the sofa. We need to appreciate the impact that can have on staff.”

Listen and subscribe to The BMJ podcast on Apple Podcasts, Spotify, and other major podcast apps Edited by Kelly Brendel, deputy digital content editor, The BMJ

66 16 January 2021 | the bmj ANALYSIS Elimination: the optimal strategy for covid-19 and other emerging diseases? Michael Baker and colleagues argue that aiming for elimination of community transmission of the SARS-CoV-2 virus could off er important advantages over a suppression or mitigation strategy

he covid-19 pandemic might be remembered for the astonishingly rapid development T of eff ective vaccines. But it should also be remembered as the fi rst respiratory disease pandemic in which non-pharmaceutical interventions were widely used to eliminate transmission, including in large countries such as China. As the pandemic continues to intensify across much of the globe, many countries are increasing their use of non-pharmaceutical interventions such as “lockdowns” to mitigate its harmful eff ects. Here we describe the potential benefi ts of using an elimination strategy to minimise the negative health and economic eff ects of covid-19. Pursuing this

strategy will become more feasible when HOPKINS/GETTYHAGEN IMAGES eff ective vaccines are widely available. Wellington in December, three months after Covid restrictions were eased across most of New Zealand

Strategic choices for diff erent response strategies (fi gure). disruptive interventions, such as school pandemic responses The New Zealand government chose an closures, to be held in reserve to fl atten the explicit elimination approach.6 7 Australia peak. By contrast, the goal of elimination The typical approach of high income also has elimination of community rapidly escalates control measures to nations has been a “suppression strategy,” transmission as the stated goal, but extinguish chains of transmission. sometimes after initial use of a “mitigation has generally described its strategy as Choosing a strategy is not necessarily strategy” (fi gure overleaf). The goal of “aggressive suppression.”8 A related strategy a fi xed path, and countries might change suppression is to fl atten the epidemic curve that also aims to achieve zero community their approach. Sweden, for example, further than with mitigation, but still without transmission is the exclusion approach that initially seemed to pursue a version of expecting to end community transmission.1 has been successfully used by some Pacifi c mitigation with the intent of achieving herd These approaches are largely consistent Island countries and territories (fi gure). immunity and then seemed to switch to a with plans designed to mitigate or suppress The goal of elimination is a major suppression strategy. 9 pandemic infl uenza. departure from pandemic infl uenza Disease elimination has been used to By contrast, China’s success in containing mitigation. With a mitigation goal, the control a wide range of infectious diseases, the pandemic has shown that SARS-CoV-2 response is typically to increase stringency although an eff ective vaccine is generally can be eliminated even after widespread as the pandemic progresses and for more required for the fi nal phase.10 community transmission.2 Confronted with the rapidly spreading KEY MESSAGES pandemic in January 2020, New Zealand • A goal of eliminating community transmission of SARS-CoV-2 is achievable and initially implemented its existing infl uenza sustainable for some jurisdictions using non-pharmaceutical interventions and will pandemic plan as the basis for its response. be facilitated by eff ective vaccines Australia did likewise. Fortunately, both • Elimination of community transmission off ers public health, equity, and countries had a brief period to refi ne their potentially economic advantages compared with a control strategy approaches before the fi rst reported covid- • Conditions favouring successful elimination include informed input from 19 case arrived on 25 January in Australia scientists, political commitment, suffi cient public health infrastructure, public and 26 February in New Zealand. This engagement and trust, and a safety net to support vulnerable populations gave them an opportunity to learn from • Elimination might be the preferred strategy for responding to new emerging the eff ects of the pandemic on countries in infectious diseases with pandemic potential the northern hemisphere and consider the the bmj | 16 January 2021 67 Select pandemic Implement pandemic strategy Exit path strategy Exclusion strategy Maximum action to exclude disease eg, some Pacific Island countries and territories Return to carefully managed “new normal” (within 2-3 months) Requires persisting quarantine at Elimination strategy borders until effective vaccine Maximum action to exclude disease and eliminate community and/or antimicrobial interventions Select pandemic transmission eg, mainland China, Taiwan, New Zealand response strategy Assess threat, Prolonged control measures choose strategy, Suppression strategy until effective vaccine and/or select Action increased in stepwise and targeted manner to substantially lower case antimicrobial interventions interventions*, numbers and outbreaks eg, most countries in Europe and North America implement (12-18+ months) or switch strategy surveillance and evaluation, fine tune mix Mitigation strategy of interventions, Action taken to ‘flatten the peak’ to avoid overwhelming health Pandemic spreads through communicate and services and protect the most vulnerable eg, Sweden (at least initially) population until “herd immunity” coordinate actions and/or effective vaccine and/or antimicrobial interventions No substantive strategy (12-18+ months) or switch strategy Largely uncontrolled pandemic wave eg, some lower income countries

* Pandemic interventions: Border controls to “keep it out”; testing, contact tracing, case isolation and contact quarantine to “stamp it out”; improved hygiene behaviours and use of masks; physical distancing; movement restrictions; combinations including “lockdown”; vaccines; antimicrobials NB. There are multiple other interventions to reduce harm, including protecting vulnerable populations, reorienting health services, social and economic support

Strategic choices for responding to covid-19 and other pandemics. Although the framework divides approaches into five strategies, they exist on a continuum in and between categories. Countries may also change their strategic direction based on experience with controlling the pandemic

Countries pursuing elimination aim for regain it in the event of an outbreak: border included multiple economic actions and zero transmission in the community but management with closely supervised income support measures to protect the accept that outbreaks from border control quarantine of all arrivals from places that most disadvantaged people. Australia was failures might occur, resulting in a temporary have not eliminated the virus; case based likewise rapid to implement economic loss of elimination status until community control measures, notably testing, case support nationally to employers who kept transmission is again stopped. isolation, contact tracing, and quarantine; workers on the payroll while unable to work. and population based interventions such It also dramatically increased unemployment Achieving and sustaining as physical distancing and mask use. In benefi ts for those becoming unemployed, disease elimination addition, disease surveillance, coordination, and states and territories such as Victoria also and communication activities are critical to initiated support packages. New Zealand and Australian experiences delivering an eff ective response.7 - 17 of the covid-19 pandemic off er lessons for Thirdly, outbreaks arising from border Benefits, costs, and areas of achieving and sustaining elimination. control failures might occur after elimination uncertainty with elimination Firstly, elimination is more likely to be has been achieved and these require swift and achieved quickly with informed scientifi c decisive action. New Zealand experienced Achieving elimination off ers major input, strong political commitment, and such an outbreak after three months without advantages, but also some disadvantages, decisive action. To achieve elimination, a case in the community (see supplementary compared with a suppression strategy that New Zealand probably had no feasible fi le online). This outbreak was brought under allows continued virus circulation. The alternative to a national lockdown (which control and elimination status regained after balance of benefi ts and costs is uncertain, began on 26 March). The country’s public extensive testing, contact tracing, physical however, and may not be clear until after health infrastructure was at a low point distancing, and mandated use of masks. the pandemic has been fully controlled (see after decades of neglect.13 Time was needed Improved case based controls enabled these supplementary fi le). to expand essential activities such as interventions to be targeted with a shorter and Obvious benefi ts of rapid elimination are testing and contact tracing. A lockdown less intense lockdown. The state of Victoria greatly reduced case numbers, a lower risk was probably also required to ensure the in Australia experienced a major resurgence of health sector overload, and fewer overall population would swiftly understand and peaking at over 700 cases a day yet managed deaths. There is also an opportunity to avoid adhere to the physical distancing behaviours to eliminate community transmission in three serious health inequalities, such as the needed to limit spread of the virus.6 - 14 Better months using lockdowns and a detailed plan catastrophic eff ect of previous pandemics preparedness, as seen in countries that (“roadmap”) underpinned by modelling. 8 on Māori people in New Zealand.18 Similar experienced the SARS pandemic in 2003, Finally, given the inevitable loss of concerns apply to the health of Indigenous reduced the need for stringent lockdowns, as employment and other social disruption Australians.19 Given the growing evidence exemplifi ed by Taiwan.15 16 when stringent lockdowns are used, a range for long term eff ects from SARS-CoV-2 Secondly, investment in three broad of health, social, and economic support infection, there are also benefi ts from categories of public health infrastructure measures are likely to be required. 7 14 The reducing the numbers of even mild is needed to achieve elimination or quickly New Zealand government’s response has infections.20

68 16 January 2021 | the bmj One of the perceived barriers to applying possible is important. One such benefi t is Global eradication could eventually a vigorous response, such as elimination, to improved public health infrastructure that can be considered if national and regional the covid-19 pandemic is the belief that this support a more rapid and eff ective response elimination proves feasible might sacrifi ce the economy and ultimately to future pandemics, as seen in Taiwan.15 The result in more hardship and negative health covid-19 response has also emphasised the prevent importation of covid-19 from eff ects. Our preliminary analysis suggests importance of integrating scientifi c advice adjacent jurisdictions. Conditions favouring that the opposite is true. Countries following into decision making that could improve successful elimination include informed an elimination strategy (notably China, capacity to respond to a range of existential input from scientists, political commitment Taiwan, Australia, and New Zealand) have threats, including climate change. to take decisive action, suffi cient public had markedly lower covid-19 mortality than health infrastructure to deliver the necessary those in Europe and North America pursuing Future use of elimination interventions, public engagement and trust in mitigation and suppression. Similarly, the strategy the measures being taken, and a social safety eff ect on gross domestic product (GDP), based net to support vulnerable populations. on International Monetary Fund projections Several institutional, technical, and scientifi c The introduction of eff ective covid-19 for all of 2020, was more favourable for actions could enable more widespread vaccines is also likely to facilitate elimination. countries with elimination goals than adoption of elimination approaches and Countries and jurisdictions combating the for those with suppression goals (see better chances of success for jurisdictions pandemic will need to consider two main supplementary fi le). already committed to an elimination goal choices. They could take a control approach However strategic choices are assessed, (box). The World Health Organization would (suppression) using vaccination strategies to the benefi ts and costs need to be considered be the ideal agency to facilitate some of these protect the most vulnerable people (as with using realistic scenarios or counterfactuals. institutional measures, supported by other seasonal infl uenza) and accepting that SARS- International tourism, for example, is agencies. Technological advances in such CoV-2 virus infection might become endemic substantially reduced regardless of border areas as rapid point-of-care antigen testing in their population. Or they could follow control restrictions. Iceland reopened to could make elimination more feasible.23 an elimination strategy using vaccination tourism but demand remained low, imported Experience with covid-19 elimination systematically to reduce transmission to cases of covid-19 increased, and the net eff ect indicates that this goal is achievable in zero in the population and to help contain was a larger fall in GDP than in New Zealand.21 a wide range of settings. Asian countries outbreaks if they occur (as most countries Given the huge costs of the pandemic and some Australian states have managed now approach measles). Global eradication response, gaining as many co-benefi ts as to control long complex borders to largely could eventually be considered if national and regional elimination proves feasible. Actions to support use of an elimination strategy for covid-19 and future pandemic diseases Some of the most important lessons from the covid-19 response are about Institutional actions, including guidelines responding to future severe pandemic the management of future pandemics. • Develop a standard definition for covid-19 threats, including influenza. These plans Elimination is probably the preferred elimination could include a typology of strategic response strategy for responding to new emerging • Revise WHO reporting processes and options (figure) and guidelines to help select standards to accurately represent the an optimal approach (including exclusion infectious diseases with pandemic potential 22 elimination status of countries, notably to strategies ) and anything more than moderate severity, distinguish imported cases from those in • Establish a network of agencies to share particularly while key parameters are the community and to report if they have knowledge about the elimination approach. being estimated. Some biological and achieved elimination and the date this was ecological factors also need to be considered reached Technical and scientific actions before deciding that a novel disease • Develop a process for review of country • Improve SARS-CoV-2 testing, notably rapid, can be eliminated, notably the role of progress towards elimination to facilitate low cost, point-of-care antigen testing animal reservoirs. 10 Non-pharmaceutical quarantine-free movement between countries • Develop tools to support rapid contact interventions are usually the only early meeting agreed standards (analogous to the tracing, notably digital and analytical tools interventions available. verification approach applied to elimination that enhance manual contact tracing The experience of Asia-Pacifi c countries of diseases such as polio, measles, and • Evaluate and document case studies and such as China, Taiwan, Australia, and New rubella) methods used to achieve elimination of Zealand shows the benefi ts of applying • Identify conditions and infrastructure needs SARS-CoV-2 community transmission (eg, these measures rapidly and intensively with to support an elimination approach at mandated mass masking) the goal of elimination. The New Zealand national and subnational levels (for example, • Analyse and evaluate optimal use of the by state and territory in Australia) elimination approach (relative to control response also eliminated seasonal infl uenza • Develop evidence informed guidelines options such as mitigation and suppression), in the winter of 2020, showing that it is also a for approaches that countries can use to notably its role in complementing future potential option (cost eff ectiveness aside) for engage populations in disease elimination vaccination scenarios preventing future infl uenza pandemics.24 programmes, including partnerships with • Conduct an integrated epidemiological Michael G Baker, professor of public health at-risk groups in strategy decision making; and economic analysis of future pandemic [email protected] ensuring transparency and accountability; management choices (figure) to guide Nick Wilson, professor of public health effective public communication decision making that considers wider medium Tony Blakely, professor of epidemiology, University of • Revise pandemic plans to reflect the role and longer term health, equity, and economic Otago, Wellington, New Zealand of elimination as a potential method for effects Cite this as: BMJ 2020;371:m4907 the bmj | 16 January 2021 69 BMJ OPINION Anthony Harnden, Andrew Earnshaw, and Mary Ramsay Making the most of the covid vaccines

iven the current One million protection, but analyses suggest this it also advises that every eff ort should epidemiology of covid-19 additional first may be explained by a longer time be made to complete the course with in the UK, the public dose vaccines interval between doses. The immune the same vaccine. If the same vaccine Ghealth imperative is may prevent response takes two to three weeks to is not available, or if the initial vaccine to vaccinate as many 3000-4000 develop. An exploratory analysis by is unknown, it is reasonable to off er the of the most vulnerable people as Oxford AstraZeneca indicates that locally available product as a second fast as possible. In response, the deaths in the from 22 days after the fi rst standard dose to complete the schedule. Joint Committee on Vaccination and over 80s dose, vaccine effi cacy is 73%, with In JCVI’s view it is better in these Immunisation (JCVI) advised on 30 protective immunity likely to last at exceptional circumstances to have a December that the interval between least 12 weeks from the fi rst dose. second dose of an alternative vaccine the two doses of both the then For the Pfi zer BioNTech vaccine, than to have no second dose at all. authorised vaccines could be extended the published trial reported effi cacy to 12 weeks, with prioritisation of of 52% after the fi rst dose, including Transmission delivery of the fi rst dose. Every second cases occurring from day 1 until the Current vaccines can prevent dose delivered is one less dose to give second dose. In further analyses, symptomatic infections and to someone who has no protection. Public Health England (PHE) admissions to hospital, but we do Based on the mortality in those over calculated an effi cacy of 89% after the not yet know whether they prevent 80 in the fi rst wave, and assuming an fi rst dose, based on cases observed asymptomatic infection and effi cacy from the fi rst dose of 70-90%, from day 15 (and up to day 21). This transmission. Until we do, the correct it is estimated that one death could be fi gure is higher because it excludes strategy is to focus on preventing prevented for every 260-330 fi rst doses cases of laboratory confi rmed covid-19 disease. Surveillance of the long term given. One million additional fi rst dose that occurred too soon after the fi rst safety and eff ectiveness of the vaccines vaccines may therefore prevent around dose to be true vaccine failures. For a is being conducted through the 3000-4000 deaths in this age group. similar mRNA vaccine developed by Medicines and Healthcare Products The fi rst nine priority groups identifi ed Moderna, effi cacy from 15 days after Regulatory Agency (MHRA) and for vaccination should target 99% of Anthony Harnden, the fi rst dose was an estimated 92% PHE, including studies to determine potentially preventable deaths from deputy chair, Joint after a median follow-up of 28 days. whether vaccination prevents covid-19. Committee on As the fi nal method of production of transmission. If it does, the focus Vaccination and the spike protein is common to all the of the second phase of the strategy Immunisation Change in schedule vaccines, there is no immunological could shift from preventing disease to and professor of There has been understandable reason to expect the immune response preventing transmission. primary care, Oxford concern about the change in schedule. University to a single dose of the Pfi zer BioNTech JCVI will continue to advise in a Patients who were told they would Andrew Earnshaw, vaccine to be less robust or to fall away timely manner on the optimal strategy, receive a second dose of the Pfi zer head of Scientific more rapidly than the response to a paying careful attention to the evolving BioNTech vaccine in three weeks Secretariat, JCVI single dose of Oxford AstraZeneca’s. epidemiology. JCVI will closely monitor are now being asked to rebook Mary Ramsay, head Despite newspaper reports, JCVI surveillance by the MHRA and PHE to those appointments. From a public of immunisation, advises that people should have a assess the vaccines’ long term safety. health perspective, however, this is Public Health second dose of the same vaccine, up to We will receive reports on coverage a necessary step that will save lives. England 12 weeks later. In PHE’s “green book” and play our part in monitoring the The World Health Organization has programme as a whole. also made provision for countries to The massive logistical exercise of delay the second dose for a few weeks ensuring there is suffi cient capacity to to maximise the number of people administer vaccines to as many people benefi ting from a fi rst dose. as possible in the shortest period of The three vaccines approved for time is the role of the NHS. We do not use in the UK encode for the SARS- underestimate the challenges ahead. CoV2 spike protein to provide an At this point in the pandemic, intracellular antigen and induce a we must do all we can to protect all host immune response. The Pfi zer vulnerable populations as quickly BioNTech and Oxford AstraZeneca as possible. Vaccine supply and vaccines are reported to off er high NHS capacity are key factors and protection after two doses. For the prioritising the fi rst dose is a pragmatic Oxford AstraZeneca vaccine, a half and scientifi cally justifi able approach fi rst dose and a standard second dose which will result in more widespread was initially reported to provide higher protection in vulnerable groups.

70 16 January 2021 | the bmj LETTERS Selected from rapid responses on bmj.com

COVID-19 AND BETRAYAL health lost by those whose treatment LETTER OF THE WEEK OF CHILDHOOD will be displaced, maximising health Focus on training and wellbeing within a fixed budget. Children’s centres help for specialty recruitment We have wondered whether we to build communities should extend this to a wider societal Aynsley-Green praises Labour’s Every perspective, and have previously Child Matters policy (Personal View, found technical, ethical, and legal 5 December), which included the Sure challenges, particularly related to Start programme. Its vision was to age and equality, that need careful strengthen communities around consideration. We would also like to young children in areas of social explore environmental sustainability. deprivation, but the focus was We are keen to work with others blurred when Treasury funding was including health economists, dispersed to local authorities, methodologists, ethicists, and funders DOUG MARTIN / SPL DOUG MARTIN / compounded by the financial crash to develop these ideas. We share the concerns of the Royal College of and the election of a Conservative led Felix Greaves, director for science, evidence, Anaesthetists about the workforce gap in anaesthetics government. and analytics; Meindert Boysen, director, (Seven Days in Medicine, 28 November). This problem Research shows that, by the start of Centre for Health Technology Evaluation , NICE BMJ is not exclusive to anaesthesia and exists in many secondary school, 30% fewer of the Cite this as: 2021;372:n7 specialties; the NHS was experiencing a workforce most disadvantaged children from crisis long before the covid-19 pandemic. Consultant Sure Start areas had been admitted HARMS OF PUBLIC HEALTH posts are unfilled across the UK, but the lack of to hospital for injuries—one of Sure INTERVENTIONS specialty trainee year 1 and year 3 posts is causing Start’s original targets—averting costs Lockdowns don’t kill women, a bottleneck. The current training crisis is likely to to the NHS of £65m. abusive men do compound the problem, with many trainees requiring Such outcomes are the tip of extensions to their specialty programmes owing to an iceberg of socially promoted Bavli and colleagues report that loss of training opportunities during the pandemic. If resilience, gained through both home public health interventions against training and career progression are not maintained, we visits from staff and social bonding covid-19 are associated with increased are likely to see a fall in trainee retention rates. between adults meeting at children’s rates of domestic violence (Analysis, The provision of good quality training throughout centres. Aynsley-Green calls for early 21 November). this ongoing pandemic requires a conscious intervention and leadership to build We need to change how women are buy-in by all stakeholders. The loss of face-to-face local communities. Creating as many portrayed when they are murdered by training opportunities has been a catalyst for rapid children’s centres as there are primary men. Headlines should not provide development in medical education. Trainees must schools is the place to start. context, which apportions blame to seek every opportunity for learning and make use Sebastian Kraemer , honorary consultant, the victim. Similarly, the term “honour of these novel resources. Trainers must continue London killing” carries implicit justification to deliver education despite the demands of Cite this as: BMJ 2021;372:n41 that the women were “fair game” the pandemic, and training institutions have a because they deviated from some responsibility to assist both of these groups. If we do COST EFFECTIVENESS cultural norm. Language matters. not invest in training today, we will find ourselves in a OF COVID-19 VACCINES “Honour” paints the perpetrator as a worsening workforce crisis in the near future. NICE’s approach to hero, emboldening others to commit With rates of physician burnout increasing, it has measuring value such crimes. never been more important to support the wellbeing Lockdown does not make men kill of doctors. Good resources are often poorly advertised Appleby asks whether covid-19 women. The most vulnerable people in to those who would benefit from their use. It is the vaccines would be considered cost society were not adequately protected responsibility of all to ensure that doctors are regularly effective using the NICE approach before covid-19. The pandemic has signposted towards wellbeing initiatives. to measuring value (Data Briefing, brought to light the very problem with We agree that increased specialty recruitment is 28 November). He is correct that we inequality: vulnerable people lose out vital if we are to meet growing clinical demands, but don’t consider the benefit and costs most. The excellent work of health, we think that maintaining the training and wellbeing of vaccines, but this is an opportunity social, and third sector services that of clinicians already in specialty programmes must be to reflect. strive to protect women is under given equal consideration, to maintain the existing In most circumstances, we look at threat. We need systemic and societal workforce. the value of a health technology from changes, not just discussions around Ricky Ellis, specialist registrar in urology and intercollegiate an NHS and personal social services the validity of lockdowns. research fellow; Reena Ellis, specialist registrar in anaesthesia , perspective. This allows for trade-offs Ian Sinha, consultant respiratory Nottingham between the health benefits gained by paediatrician , Liverpool Cite this as: BMJ 2021;372:n39 those receiving a new technology and Cite this as: BMJ 2020;371:m4795

the bmj | 16 January 2021 71 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES

Ronald George Clark Robert William Walker Paterson Jo Ann McLaughlin General practitioner Consultant ophthalmologist Consultant in child and (b 1933; q St Andrews (b 1938; q Glasgow 1962; adolescent psychiatry 1956; DObst RCOG), died DObst RCOG, DO Eng, FRSC Nottingham Healthcare from old age on 7 June 2020 Eng), died after six months NHS Trust (b 1956; Ronald George Clark with prostate cancer on q Leeds 1980; MRCPsych, (“Ron”) was educated 28 August 2020 MMedSci), died from at Perth Academy. After Robert William Walker metastatic breast cancer on completing national Paterson (“Robin”) took a 17 August 2020 service with the Black Watch, he accepted a post as senior registrar at Edinburgh Royal Jo Ann McLaughlin grew up in the USA, partnership at the Victoria Street practice in Infirmary in 1968. He became a consultant Surrey, and Swindon. When she was 12, her Perth in 1960. He remained with the practice ophthalmologist in 1970 and spent seven family moved back to her native Merseyside. until he retired in 1996. He had a sharp years at Paisley Eye Infirmary before She started her medical training at Leeds medical mind and was highly regarded by moving to a long term consultant post in University in 1975, and three years later patients and colleagues. Ron enjoyed all Ayr in 1977. The remainder of his medical met Ian, her future husband. Jo joined the sport and was capped for Scotland for cricket. career was spent in Ayrshire, initially at Yorkshire psychiatry training scheme and He was a low handicap golfer and captain of Heathfield Hospital and then latterly at Ayr specialised in working with children and Craigie Hill golf club. A lifelong St Johnstone and Crosshouse Hospitals. He retired in adolescents. She moved to Mansfield in 1990 fan, he became team doctor for the club, 1996, and he and his wife, Joan, enjoyed a to take up a consultant post, where she stayed and winning the Scottish Cup Final in 2014 long happy retirement, travelling around the until she retired in 2012. Jo always had a high was a major highlight. In retirement Ron globe several times to visit their children and clinical caseload but found time continually remained active with his family, sport, and enjoy the wonders of the world. Robin died to improve and shape the service. She spent the Rotary Club. He leaves his wife, Irene; two peacefully in Creggan Bahn Court nursing her last few months with her family, enjoying daughters; four grandchildren; and one great home in Ayr. Predeceased by Joan in 2019, he the sea air on the Isle of Wight. She leaves Ian, grandson. leaves three children and five grandchildren. three children, and a granddaughter. John Clark Ian Paterson Ian Clegg, Lesley Hewson, Anne Taylor Cite this as: BMJ 2020;371:m4271 Cite this as: BMJ 2020;371:m4283 Cite this as: BMJ 2020;371:m4275 Raymond Emmanuel Goodman Jean McIldowie Smellie Nicholas Wilson-Holt General practitioner and Paediatrician University Consultant ophthalmologist specialist in psychosexual College Hospital London Royal Cornwall Hospital medicine Salford Health and Wessex (b 1927; (b 1957; q London 1982; Authority (b 1938, q Oxford/University FRCOphth), died from q Manchester 1963; MRCGP, College Hospital, London, disseminated cancer of MSc, FRSB), died from 1950; DCH Eng, FRCP Lond, unknown primary on 7 July prostate carcinoma and DM, Hon FRCPCH), died 2020 fractured atlas vertebral from old age and dementia Nicholas Wilson-Holt metastasis in July 2020 on 14 September 2020 (“Nick”) was accepted on the Moorfields Raymond Emmanuel Goodman was a GP Jean McIldowie Smellie was appointed registrar training programme, where he in Gorton for 22 years. He then moved into to a part time post at University College also completed a subspecialist vitreoretinal psychosexual medicine and pioneered a Hospital in London with a remit to look after fellowship. While a junior doctor, Nick met clinic in Salford, which was named after children who had urinary infections. Many Mary Daniels, an anaesthetic trainee, whom him and flourished until his retirement. children had extensive investigations and he married. They settled in Cornwall, where He was an expert adviser to serious crime surgery because of concern about scarring of Nick modernised the eye department at the squads dealing with sexual murder and other kidneys. Since then it has become apparent Royal Cornwall Hospital. His attempts to sexual associated deaths and crimes. He that in many the kidneys are already establish a vitreoretinal service floundered travelled widely to, and lectured at, many damaged at birth. Children are now rarely on the rocks of managerial interference and conferences and penned numerous articles. subjected to cystography or to surgery to obstruction. But, unperturbed, he developed A warm hearted, generous man of great wit prevent reflux. The clear guidance produced Cornwall’s diabetic retinopathy screening and humour, he never lost his intellectual by the National Institute for Health and Care service. He was active in the Royal College curiosity in science, medicine, and life itself, Excellence in 2010 on urinary tract infections of Ophthalmologists and numerous other nor spoke ill of anyone. He was a devoted in children was undoubtedly influenced committees. Away from medicine he created family man and married Beryl in1963. He by the meticulous studies led by Smellie. a spectacular space at his home in Cornwall. leaves Beryl; two sons, a granddaughter, a Predeceased by her husband in 2011, she He leaves Mary; three children; and a sister, and a brother. leaves three children. granddaughter. Anthony Morris , Beryl Goodman A l a n C r a f t Will Westlake, Andrew Wilson Cite this as: BMJ 2020;371:m4272 Cite this as: BMJ 2020;371:m4285 Cite this as: BMJ 2020;371:m4273 the bmj | 16 January 2021 83 OBITUARIES Raine Roberts Founder of the UK’s fi rst sexual assault referral centre

Raine Emily Ireland Roberts Turner medical, Dunville surgical, and the The following month, Roberts wrote (b 1931; q Manchester 1955; FRCGP, CP Lapage paediatrics prizes. After jobs at to the Times , calling for special units for DMJ, MBE), died from multiorgan Manchester Royal Infi rmary and Blackburn victims of sexual assaults, away from police failure on 5 September 2020 Royal Infi rmary, she joined a practice in stations, with skilled, sympathetic staff , Wythenshawe. For 30 years she worked and facilities for aftercare. At the time, male Raine Roberts, who has died aged 88, was there with her husband, James, whom she police surgeons in Manchester outnumbered the police surgeon who founded the UK’s met at the freshers’ dance at medical school. women seven to one and Roberts criticised fi rst sexual assault referral centre, at St She moved into forensic work in the 1960s them for standing in the way of women Mary’s Hospital, Manchester, in December and developed a reputation as forthright and being seen by a female doctor, an allegation 1986. Jointly funded by Greater Manchester feisty. She was awarded an MBE in 1995. refuted by the Association of Police Surgeons Police and the NHS, the centre was the result Having chosen general practice, rather at the time. of years of campaigning on Roberts’s part. than a hospital career, for the sake of family “The pressing need is for a proper forensic “Raine was a battler and always being life, she told the Manchester Evening News service to be set up, staff ed by fully trained criticised, but stalwart and absolutely she regretted seeing so many children forensic physicians of both sexes, independent determined to do the right thing,” said being brought up without a mother and of the police, and perhaps appointed by Albert Yates, former detective chief father in a stable family. “Yes, it can be the Home Offi ce,’’ Roberts urged in a letter superintendent of Greater Manchester claustrophobic, and limiting, but a child to The BMJ in April 1982 (www.bmj.com/ Police, who worked on the establishment being ‘minded’ by a teenage girl who has content/284/6321/1048.3). “At present any of the centre, now one of 50 across the learnt no parenting skills is not having the doctor can become a police surgeon without UK. “At the time, women were being best start in life,” she said. training, and this leads to cases being botched, examined in grubby police stations, In February 1997 she wrote to The BMJ , where evidence has been missed, swabs often with the suspect next door. It was a criticising the Royal College of General wrongly taken, statements inadequately terrible experience for women to have to go Practitioners for what she saw as its written, and doctors ignorant of the law giving through.” preoccupation with “frills and luxuries”— evidence in court,” she said. Initially staff ed with fi ve counsellors and such as the dynamics of the consultation Roberts was involved in the training of 200 eight doctors, the team now includes 25 rather than tackling the problems of bad forensic physicians, and she was an examiner sessional forensic physicians. clinical medicine. for the Diploma in Medical Jurisprudence of Public concern about the treatment of the Society of Apothecaries. “Her work was of Early life and career women in rape cases was heightened by fundamental importance to forensic medicine Roberts was born in Lancashire. After a BBC documentary, A Complaint of Rape , and in particular sexual off ence medicine,” Burnley High School for Girls, Roberts went broadcast in January 1982, which featured said Ian Wall, past president of the Faculty of to Manchester University Medical School, aggressive questioning by offi cers with Forensic and Legal Medicine. where she qualifi ed in 1955, winning the Thames Valley Police. She gave evidence to the 1987 Cleveland Inquiry into Child Abuse, and the inquiry Roberts called for special units report commended her for very helpful advice for victims of sexual assaults, about the training of police surgeons and her “invaluable experience.” But the report away from police stations also criticised her evidence as “extremely and unnecessarily critical and contentious.” But at the Manchester centre, where she remained clinical director until she retired in 2003, she is remembered for her emphasis on impartiality. A keen water skier, Roberts was British water skiing slalom champion in the over 50s class, and pursued the sport until she was 86. Predeceased by her husband in 2011, Roberts leaves their daughter, Philippa Shedd, a family doctor in Indiana in the US; and their son, Simon, a consultant orthopaedic surgeon in Oswestry. Joanna Lyall , London [email protected] BMJ PA Cite this as: 2020;371:m4026

84 16 January 2021 | the bmj