Covid-19: What should we do about B.1.617.2? A classic case of decision making under uncertainty

The new variant of concern has fundamentally changed the risk we face and therefore the government’s criteria for moving ahead with the road map have not been met, argue Stephen Reicher and colleagues

There are many things we know and many things we don’t know about the B.1.617.2 variant. 

We know that it is spreading fast (roughly doubling each week in the UK and nearly tripling last week from 520 to 1313 cases), that it is becoming established in a number of areas across the country, and that it is already the dominant variant in places such as Bedford, Bolton, and Blackburn. [1,2]

Compared to the dominant B.1.1.7 variant, we know that B.1.617.2 is very likely to be more transmissible and that it might be better able to transmit between people who are fully vaccinated. [3]

We don’t yet know how much of the faster transmission is down to characteristics of the variant itself as opposed to the characteristics of those who are infected and hence how much more transmissible the variant is.

We don’t yet know whether and to what extent the new variant undermines the ability of vaccines to protect us against infection, hospitalisation, and death or to stop us transmitting infection to others. We don’t yet know whether this variant causes more severe disease.

In sum we know enough to say that this new variant could be extremely serious. SAGE’s “worst case” scenario modelling suggests that if B.1.617.2 were 40-50% more transmissible than B.1.1.7 it could cause an increase in hospitalisations worse than January 2021, and if it also escapes the vaccines more, the level could be considerably greater. We don’t know enough to be sure exactly how serious it would be if it became the dominant variant in the UK. 

So we face a classic case of decision making under uncertainty in which our choices necessarily depend not only on the emerging data, but also on our evaluation of the different possible outcomes—which is a matter of morality and politics as much as science. Essentially, how do we weigh the possibility of taking action (notably delaying the reopening of indoor spaces including homes and entertainment venues) which subsequently turns out not to have been necessary versus the possibility of not taking action (allowing the reopening to go ahead) which, through a new wave of the pandemic, turns out to have been necessary after all?

Before we come to that choice, however, there are a number of things we should be doing anyway, irrespective of the characteristics of the new variant, but made even more urgent by the potential threat it poses.

First, the situation we are in with the emergence of dangerous new variants flows from the way in which, at a global level, the pandemic is more serious than it has ever been with infections raging out of control in South America, South Asia, and beginning to grow in Africa. What is happening reinforces the adage that “no-one is safe until everyone is safe” and reinforces the case for both vaccine redistribution for the short term and vaccine patent waivers for the medium/long term. [4] The UK Government is now one of the few remaining countries to resist such waivers, thereby not only allowing unnecessary death and disease across the world, but also endangering its own population.

Second, in order to limit the circulation of new variants (not only “theirs” coming to “us,” but also “ours” going to “them”) we need far more systematic and effective border controls. The present “traffic light” system, whereby quarantine is only needed for those coming from particular countries, is both leaky and slow. By the time a country is identified as a problem and put on the “red list” for quarantine, it is generally far too late. It is estimated that some 20,000 travellers came to the UK from India from the time that B.1.617.2 emerged as a threat. [5]

Third, we need an effective locally based test, trace, and isolate system with not only testing capacity, but also sufficient skilled contact tracers to identify infections as quickly as possible. [6] Moreover, we need enhanced financial and practical support so that those required to self-isolate can do so. Indeed, if B.1.617.2 turns out to be more transmissible than B.1.1.7 among those living together (as anecdotal data suggests), this makes it particularly important to provide decent local accommodation outside the home 

Fourth, given the growing evidence regarding aerosol transmission and hence the critical role of ventilation as a means of mitigation, adequate ventilation should be a criterion for commercial reopening, along with an enhanced inspection regime and grants available for improving ventilation, both in businesses and in the home. [7,8]

Fifth, we need clear and consistent public messaging to communicate the changing risks from covid-19 along with clear guidance on how people can identify and reduce those risks in their own lives. [9] There is a particular need to avoid the mistakes of summer 2020 when people were urged to return to offices (even when they were able and willing to work from home) and go to pubs as their “patriotic duty.” This creates a sense of “it’s all over” and encourages people to lower their guard. [10]

In combination, these measures constitute an effective strategy of infection suppression against all variants without greatly restricting everyday life. [11] They make a return to more stringent legal regulation (“lockdown”) less likely. The controversies about pausing the “roadmap” must not be allowed to distract from the fact that these measures could and should be implemented without delay. 

As concerns the “roadmap” timing itself, every choice raises a dilemma. Many businesses are struggling to survive, many in work are desperate for more security, and many people are yearning to meet up in their homes and go out to the pub, the club, the cinema together. No-one wants to wait yet longer.

On the other hand, increasing indoor mixing (where the great majority of infection transmission takes place) runs a big risk of accelerating the growth of B.1.617.2, especially in those areas of the country where the variant is already rising fast. Ideally, the decision as to how to proceed would be informed by consultation with the public, local communities, and local Directors of Public Health. But this is not the response style of the current government. Communications have been contradictory and unclear. We have not instituted the structures to allow communities to input their views into the policy process. Directors of Public Health have been largely side-lined from the decision making. 

Our assessment is that this new variant of concern has fundamentally changed the risk we face and therefore the government’s fourth criterion for moving ahead with the road map has not been met. [12,13] We consider a pause of a couple of weeks would provide sufficient evidence to inform the decision as to whether increasing indoor mixing can go ahead without risking a third wave. The pause should come with continued financial support for affected businesses and workers. A third wave would harm businesses as well as people—physically and mentally—and put further strain on the NHS which is already trying to cope with 5 million people waiting for treatment. [14]

Throughout this pandemic, the government has repeatedly delayed action on the assumption that the public wouldn’t accept it and they have been proved systematically wrong. [15] In particular, fear that people would socialise at Christmas come what may led to relaxing the rules so as to allow three households to mix. When the emerging evidence of the new B.1.1.7 variant finally forced the government to backtrack, people by and large understood and adhered to the new regulations, however disappointed they were. [16]

If the fear of delaying the road map is economic, we would refer to the evidence that countries which act early and adequately to suppress infection do better, not only in terms of health, but also economically, and in relation to civil liberties. [17] Were a new wave to take hold, the economic devastation would match the health costs.

If the fear is about a loss of political support, then we have less in the way of consolation. Pausing now after building expectations so high won’t be a popular choice (at least in the short term). But good government is first and foremost about protecting the population, not pitching for popularity.

Stephen Reicher, School of Psychology and Neuroscience, University of St. Andrews

Susan Michie, Division of Psychology and Language Sciences, University College London

Christina Pagel, professor of operational research (branch of applied mathematics), director of the Clinical Operational Research Unit & co-director of the UCL CHIMERA hub, University College London. 

Competing interests: Sr and SM participate in the UK’s Scientific Advisory Group for Emergencies and/or its subgroups and in Independent SAGE. SR participates in the advisory group to the Scottish chief medical officer. CP is a Member of Independent SAGE. All authors are writing in a personal capacity.