THE easing of lockdown restrictions in the UK has prompted growing concern from those taking extra precautions because they are particularly vulnerable to the coronavirus. On 31 May, the UK government announced that so-called shielders in England and Wales could now leave their homes. But what is the evidence behind the idea of shielding vulnerable people, and is it really safe for this to now stop?
Many countries have told those thought to be at higher risk from coronavirus due to illness or age to take extra safety precautions. But because this virus is so new, advice has largely been based on people’s best judgements, rather than scientific evidence, and the details of the advice has varied between countries.
The UK has been unusual in distinguishing between two groups of people at higher risk. In March, letters were sent to about 2 million people thought to be “clinically extremely vulnerable”, including some people with cancer, lung conditions such as severe asthma, and those who had had an organ transplant or have weak immune systems. Recipients were told they should stay home at all times. If they had no friends or family who could fetch essentials, they could get food parcels sent.
There has also been advice that a larger group of people at more moderate risk, described as “clinically vulnerable”, should try to stay at home if possible, but can still go out when necessary. This group encompassed everyone over 70, plus those who are pregnant or who have any of a long list of health conditions.
There has been some confusion between the two groups, leaving some people officially classed as at only moderate risk believing they shouldn’t ever go outside.
Such confusion can have serious effects on well-being. Socialising and getting out are some of the first things that doctors recommend for people with mental health conditions such as depression, says Stephen Bradley, a family doctor in Leeds, who wrote an article in the BMJ calling for the UK government to be clearer on shielding. “These are quite drastic measures to take – it can have a big effect on people to be told not to leave the house.”
The UK health minister Matt Hancock has himself confused moderate and high-risk groups within a tweet that rebuked a newspaper for making the same mistake. “The messaging has been disastrous,” says George Davey Smith, a clinical epidemiologist at the University of Bristol.
As more information on the coronavirus emerges, it may be that the risk classifications need refining. We may have underestimated the risk that comes from being elderly, says Mark Woolhouse, an epidemiologist at the University of Edinburgh.
According to a report published last week by Public Health England, people over 80 who are hospitalised with coronavirus are 70 times more likely to die than those hospitalised who are under the age of 40.
“Nothing has an effect anywhere near as strong as age,” says Woolhouse. “Probably the right metric is going to be something like frailty – age modified by your general state of health.”
After 10 weeks, shielders in England and Wales have been told they can leave their homes, providing they maintain social distancing while out.
What was the basis for the change? The UK government initially said on 31 May that it was because “covid-19 disease levels are substantially lower now than when shielding was first introduced”.
But that was wrong. While infections are falling, the UK is still seeing about 1500 new confirmed cases a day, compared with about 1000 a day in March, when the first letters were sent to shielders. The total number of new cases a day is likely to have been higher in both March and May, as not everyone gets tested.
By 3 June, the explanation on the government website had changed, saying the move was because “covid-19 levels have decreased over the last few weeks”.
Unfair and impractical
Shielders in Scotland have been told to continue staying at home until 18 June, even though only a handful of new cases are being reported there each day. Shielders in Northern Ireland, meanwhile, were told they could go out this week.
The relaxation of shielding advice in England took doctors by surprise. NHS England’s head of primary care, Nikita Kanani, tweeted on 31 May that she would share more information with doctors “as soon as I know more”.
“We have not eliminated this virus or suppressed it to what I would say is a safe level”
Doctors remain unsure what to tell high-risk people who ask their advice on whether it is safe to go out. “It’s quite difficult to support people when they ask you for information if you have just read about it in the newspaper,” says Bradley. “I worry that policy is being motivated by the need to come up with good news rather than evidence and consultation.”
“We have not eliminated this virus or suppressed it to what I would say is a safe level,” says Stephen Griffin, a virologist at the University of Leeds.
One question that some are asking is why shielders can’t stay at home so that restrictions for those at a lower risk from the coronavirus can be relaxed further.
“That’s incredibly unfair,” says Griffin. “You can’t lock 2 million people away indefinitely, it’s just not reasonable.”
It is impractical, too, as many people who are shielding need regular medical appointments. It would also affect not just those who need to shield but their family members and carers, says Griffin, whose household is maintaining isolation because one member is at high risk.
Rather than simply switching between it being safe or not safe for shielders to leave their homes, some intermediate options are being explored in other countries. Dublin in Ireland has created 2-hour time slots when parks are only open to vulnerable people – who are called “cocooners”.
Woolhouse says carers and family members of those at high risk should be allowed to take frequent coronavirus tests even when symptomless, to avoid passing it on. Davey Smith has called for people to be told current local infection levels so they can stay home when risks are higher.
Ultimately, the safest option for shielders would be to further bring down the level of infection. “The best possible policy you can have, whatever your other risk mitigation strategies, is to suppress the number of cases in your population,” says Griffin. “[This is] not a problem that will go away. While we have circulating virus, the risks are still there.”