COVID-19: we’ve done well but “the race isn’t over”

IT has been a long 11 months since Victorian health authorities announced Australia’s first confirmed case of the novel coronavirus on 25 January 2020.

In those embryonic days of the global pandemic, the World Health Organization (WHO) was yet to coin the “COVID-19” (coronavirus disease 2019) name and it was still impossible to imagine that Australia’s international borders would close on 20 March, with state border closures following soon after. Globally, there have been 69 363 786 COVID-19 cases and 1 578 008 deaths.

By far, the US has seen the most COVID-19 deaths (291 403), followed by Brazil (179 765 deaths), India (141 772 deaths) and Mexico (111 655 deaths).

Australia has fared much better with 28 000 cases and 908 deaths.

Presenting the keynote address last week at the Australasian COVID-19 Virtual Conference, Acting Chief Medical Officer Professor Paul Kelly said Australia was in a “very good place” with COVID-19.

He said the “relatively controlled state of the pandemic in Australia is a testament to Australia’s excellent health system, the high level expertise and dedicated efforts of all health sector players”.

“It is also a testament to the way that science has led Australia’s pandemic response, our research has been turned into policy and epidemiological analysis has been crucial to informing decisions,” Professor Kelly said.

He said Australia acted swiftly, with a broad public health response and pursued aggressive suppression, which has led to periods of elimination in parts of the country.

“In fact, most of Australia has now experienced more than 100 days without a locally acquired COVID-19 case. This strategy has been adjusted to local circumstances as we face the ongoing risks COVID-19 throws our way. We have seen occasional outbreaks, which have been quickly brought under control by our public health teams through excellent contact tracing capabilities to test, trace and isolate all cases.”

Professor Raina MacIntyre, Professor of Global Biosecurity at UNSW, told InSight+ that the largest contributor to Australia’s success was the March closure of international borders alongside the introduction of hotel quarantine.

“Those two steps made it really feasible to control the disease; and whenever outbreaks occurred they could be controlled,” she said. “Even the Victorian outbreak – which got out of hand because they didn’t have the resources to do the contact tracing and so on – was able to be controlled.”

Also, she said, Australia’s relative success demonstrated the importance of cultural influences in a pandemic response.

“Our culture and our way of thinking and behaving has worked to our advantage. Australian governments made some difficult decisions earlier this year with the lockdown, and then a second lockdown in Victoria, but Australian culture is quite accepting of those public health interventions,” Professor MacIntyre said.

“We even have an expectation that government will step in and fix things, which is quite different, say, from the US where there has been opposition to government interventions and public health orders.”

Professor Deborah Williamson, Director of Clinical Microbiology at the Royal Melbourne Hospital at the Doherty Institute, added that an early focus on high quality laboratory testing was another essential component of Australia’s successful response.

“Getting high quality laboratory testing up and running really early has been a cornerstone of our response,” she said. “Put very simply, without a test result, there is no public health action. And we have had one of the highest testing rates per capita globally and that has really facilitated the public health response.”

To date, more than 10 million tests have been performed in Australia, and Professor Williamson noted that the crucial role of laboratory staff continues.

“The people on the frontline – the [emergency department] workers, the [intensive care unit (ICU)] workers – have been the high profile heroes and they have put themselves at immeasurable risk,” she said. “But there has been another, if you like, twilight world of workers in pathology and in the laboratory who have kept the response going.

“Their work doesn’t stop when there are no cases, and in fact it becomes even more important.”

Professor MacIntyre said Australia had clearly done well, but “the race isn’t over” until most Australians are vaccinated.

And with restrictions easing around Australia – including Melbourne last week opening to international flights once more – there continues to be the possibility of COVID-19 outbreaks.

“[Outbreaks] will always be possible until we have herd immunity, which can only be achieved through vaccination and we would need about 80% of the population to be vaccinated. Until that time, there will always be the risk of outbreaks,” Professor MacIntyre said.

She said Australia’s lack of a clear vaccination goal would make this target hard to reach.

Asked if growing community complacency was a concern, Professor MacIntyre said it was, particularly coming into the festive season.

“Back in July, probably about 40% of people were wearing masks, now hardly anyone is wearing a mask. The restrictions are being eased, so that level of complacency and especially coming into a period like Christmas and New Year, when there are going to be more gatherings and so on, is quite risky.”

While initial government estimates stated that a COVID-19 vaccine would be available for rollout in Australia from March 2021, the Prime Minister Scott Morrison suggested in a radio interview last week that a vaccine may actually be available “a bit earlier”.

Professor Kelly told the COVID-19 conference that Australia’s advance purchasing agreements with four companies would, if approved by the Therapeutic Goods Administration, result in 134 million doses available for distribution.

“What lies ahead is no small feat,” he told the COVID-19 conference. “We are looking at the biggest ever vaccine rollout in history to all Australians who choose to be vaccinated by the end of 2021. We are actively planning for the distribution of the vaccine and for the recording of doses and monitoring of adverse events which will be so important to maintain public confidence.

“Only when a sizeable proportion of the Australian population is vaccinated will we see normal no longer prefaced with ‘COVID’.”

Professor MacIntyre said, however, it would be difficult to reach the required 80% vaccination target without a clearly defined goal.

“As far as I know, there is no goal to achieve herd immunity, but I think we need to re-evaluate that continually, especially with very high efficacy vaccines likely to be available. We should look at what’s the end-game here. What are we trying to achieve? We want safety, prevention of infection and full economic recovery. Surely, if it’s possible and feasible to stop transmission in the community, that’s what we should be aiming for.”

And there are likely to be many bumps along the road to achieving herd immunity with reports out of the UK last week that two National Health Service workers reported “anaphylactoid reactions” after receiving the Pfizer/BioNTech vaccine in the first days of UK’s national rollout.

The workers, who both had a history of serious allergy, have both recovered, but the cases have prompted regulators to warn that people with a history of serious allergy should not receive the Pfizer/BioNTech COVID-19 vaccine.

While acknowledging Australia’s success in tackling the most significant global health event since 1918, there are still areas in which experts say there is room for improvement.

Professor MacIntyre said there remained a lack of understanding of the importance of the public health initiatives in Australia’s COVID-19 response.

“There is a good understanding of the acute health system response – so the need for surge capacity in ICU beds, ventilators etc. In March, Australia expanded its capacity for [ICU] and hospital beds by 120%,” she said. “But the understanding that you needed an equal surge capacity for contact tracing and case finding and so on wasn’t there. So, when the Victorian second wave happened, there hadn’t been any investment and they weren’t able to keep up with those requirements.”

Professor MacIntyre added that even in the wake of the Victorian second wave, there were no additional funds for public health capacity announced in the Victorian State Budget.

A further significant issue, Professor MacIntyre said, was the “entrenched denial” in Australia of the role of aerosol transmission.

“It’s been a global thing with WHO denying it for a long time, but they finally admitted it by the middle of the year,” she said.

“In Australia, there is more entrenched denial of airborne transmission as a major mode of spread, which then has flow-on impacts. Control measures have to be tailored for how the virus is spread and if you are denying a mode of spread, then your control measures are never going to be adequate,” she said, noting that this was particularly the case in hotel quarantine.

“We get some poor woman commuting every day to work her guts out in her job, and she has been victim-blamed for going on a bus, where she was actually wearing a mask, and the actual issue is that hotel quarantine is a high risk environment.”

Professor MacIntyre said it was essential that ventilation in hotel quarantine be addressed and that quarantine workers be provided with N95 masks.

Professor Peter Collignon, infectious disease physician and member of the Infection Control Expert Group, noted on Twitter, however, that “the epidemiology of SARS-CoV-2 indicates that most infections are spread through close contact, not airborne transmission”, pointing to a Centers for Disease Control and Prevention Scientific brief.

“If aerosols are [a] major route of infection, we’re all in deep trouble,” he further wrote on Twitter. “We will need to wear N95 respirators all the time. Restaurants, schools, flights, public transport all likely to need to stay closed while any community transmission, as aerosols stay suspended in air for [hours].”

Professor Williamson said the flow of information across Australia’s internal borders also needed to be improved.

“If somebody has a test in one jurisdiction, the results can’t easily be accessed in other jurisdiction, and as we start to move more freely, rapid access to information becomes extremely important,” Professor Williamson said.

Also, she said, there was still much to learn about COVID-19 immunity.

“We do need to understand what it really means to be immune,” she said. “What truly protects us? Is it antibodies? Is it cellular immunity? It’s most likely a combination of the two, but we need more understanding about what protects us and how long that immunity may or may not last.”

Professor Williamson said the rapid innovations made in testing in the past year would have far-reaching benefits.

“We have seen things like genomics applied to SARS-CoV-2, innovations in rapid diagnostics using CRISPR technology or nanotechnology, and the development of 3D printed swabs,” she said. “If somebody had said to me a year ago, ‘you are going to be testing thousands of specimens a day for a virus you have never heard of and you will be using 3D printed swabs to collect the specimens,’ I would have laughed, but this is now our reality.”

She said such innovation would eventually be applied to a range of respiratory and other infections.

A further silver lining, Professor MacIntyre said, was the rapid adoption of technology in the workplace.

“We have had technology available to us for a long time to work remotely and hold virtual meetings, but there has been a very old-fashioned 20th century view that a meeting has to be face-to-face to be effective,” she said, adding that this was not only expensive and time-consuming but, particularly in the case of international travel, left a large carbon footprint.

“I think a lot of workplaces will now re-evaluate the need for so much travel and face-to-face meetings.”