Why Covid-19 will never become endemic
For most of the pandemic Australia has worked to contain the virus through evidence-based public health measures such as border closures, case finding, contact tracing, quarantine, social distancing, vaccines and, at times, lockdown. Sadly, the weaponisation of lockdown as a pointscoring issue and emotional trigger has led to a conflation of lockdown with all other public health measures, most of which do not impinge on freedoms. Denial is a major theme during the pandemic. Denial of airborne transmission, denial of science, denial of Omicron being serious and denial about what it really means to “live with Covid-19”.
The denial of the airborne transmission of SARS-CoV-2 was started by experts on the World Health Organization infection control committee and allowed all countries to take the easy way out. If handwashing is all you need, onus can be shifted to “personal responsibility”; if ventilation needs to be fixed, that shifts responsibility to governments and private organisations. Australia only acknowledged airborne transmission after the Delta epidemic in mid-2021, almost a year after the WHO acknowledged it. Globally, 18 months was spent on hygiene theatre and actively discouraging mask use. As a result there is low awareness among the general public of the importance of ventilation and masks in reducing their personal risk.
We had effective campaigns on handwashing, but no campaigns of similar effect have been used to empower people to control their own risk with simple measures such as opening a window. People living in apartments are largely unaware of the structural factors that make them high risk for transmission, or of the simple measures to reduce risk. The failure to focus on airborne transmission has hampered the ability to control the spread and has endangered health workers. Correcting it is critical to the long-term sustainability of health, business and the economy. How can restaurants recover without a safe indoor air plan that may prevent a lockdown cycle that disrupts and ruins their business?
Denial of Omicron being serious suits an exhausted community who just wish life could go back to 2019. Omicron may be half as deadly as Delta, but Delta was twice as deadly as the 2020 virus. Importantly, the WHO assesses the risk of Omicron as high and reiterates that adequate data on severity in unvaccinated people is not yet available. Even if hospitalisation, admissions to intensive care and death rates are half that of Delta, daily case numbers are 20-30 times higher – and projected to get to 200 times higher. A tsunami of cases will result in large hospitalisation numbers. It is already overwhelming health systems, which common colds and seasonal flu don’t. Nor do they result in ambulance wait times of hours for life-threatening conditions. In addition, a tsunami of absenteeism in the workplace will worsen current shortages, supply chain disruptions and even critical infrastructure such as power. The ACTU has called for an urgent raft of measures to address the workforce crisis.
As for denial of the risk in children, the majority of vaccine-preventable diseases that we vaccinate children against are mild in most children. Only a small percentage suffer serious complications. Polio and measles are examples where well over 90 per cent of children who become infected do not have severe complications, but in a small percentage there are serious and potentially fatal complications. SARS-CoV-2 is similar. Other than long Covid and multisystem inflammatory syndrome, we are only now learning about other longer-term complications of infection. For instance, there is more than double the risk of developing diabetes in children following Covid-19. A study from the United States showed the virus persisting in the brain, heart, lungs, kidneys and almost every other organ after the initial infection. A rare brain inflammation has been described in adults and children. Another study found a significant drop in cognitive function and IQ in survivors. The virus directly kills heart muscle. It is too early to know if Covid-19 will result in early onset dementia or heart failure in a decade’s time, but the evidence warrants a precautionary approach. We know some infections have very long-term complications – measles, for example, can cause a rare and fatal encephalitis about 10 years after the initial infection. We should do everything possible to prevent mass infection of children and adults.
Denial of the science of epidemiology is widespread, even among “experts”. We are told repeatedly that SARS-CoV-2 will become “endemic”. But it will never be endemic because it is an epidemic disease and always will be. The key difference is spread. As an epidemic disease, SARS-CoV-2 will always find the unvaccinated, undervaccinated or people with waning immunity and spread rapidly in those groups. Typically, true epidemic infections are spread from person to person, the worst being airborne transmission, and display a waxing and waning pattern such as we have already seen with multiple waves of SARS-CoV-2. Cases rise rapidly over days or weeks, as we have seen with Alpha, Delta and Omicron. No truly endemic disease – malaria, for example – does this.
This is the reason governments prepare for pandemics. The propensity for epidemics to grow rapidly can stress the health system in a very short time. Respiratory epidemic infections follow this pattern unless eliminated by vaccination or mitigated by non-pharmaceutical measures. Natural infection has never eliminated itself in recorded history. Not smallpox, which displayed the same pattern over thousands of years, and not measles, which is still epidemic in many countries.
Eradication occurs when a disease no longer exists in the world – the only example of this in humans is smallpox. Elimination is a technical term and means prevention of sustained community transmission. Countries that met WHO measles elimination criteria, including Australia, still see outbreaks of measles imported through travel, but when elimination is achieved, these do not become uncontrollable.
Unlike for measles, however, current vaccines do not provide lasting protection. Masks and other public health measures are also needed to prevent the recurrent disruption of epidemic waves. There is hope for better vaccines, schedules and spacing of doses, but we must be agile and pivot with the evidence and have an ambitious strategy. The current strategy is focused on vaccines only, with no attention on safe indoor air or other mitigating factors. Instead, we have seen abandonment of test and trace because of failure to plan ahead for the expected explosion of cases. Testing and tracing are pillars of epidemic control, and the WHO has called on countries to strengthen both to deal with Omicron. Australia has done the opposite.
Without adequate case finding (which relies on testing at scale) and contact tracing, we are on a runaway train coming off the rails. Testing allows us to find infected people and isolate them so they do not infect others. Now, during the Omicron wave, testing is a massive failure. Both the federal and New South Wales governments made a conscious decision to “let it rip”, but failed to plan for adequate TTIQ (test, trace, isolate, quarantine) capacity. Instead, when it was clear testing capacity was exceeded, they restricted testing to a small fraction of people. Very few people are now eligible for a polymerase chain reaction test (PCR), and rapid antigen tests (RATs) are in short supply. While it has improved the optics by hiding the true scale of cases, this has allowed unfettered transmission.
Contact tracing is routinely used for many serious infections such as tuberculosis, meningococcal disease, measles or hepatitis A. It is conducted because close contacts are at highest risk of becoming infected next, and if they are not identified and quarantined they will go on to infect others and cause exponential epidemic growth. Contacts need to be traced within 24-48 hours to stop them infecting others. A range of digital contact-tracing methods such as apps, QR codes and tracking digital footprints through other means can be used when case numbers are high. Yet NSW has removed and flip-flopped on QR codes.
Denial of the reality of “living with Covid-19” has seen us rush headlong into letting it rip in a largely unboosted population, with kids aged five to 11 unvaccinated, without any planning for increased testing, tracing or even procurement of promising new drugs to face the numbers that will come. The booster program has not been expedited, with on Friday less than 17 per cent of the population aged 18 and over having had a third dose, and two doses barely protective against symptomatic infection with Omicron. So Omicron has caused business and hospitality to suffer mass cancellations. Mass absenteeism has crippled supply chains, affecting food, diesel, postal services and almost every other industry. The first serious impacts will be in regional and remote Australia. We saw it in July, when vaccine supplies slated for remote towns were diverted to Sydney, leaving Wilcannia, in the far west of NSW, a sitting duck for the epidemic to come.
Many do not understand “public health” and equate it with provision of acute health care in public hospitals or confuse it with primary care. Public health is the organised response by society to protect and promote health, and to prevent illness, injury and disability. It is a core responsibility of government.
Public health comprises three components. The first is “health protection”, such as the banning of smoking in public places, seatbelt legislation or emergency powers that allow pandemic control measures such as lockdowns. “Health promotion” refers to the process by which people are enabled to improve or control their health, through the promotion of mask use, for instance. The third component – “disease prevention and early detection” – includes testing, surveillance, screening and prevention programs. Vaccination programs are an example of disease prevention.
During the pandemic we have seen resources committed to surge capacity for clinical medicine, but there has been a lack of understanding of the need for public health surge capacity, including TTIQ. The price was paid in the Victorian second wave in 2020. Now, with the abandonment of contact tracing and restrictions on testing during the Omicron wave, we are seeing what happens when this capacity is ignored by government.
Another outcome of these failures are the unscientific theories being pushed in many countries – such as the argument for “herd immunity by natural infection”, which has become a household narrative during the pandemic despite four pandemic waves providing little protection to date. The same people who peddled herd immunity by natural infection had no ambition to achieve herd immunity by vaccination. Instead they tell us “we have to live with Covid-19” and fall back on negative, defeatist messaging.
The least ambitious goal of vaccination is to prevent us from dying, and that is the low bar set in Australia. This has reduced policy outcomes to a false binary of dead or alive. There is no concern in this for First Nations people, the disabled, people with chronic medical conditions, people in remote Australia or even children, who are being sent back to school at the peak of the pandemic while primary-schoolers are largely unvaccinated. The hundreds of aged-care outbreaks pass without comment in what essentially has become survival of the fittest and richest.
The vaccine game is dynamic and ever-changing. Some countries have used ambitious, determined, organised strategies for vaccination and adapted quickly as the evidence has changed. We know the mRNA vaccines can greatly reduce transmission, but current vaccines were developed against the original Wuhan strain and, even after two doses, efficacy wanes. Omicron-matched boosters are in the wind, a seed of hope and a reason to be ambitious, but that will require agile vaccination policy.
There is a massive vaccine and drug development effort, so it is almost certain we will have better vaccine options, including ones that are variant-proof. But what the past month has shown us is we cannot live with unmitigated Covid-19. Vaccinations will not be enough. We need a ventilation and vaccine-plus strategy to avoid the disruptive epidemic cycle, to protect health and the economy, and to regain a semblance of the life we all want.
This article was first published in the print edition of The Saturday Paper on Jan 15, 2022 as "A pandemic of denial".
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