Hope, denial and Covid-19
This is the year of hope, denial and cognitive dissonance about the emergence of newer and more challenging variants of SARS-CoV-2 far outpacing vaccine development. Like saying your grandfather smoked all his life and lived to 100, thus smoking is fine, people are telling each other “I had Covid and it was mild”.
The virus doesn’t care that we are fed up with dealing with its fallout. It is here to stay – not a cold, as we were promised, and not even the flu, but a rapidly mutating virus that affects various organs, including the brain, and can cause debilitating long-term illness.
Reinfection is common and increases your risk of bad outcomes. Being infected with Omicron BA.1 earlier in 2022 does not give you much protection against the newer variants. One health leader told us getting infected is “necessary”, but sadly herd immunity is not a thing, not with current vaccines, not after infection and not with “hybrid immunity”. Adding to the confusion are health experts who drove our pandemic response now saying they just didn’t see this coming. But plenty of experts did see it coming – and urged the government to act.
One part of the answer is expanding and improving third and fourth dose vaccinations. Vaccines are both primary prevention in normal times and an epidemic control measure. For the latter, though, policy must be agile and timely to ensure as many people as possible can be protected in the face of an oncoming wave. Vaccine policy in the good times can proceed at a slow and considered pace, but, in a pandemic, time is critical, and delayed or restricted access to vaccinations will result in missed opportunities to prevent disease.
Every additional booster given will save lives, prevent hospitalisations and protect against long Covid. We still have no ATAGI recommendation for children aged two months to five years, long after the United States approved vaccines for this age group, and even after the Therapeutic Goods Administration approved vaccines for this cohort.
The rate of vaccination in children aged five to 11 years – just 40.5 per cent have had second doses – remains abysmally low. Meanwhile, day care, schools and families remain disrupted by Covid-19 outbreaks, with teachers and child carers, like health workers, burnt out and seeking other careers, and parents at their wits’ end as reinfections affect households again.
We now face a wave of BA.4/5, the globally dominant new variants. These are so distant from the original virus that the vaccines designed to combat the first wave do not protect nearly as well as they did for Delta or even BA.1. Most of the monoclonal antibodies are also ineffective against BA.4/5, but antivirals remain effective. Currently Australia has between 40,000 and 50,000 confirmed new cases a day, which is likely to be an underestimate. There are more than 5000 people in hospital and upwards of 11,000 deaths, most of which have occurred this year. That excludes deaths that do not get counted as Covid-19-related, such as a sudden cardiac arrest, heart attack or stroke in an adult months after they had the coronavirus – a risk that remains for at least a year after infection.
The BA.4/5 wave might peak in August, so the worst could still be ahead. As for long Covid, an unfortunate term that tends to minimise the illness and the real pathology of it, we face health, disability, economic and workforce impacts well into the future – another reason to use a vaccine-plus approach, with layered strategies to mitigate transmission. Widespread and affordable access to antivirals will also help, but currently the majority of people who don’t qualify for discounted Pharmaceutical Benefits Scheme prescriptions have to pay about $1200 a course.
We don’t have data yet, but perhaps the rapid use of antivirals may reduce the burden of long Covid. To realise the promise of antivirals, testing is essential – treatments can never benefit the economy until testing is widespread, accessible and cheap or free, because to get treatment you need a positive test. Many people do not get tested because taking multiple rapid antigen tests – at $8 to $15 a test – becomes expensive quickly, and PCRs are no longer free or easily available to all. Use of QR codes, too, would help reduce case numbers, because contacts are the next tranche of cases. Forewarning people by using digital tracing would help. Clear treatment guidelines for Covid-19 in the community would also reduce the burden of disease, with cheap treatments such as asthma preventers and other drugs shown to reduce severe outcomes.
SARS-CoV-2 is airborne and is spread through inhalation of contaminated air, a fact many remain unaware of as they religiously apply sanitiser to their hands. A public campaign to educate and empower the community on transmission would go a long way to reducing the spread of the virus but has been left to private groups such as The John Snow Project.
Masks have been shown to work, especially high-quality ones such as the P2 or N95 respirators, but without a mandate only about 30 per cent of people will wear one. With a mandate, as we saw in Australia, that number rises to more than 70 per cent, and this would make a massive difference to transmission.
Masks remain a dirty word and disinformation keeps pouring into our feeds without correction.
For heaven’s sake, it’s just a mask. Get over it, mandate it, save more lives, prevent more illness and protect businesses. Cases matter – they can all cause workplace absenteeism, disruption to schools and households, hospitalisations and deaths. Reducing cases will reduce those unwanted outcomes and will be best for our lives, our health, our businesses and our economy. Time is short and the new government should not tiptoe around the politicised and polarised landscape that is the legacy of the previous incumbents.
The first Omicron wave in January saw supply chains affected, supermarket shelves empty and delays in essential services, all due to mass workplace absence. Absence from work rose from a normal rate of about 2 per cent to more than 20 per cent at the peak. People complain of chaos at airports all over the world, wondering why their luggage didn’t arrive or their flight was cancelled. It’s partly because workers are sick with Covid-19. Chances are if you need your car serviced, or groceries delivered, or your oven fixed, there will be delays because so many staff are off sick with Covid-19.
As soon as it was allowed, your boss likely insisted everyone come to the office – just like in the 1990s, when they insisted you keep using the fax machine instead of emails – even though productivity was unchanged or even improved with remote working. And then, when everyone obeyed and came back to the office while Covid raged on, productivity took a hit when mass infections occurred at work. These effects will be even worse when long Covid impacts the workforce. The blinkered approach by many countries in ignoring the chronic burden of disease and only focusing on acute infection is a mistake. It is not a choice between unmitigated transmission and zero Covid. Any measures that are used to reduce the spread of the disease will reduce the potentially crippling effects on society and the economy of long-term disability and chronic illness. Our children and young people are our future, but a new study shows that after mild Covid, people aged 18 to 30 years are at highest risk of long Covid.
And yet here we are, waiting passively for another rinse-and-repeat cycle of health, economic and societal pain. Covid-19 does not look as if it will be ending any time soon, and it is a question of how much loss and societal damage we will endure before beginning to address things such as safe indoor air, masks as a part of normal life in the same way seatbelts are, and flexible work models for a more sustainable “living with Covid” future.
Meanwhile, there was a failure to prepare ahead of the event for monkeypox, which has left us without the required antivirals and with limited vaccine choices at the start to aggressively stamp out the epidemic. If it becomes established in animal hosts in Australia, we will live with it forever. It is another all-too-familar catch-up game.
Japanese encephalitis, never previously present on the mainland, was missed entirely while it silently crept across Australia somewhere between 2019 and 2022. This catastrophic failure, for which no one has taken responsibility, has condemned us to forever live with JE, a fatal disease in up to 30 per cent of humans and devastating to our livestock industry. Another biosecurity threat, foot-and-mouth disease, is also knocking on our door.
Like it or not, we face a future that will never again look like 2019. The sooner we accept that and adapt, the better off we will be. Looking ahead a decade or two, Covid may be the defining event that tipped the balance of power globally between the US and China.
If China keeps the virus under better control, its population will be fitter and healthier into the future, while the US, Europe and much of the rest of the world, including Australia, will be groaning under an unprecedented burden of chronic disease and disability that will have major long-term economic impacts. This is not a call for lockdowns, just for better control using layered strategies that do not impinge on freedoms.
In Australia, we are at a crossroads, with a new government and a rapidly closing window of opportunity to change course with Covid to control and forge our own path ahead.
This article was first published in the print edition of The Saturday Paper on July 30, 2022 as "Hope, denial and Covid-19".
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