Raising the Portcullis of Fortress Australia

The conversation about how to “open up” Australia started rather awkwardly during a time that COVID19 continues to cause great hardship in the world. We hear “tolerance of risk” and “when we allow COVID19 back onto our shores and it circulates in our community, that we are prepared and comfortable for that to happen”.

For the best part of 20 years, I have stood watch at the doors of the emergency departments around the world, weathered SARS-1, bombs … and I wonder now what will come. Are we prepared? Are we comfortable?

The arrival of vaccines, far more effective than we had thought possible, is fostering the call for “opening up” ever stronger. “Targeting Zero” was never a national strategy and has now been branded as extreme in this new scenario.

Targeting Zero raises uncomfortable ethical considerations. Whilst it is the most stable target to achieve, the reliance on limited quarantine capacity has led to the exclusion of citizens from reasonable access to a safe passage home. Families remain separated, children from parents, partners and loved ones.

Economically, our control measures have created a two-tiered economy where domestic sectors (hospitality, entertainment, retail, etc.) have remained buoyant, whilst industries exposed to the externalities of our control measures have languished (international tourism, education and travel). There has been a shortage in migrant skills and labour affecting many sectors including agriculture.

So, faced with this pressure, should we allow COVID19 to circulate in our community? Intermittently, there are hints that testing in the community, and community cases will become less important, as COVID19 becomes less harmful than the common cold (arguable). That we should only look at hospitalisations and deaths as end-points. Many have argued for endemic COVID19.

It is well known and published many times by Australian College of Emergency Medicine that emergency departments around Australia are severely burdened. “Whole of hospital” resources and funding for community resources remain inadequate. Ambulances wait for long times, and adverse events occur.

We have also observed that outbreaks of COVID-19 in hospitals are difficult to control. Current engineering and infection control practices do not seem to be enough to keep services running during an outbreak. Rural hospitals operate in a precarious and delicate balance many kilometres from help. On the background of this, we are planning to introduce a new disease.

We are not prepared or comfortable.

COVID-19 is an aerosol and airborne disease. By its very nature, it is highly transmissable. Once released into the population, it requires huge effort and massive economic sacrifices to control. It persists in the human gastrointestinal tract, faeces and sewage for many weeks, perhaps longer. In some parts of the world, it has been found in the local wildlife.

Known consequences of widespread COVID19 circulation include excess deaths, new chronic disease and suboptimal management of other pressing health needs. There are now also reports worldwide of community health services being overwhelmed as the chronic disease and mental health burden grows. Evidence suggests that COVID-19 may also be adapting to children, causing more symptomatic (more severe?) disease as time passes.

There are economic consequences as confidence to travel and socialise drops, people stop working to care for sick children, due to their own ill health and also to do home schooling. Extra services to cope with the health problems will need vast human resources and investment. Lastly, there are unknown unknowns.

What is being proposed is that vaccines are leaned on heavily, as the means to prevent these problems occurring. That disease reduction by test, trace and isolate is abandoned. I do not think a single defence strategy such as this is wise. If for any reason, should vaccines fail, the outcome would be dire. Our future strategy cannot be a one-legged table.

We need more.

I believe stopping sustained community transmission is the key to COVID-19 safety and stable long term economic recovery. If we know that an outbreak can’t take off, it is less likely it will have a chance to spread, mutate, and become more deadly. If we stop monitoring outbreaks, await deaths and hospitalisations, we will miss important early indicators that could prevent further deaths. Furthermore, we may also miss early signals that tell us when population immunity is waning and requiring vaccine boosters.

By the time a concerning variant is identified, that can transmit despite vaccines, and cause hospitalisation, it may have spread through many states, and even to the rest of the world, threatening the recovery of low-income countries that can’t vaccinate their way out of trouble fast enough. Any COVID-19 variant that can circulate despite vaccination is a threat to Australian and global recovery. A concerning variant may turn up, unexpected in an emergency room.

So, what options are available? Is “herd immunity” one of them? With highly adaptable technology now at our disposal, and the ability to prevent up to 92% of all infection (Dagan et al NEJM) herd immunity seems to be the obvious answer. So why not?

Herd immunity for a highly transmissible disease requires a high uptake of a high efficacy vaccine. If this occurs, it is not actually possible to “allow covid to circulate”. An attempt to gain herd immunity eventually through vaccination would be very desirable. (This should not be taken to mean that individuals should wait for any particular vaccine.)

Herd immunity may not be achievable for many reasons including supply, vaccine hesitancy and variants that lower the efficacy of the vaccine. Vaccine hesitancy may be increased in particular geographical locations, providing ample opportunity to sustain a significant outbreak.

Children would have to be included in any strategy to attain herd immunity. They do suffer serious illness at times and some may die. Until safe vaccinations are found and licensed, they remain able to contribute to transmission of disease, and could be a large reservoir for re-infections, threatening the vulnerable in the rest of the population unless protected through non-pharmaceutical interventions like masks and engineering controls.

What if everyone that wants a vaccine has had one, but the coverage is not high enough for herd immunity? Can we move on without them? I believe not. Whether or not we agree with their choice, we are one population and we sink or swim together. Threats won’t work as evidenced in other countries with vaccine hesitancy despite large outbreaks. Incentives might, but they come with ethical difficulties. Ignoring the issue will allow this group to have large outbreaks and threaten the stability of the recovery with domestic variant emergence. Large outbreaks may also disrupt the delivery of normal medical services.

Herd immunity through vaccination is not however the only tool we have to stop COVID-19 transmission. Population resilience to sustained community transmission can be augmented through:

● Building plenty of air gapped long-term quarantine to prevent entry of resistant strains but maximise the movement of people.

● Use of non-pharmaceutical interventions such as community masks (if any outbreak requires community masking, they should be mandated for all as asking only the vulnerable to do it is not as effective), test/trace/isolate, education to avoid crowds/closed spaces/close contact).

● Widespread use of CO2 monitors with legislated upper CO2 limits.

● Ventilation and filtration upgrades with early attention paid to aged care, hospitals, schools and workplaces.

● Installation of portable HEPA filters where needed.

● Mandated use of PPE to protect against aerosol/airborne disease for all suspected COVID-19 work.

● Selected use of professionally fitted upper room ultra-violet germicidal irradiation.

● Assisting countries to become low risk countries before permitting modified quarantine or quarantine free travel. This means that the country should agree to the common goal of controlling COVID-19 outbreaks, with an aim to zero sustained community transmission, have no/very low COVID-19 prevalence and not to have known variants of concern, or variants that can transmit despite vaccines.

It was proposed that we should first stabilise the border opening between states, before opening internationally. This model can be used to find out what is needed to maintain control of COVID-19 while maximising human travel. The resources needed to track COVID-19, detect sustained community transmission, what NPI’s are needed on top of the vaccination levels in the community and how to take appropriate action in a timely manner to stop outbreaks can all be explored using the interstate model. Successful models could be shared with other countries that are willing to engage in a strategy to aim for zero sustained community transmission of COVID-19.

Data transparency, rapid communication, trust, shared targets, shared technologies (computer programs may be able to detect clusters faster than manually), and strong diplomatic ties will be needed.

It is expected that the public will want ongoing access to the data. A website that is updated every day with accurate outbreak information will be needed for a long time. People are scarred, and scared. This anxiety is unlikely to abate for a long time, and perhaps not until the COVID-19 pandemic is out of living memory. This data will allow health and social equity to be maintained for the vulnerable that do not respond to vaccines.

Australia, and other countries that have managed COVID-19 well, remain a hope to humanity. We have a responsibility to model the best possible outcomes. We do not want to be exporting vaccine resistant COVID-19 to vulnerable countries and we do want to avoid preventable excess deaths as we approach the beginning of the end of the pandemic.

I would not turn my back on COVID-19 any more than I would turn my back on the sea. Hope is on the horizon with new vaccines that can target coronaviruses without relying on the rapidly changing spike protein, and many other innovative post exposure prophylaxis and treatments.

Now is not the time to give up and let one of the most destructive new diseases of our time onto our shores and give it free rein to circulate.