The long road to Covid normal
Two years since the first case hit our shores, we are winning against the virus – but the battle is far from over.
We have the vaccine, antiviral treatments, generally good compliance with public health measures – yet, as Australians look to the future, the question is more emphatically than ever.
When will life return to normal?
Gerrard is well placed to offer a deeply informed answer, more nuanced than the catch-alls of lockdown or vaccination. A professor of medicine, he was director of infectious disease at the Gold Coast Hospital in January 2020 when a 44-year-old Chinese tourist, visiting from ground zero in Wuhan, presented with flu-like symptoms and gave rise to this country’s debut cluster of cases as other members of the tour group fell ill. Back then, the virus didn’t even have a name.
Now he is chief health officer of Queensland, part of the brains trust charged with driving Australia to the much-anticipated point where Covid is “normalised” as just another endemic disease alongside seasonal influenza and the rest of the bugs that routinely assail us.
“We can manage this like any other infectious disease,” Scott Morrison insisted, launching the road map to recovery last July.
Then there was the fearless new year prediction of former commonwealth deputy chief medical officer Nick Coatsworth that the virus was close to burning out. “The pandemic will come to an end in 2022 because the virus will become endemic, and that means that Covid will circulate in the community,” he said, adding: “It’s not a very convenient time to be having very high case numbers but there never was a convenient time.”
Yet, as Gerrard knows all too well, having put in the hard, thankless yards in hospital wards and ICUs, this shapeshifting contagion has a nasty propensity to up-end the best laid plans. Omicron is the ultimate expression – to date at least – of Covid’s daunting capacity to jump the barriers erected by science and society: the variant is up to twice as contagious as the highly infectious Delta variant that preceded it and can infect vaccinated people, though it causes less severe illness when it does, a saving grace.
It follows on from the original Wuhan or “wild” virus Gerrard, 60, encountered in 2020 and the subsequent Beta (South Africa) and Gamma (Brazil) subtypes. Each posed a different if compounding challenge to health authorities. Nothing like Omicron, though, which has racked up record rates of infection, hospital admissions and death at a time when 93 per cent of Australians aged over 16 have been double-vaxxed and post-pandemic life was supposed to beckon.
It’s hard to contemplate that when the daily count of the dead is so grim: 71 nationally on the seven-day average, for a total approaching 3500 deaths over the course of the pandemic.
Gerrard says his home state is on the brink of turning the corner, in line with NSW and Victoria, with the outbreak due to peak in Brisbane within days and on the wane in the hotspot of the Gold Coast. But, pressed by Inquirer on when that longed-for transition to living with Covid will happen, he is caution personified.
“Once we are over this peak we’re going to regroup, look again at our approach both at a state level and a national level,” the CHO says.
“But I have a feeling this tail (of the pandemic) will go on for some time. So I don’t think it will be as simple as the flu … this is a very different pandemic.”
For all the progress made, the optimism that closed out 2021 – that near-universal vaccination was the ticket out of the pandemic – has given way to a new appreciation of how Omicron changed the equation.
The Prime Minister’s exit plan, as initially backed by the premiers seven months ago, was underpinned by modelling from Melbourne’s Peter Doherty Institute for Infection and Immunity, which in turn was based on the Delta variant first detected in India in late 2020. Its basic reproduction rate or r0 ranged between three and eight, with a mean of five, suggesting each infected person would most likely infect four others.
But with Omicron, the r0 explodes to a maximum of 15 and a mean of 12 due to a wicked packet of mutations in the spike protein on the surface of the virus, the needle-like mechanism used to penetrate host cells. There’s a caveat here, crucial to bear in mind: r0 values assume the population is unprotected and that is increasingly irrelevant in jabbed-up Australia.
Let’s put the virus’s intrinsic infectiousness aside for now, because if there’s one certainty with Covid, it’s that the roughly 5 per cent of Australian adults who have shunned the vaccine will catch it.
The real issue is Omicron’s ability to break through the shield of acquired immunity and cause serious illness. In Queensland, 60 per cent of Covid patients in intensive care in hospital have had at least one dose of vaccine, Gerrard says. Admittedly, most of them would have pre-existing health conditions, comorbidities that increased their vulnerability.
But with Omicron now accounting for more than 95 per cent of new infections, the sheer weight of numbers is placing immense pressure on the health system. This is the imperative for the booster-shot rollout. In Britain, some studies suggest the level of protection against infection offered by the standard two-dose course of vaccine may be as low as 19 per cent. Doherty Institute director Sharon Lewin cautions that the ability of vaccines to stop Omicron transmission is yet to be benchmarked, and the data is limited to household studies, not scaled up population work.
A better way to assess risk, she says, is to ask yourself: what was my chance of going to hospital in the Delta wave and what’s my chance now of going to hospital with Omicron? Based on South African and US research, the risk of severe disease is 70-80 per cent less than what it was last year when Delta was at its zenith, another product of mass vaccination.
Again, there’s a catch. Not everyone in hospital with Covid is there from Covid, an increasingly acute distinction as case numbers climb.
“Many countries, including Australia, are struggling with a definition to count this,” Lewin says. “And it’s really important because once you have Covid so common in the community, you are going to have a large proportion of people who are in hospital with Covid as opposed to from Covid.
“You might be in a car accident, for example, and are taken to emergency, where they test you and find you are positive to the virus. But that’s not why you are there … it’s hard to tease out and
we really need to understand this better.”
As Australia enters year three of the pandemic, Lewin says it’s important to recognise how far we have come. Back in 2020, there was no prior immunity to Covid in the population, no vaccine, zero treatments. The over-50s were hugely vulnerable. Half of those admitted to hospital would end up in ICU, of whom half would die.
The first breakthrough was in treatment, when doctors discovered that the administration of intravenous steroids reduced the death rate in hospital by 30 per cent. The combination of vaccination and new variants of the virus altered the profile of Covid patients presenting with severe disease: they became noticeably younger during the Delta wave, particularly among the 40-somethings, and are more youthful still with Omicron.
“The clinical spectrum here and across the world has changed with each variant,” Lewin says. “As the virus changes, as the pool of people who are vaccinated changes, people who are at risk of infection changes.”
Given its transmissibility, is Omicron as bad as Covid can get? “I don’t think we know the answer to that,” the Doherty boss says. “The vaccine is definitely holding up in reducing the risk of hospitalisation but the real concern is if we have another variant come along that causes more severe disease … and while you have lots of infection in the rest of the world, there is always a risk of something new emerging.”
Getting it wrong
Like many Australians, the research centre’s namesake, Nobel laureate Peter Doherty, has opted to ride out the storm in self-imposed isolation at home in Melbourne with wife Penny.
Despite being triple-vaxed, he rarely ventures out and is double-masked when he does. At age 81, and with a lifetime of scientific achievement to his credit, he misread the beast.
Coronaviruses were supposed to be relatively stable, less prone to the dramatic shifts that make the ever-mutating influenza virus such a handful. SARS-CoV-2 contained a genetic “proof-reading mechanism” that, Doherty thought, would prop up the vaccine. “We’ve all got things wrong,” he admits. “I didn’t think this virus’s mutation would be as big a problem as it is.”
Australian Medical Association president Omar Khorshid says a level of complacency crept into national decision-making through 2021, false security born of the accelerated vaccine take-up. Governments of all stripes, state and federal, assumed the best when they should have been planning for the worst.
He tells Inquirer: “The criticism that I have towards the decision-making that occurred at the end of last year is that with data about Omicron available, governments still made decisions that might have been more appropriate for Delta in terms of how they expected the population to be protected by vaccines, and not to spread as fast through the population because of the vaccination rate, knowing in fact that around the world people who were vaccinated were getting infected.
“They were happy to take the punt to let this virus into Australia, to not try particularly hard to control its spread because its arrival coincided with opening up, with a lot of fatigue in the community from the lockdowns and restrictions that had been in place. It was just bad news at the worst time. So they didn’t make the decisions they could have made, to be a bit more cautious and to learn more about the virus before making those calls.”
Khorshid is sceptical whether Covid can ever be managed like influenza at either a public health or individual level. Like Lewin, he argues that the “curve ball” of Omicron changed the calculations.
“I think the main problem is that we actually just don’t know,” Khorshid says. “There are plenty of people making predictions … that we will be able to treat this like the flu going forward. But it only takes another variant developing out of Omicron that is more severe and evades the vaccine, and we are straight back into an emergency. It is too early to say whether that will be even possible or at what point it might become possible.”
The hyper new BA.2 sub-variant of Omicron, dominant in Denmark, is already proving even more contagious than the host lineage. There is also the complication of long Covid, the lingering harm the virus can do to the lungs, heart and an estimated 220 bodily systems.
Epidemiologist Zoe Hyde, of the University of Western Australia, cites British research findings that one in seven Covid sufferers will experience persistent symptoms lasting at least three months; those hospitalised were four times more likely to be readmitted and eight times more likely to die than the matched control group over a follow-up period of four to five months.
Royal Australian College of GPs president Karen Price says the situation here needs to be nailed down with detailed research, a challenge when long Covid symptoms are mostly self-reported. “We have to be wary about being too certain about the future,” she says. “Treating Covid like the flu might well be a big mistake.”
It’s not all bad news. Doherty is excited by the breakthrough in Singapore by former CSIRO scientist Linfa Wang to demonstrate a cross-reactive response between immunity generated to the SARS coronavirus in the 2002-04 outbreak in Asia and its Covid-causing cousin, SARS-CoV-2.
Wang, the “batman” of Hendra virus research who traced the deadly zoonotic disease back to flying foxes, believes the consensus sequence will lead to a one-stop jab that will work against future Covid variants. Human trials are due to start by July.
“Covid is opening the door to all sorts of things, actually, in viral immunity,” Doherty says.
He sees new or repurposed oral antiviral drugs such as molnupiravir by Merck and Pfizer’s protease inhibitor, paxlovid, both recently approved by regulators here and in the US and on order by the Australian government, as potential game-changers.
“We don’t control HIV with a vaccine, we do it with a cocktail of drugs and we do it worldwide,” Doherty says.
“We could do this because we had at least two drugs hitting different mechanisms (of HIV), which we may now have with Covid. If you had a pill that you could just take as soon as you were diagnosed and stop the infection or knock it right back, then we really would be in the flu situation.”
The need for additional therapeutic tools was underlined when Omicron proved resistant to most monoclonal antibody treatments including regeneron, the drug then US president Donald Trump received in 2020 when he came down with the virus. One problem with the antivirals, however, is expense. Molnupiravir costs about $1000 a course even though it was developed nearly 20 years ago to treat influenza; paxlovid poisons the protease enzyme, used by the Covid virus to replicate within a human cell, but needs to be taken in conjunction with an HIV drug called ritonavir.
Lewin sees potential for the antivirals to be deployed as targeted prophylaxis to protect vulnerable groups, such as people in aged care, but not as a viable population-wide measure. They will form part of an ever-shifting response to the pandemic alongside proven tools such as reworked vaccines, face masks, social distancing, hygiene and the public health staples of test, trace, isolation and quarantine.
Because that’s the way you live with Covid. Be smart, nimble, ever ready to change direction to keep pace with a virus that won’t be going away anytime soon, as much as we wish it would.
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