Pearls and Irritations

The Victorian ‘lockdown’ was necessary, brutal and successful. But any COVID complacency could be literally fatal. We must ask a lot of our younger Australians who understandably chafe at restrictions placed on their social interactions.

In the last week 2 million people have been infected with the SARS-CoV-2 virus. Globally the pandemic is raging.

The situation in the US is literally disastrous with the largely self-inflicted severity of it’s epidemic featuring more than 225,000 deaths, A contemptuous disregard for evidence based strategies to minimise the spread of the virus is associated with daily infection rates of almost 80,000. The US epidemic has never been contained.

However for the majority of countries struggling with huge increases in infections and deaths, the resurgence of the virus has occurred as restrictions, including ‘lockdowns’, that had reduced flames to embers, were removed. How distressing to see during the week, vision of an Italian nurse in tears as she described the return of the tragic scenarios she had experienced in April. Yet again her hospital’s ICU was unable to provide the care so many desperately needed.

Few countries have handled the challenges presented by this pandemic better than Australia. When compared to so many other countries our situation is enviable. Indeed America’s leading infectious disease specialist, Dr Tony Fauci spoke enviously of Victoria’s success in responding decisively to its explosion of infections.

However, as is so obvious when looking at the global scene, many countries are experiencing second waves of exponential growth in infections after restrictions produced success similar to our own. Our current hard won situation remains fragile. What must we do to avoid the post lockdown resurgence being experienced in France, Italy, the UK, Spain, Israel, Belgium and so many other countries? The following facts need to inform such a discussion.

The prevalence of the virus is between 6 and 24 times the incidence detected by testing symptomatic individuals. SARS-CoV-2 is much advantaged as infected individuals, including children, without any symptoms, can be efficient virus spreaders. A number of studies have confirmed that infections are associated with the production of antibodies but their production is not sustained as is common with other corona viruses.

An increasing number of second infections are being reported confirming that any immunity from natural infection is short lived. There are zero signs of the emergence of any ‘herd’ immunity. The virus is mutating with more than 100 changes noticed since its initial appearance. These changes are not associated with more severe disease but they do appear to make the virus even more infectious. The longer we allow the virus to infect millions the greater the chance that it will become even more dangerous.

There are no therapeutic agents that can effectively treat infected individuals although a very strong steroid preparation, Dexamethasone, certainly lessens the lung damage the virus can produce. Although the American FDA has authorised the use in emergencies of the drug Remdesivir,which initially was thought to increase the speed off recovery from severe COVID-19 infections, the most recent studies have not shown any therapeutic benefit.

Disappointingly the Ely Lilly trial of treatment with convalescent plasma which contains antibodies against the virus has not met with success when administered to patients with advanced and severe infections. This is not altogether surprising as antibodies are most effective in blocking the infection of human cells with the virus so in advanced disease too many cells may already have been invaded for the antibodies to help the situation. Trials of this approach in early stage disease continue.

There is plenty of evidence that Hydroxychloroquine offers no therapeutic benefit. What is Clive Palmer doing with the 32 million tablets he bought?

What is the vaccine situation? There is general agreement among virologists and immunologists that a vaccine can be developed to minimise the spread of the SARS virus. We anticipate having our first hard evidence that this is so from phase three trials in humans in about three months. Given the weakness of the immune response to natural infection it is likely two or three doses of any vaccine may be needed to provide protection. As with the flu vaccine we anticipate the success rate will be about 60-70%, enough to protect the community if 60-70% of us get vaccinated. Vaccinating children will be essential. Annual vaccination will be needed as total eradication of the virus from the planet is most unlikely.

There is little chance of an effective vaccine being available to all Australians before the end of 2021. As already there is anti-COVID vaccination scaremongering occurring we need to implement strategies now to build community confidence in any vaccine Australia might approve. Having said that our immediate efforts to maintain our enviable control of the epidemic should not involve any “well we will soon have a vaccine” thinking.

Premier Andrews, and indeed Victorians, deserve congratulations for taming an exponential explosion of infections that saw more than 700 new cases a day in June. Some criticism for issues that were associated with this development are justified. Security of the quarantining program was inadequate and Victoria was less equipped to contact trace than some other States.

As of today many European countries have introduced lockdown strategies forced on them by the extraordinary explosion of cases they are experiencing. They would have been wise to so do a lot earlier as Andrews did. There can be no economic relief with a raging epidemic producing swamped hospitals, dangerously high rates of infection among health professionals and ever rising COVID related deaths. As I have expressed before, there is under appreciation of the longterm morbidity associated with infection in the young.
While in no way comparable to the politicisation of the epidemic in the US there are signs that we are not immune from this altogether. NSW and Queensland have restrictions in place that see both States with outbreaks that are being well handled with contact tracing. I can see no scientific argument to support the continued closure of the NSW/Queensland border. The Queensland Premier’s reluctance may be associated with her need be perceived as a strong protector of Queenslander from the virus as an election looms. On the other hand caution in Victoria as lockdown ends is appropriate as the citizens of that state move towards a restriction regimen similar to that of other Australian States.

So now for the really important challenge, living and working safely in a COVID world. Global experience suggests that we will fail. For this not to happen will require us to sustain cautious behaviour not maintained in so many countries now in desperate trouble. The development of any COVID complacency could be literally fatal. We must ask a lot of our younger Australians who understandably chafe at restrictions placed on their social interactions. Around the world it is the lack of caution among 19-29 year olds that disproportionally put infection control at risk. While certainly not invulnerable to the damage SARS can do to them their acceptance that they have a major role to play in protecting older Australians from potentially severe illness is so important.

I see little mask wearing in Sydney. We should all wear masks when in a situation where we are exposed to crowds for more than a few minutes, e.g, public transport. The vast majority of infections occur with exposure to virus infected individuals for more than15 minutes. Social brevity as well as social distancing should be our goal at the moment. I was nervous when seeing the understandable but worrying footage of Melbournians celebrating there ‘release’ at midnight in ways that did not look as if social distancing was being a focus.

If I have any criticism of our testing regimens it would relate to our relative lack of ‘sentinel’ testing. We have concentrated on having Australians with any respiratory or COVID associated symptoms (loss of smell or taste, etc.) volunteer to come and be tested. Especially with an epidemic featuring asymptomatic spreaders we need to ramp up targeted (Sentinel) testing wherein we approach many people in a given area and ask them to be tested to better monitor the prevalence of the virus in our community. Each year we target a number of GP practices and ask all attending to be checked for exposure to the influenza virus. Even more important is the need for us to know that our behaviours are resulting in very few asymptomatic infections occurring in our communities.

The ultimate COVID disaster for us would see us need to impose lockdown strategies again.The ultimate triumph for us would see us so understand and respond to the demands placed on us by an invisible enemy that we live and work safely albeit far from normally until a vaccine gives us the upper hand. Apart from the oft urged social distancing, mask wearing, hand washing etc we must now expect from our governments an appreciation of the social determinants of COVID era health. A millions of us are unemployed, mental health stress is ever more common, social security is bypassing many. These are all issues for priority action. We are fortunately a wealthy country with economists reassuring us that we are perhaps uniquely capable of accruing necessary debt as we make sure no Australian is left behind. Unlike the US where the Tump administration has said control of the epidemic is impossible it is within our hands to do just that.

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