Is this the outbreak we had to have?

Blog post by Professor Tracy Smart AO, Public Health Lead - ANU COVID Response
12 October 2021

As we emerge from Canberra's lockdown, the world looks very different from where we left it nine long weeks ago. Our elimination 'strategy' is now firmly in the rear-view mirror, and vaccination rates are everyone's focus and are exceeding the public health experts' wildest dreams. As such, our pace towards moving to the next phase of the pandemic - living with COVID-19 and reintegration with the rest of the world - has rapidly accelerated. But was this the 'outbreak we had to have'? Have all these lockdowns really been worth it? And what will life be like as we look towards the end of this year and the beginning of the next?

The Delta variant arrived in Australia at the best possible time

There is no doubt that NSW underestimated the infectiousness of the Delta variant and locked down far too late to eliminate this outbreak. The reluctance to lockdown hard and early had a big impact on Greater Sydney and large swathes of the state, and allowed spread of COVID-19 to other jurisdictions, in particular Victoria, the ACT and New Zealand. There have been more than 100,000 positive cases and 500 deaths in these jurisdictions since the outbreak in NSW began.

Purely by chance, this Delta variant outbreak happened at pretty much the best possible time during the pandemic. If this had happened last year, or earlier this year, we would have been in a world of hurt as we would not have had the vaccine or vaccine supplies to allow a pathway out of lockdown. But in June and July this year - when the combination of a variant that was far more infectious and people generally being 'over' extreme public health measures meant that Sydney could not get back to zero new cases (a fact that NSW recognised well before other states) - we finally had the hope of sufficient quantities of the vaccines. Suddenly people realised that COVID-19 did present a real and present danger. They also had a compelling reason to overcome their vaccine complacency or hesitancy at the same time that our vaccine supplies were finally arriving to meet our demand (thanks also to an extra boost from swaps with other countries).

Several pundits in recent days have used our current position as evidence that our elimination strategy, with its harsh lockdowns and closure to the rest of the world, was the wrong approach. The same pundits have lavished NSW with praise for leading the country towards our brave new world. We were always going to have to abandon this elimination strategy and learn to live with COVID-19 at some stage. While the NSW response was initially slow and extremely damaging, it gave the whole country the impetus to get to this position much earlier than we otherwise might have done.

Should we have pursued an elimination strategy in the first place?

If you recall, our initial strategy was one of suppression, not elimination, but one by one every state and territory went down the elimination path, and the Federal Government followed suit. Has it been worth it? The answer very much depends on what parameters you are using to measure the effect. There have no doubt been severe economic, social and mental health effects. I will leave it up to the experts to dissect this in more detail once we are through to the other side, but I do know that our approach has saved lives and prevented severe COVID-related illness in hundreds of thousands to millions of people.

What lies ahead?

This is the question all Canberrans are no doubt asking themselves as we approach the end of lockdown later this week. The weekend before last, when we had more than a hundred cases in two days, I was really concerned that we would be exiting lockdown in a phase of exponential growth. However, recent daily numbers have defied my prediction. This, and the steady downward trend in cases in NSW in recent weeks, is no doubt the effect of our increasing number of fully vaccinated people. Even in Victoria the outbreak appears to be peaking and there has been a definite decoupling between the rise in daily cases and the rise in hospitalisations (the rate of the latter is much less).

Nevertheless, our extreme social distancing measures are also playing a large part and as we wind these back and more people start interacting, it is likely that we will see case numbers rise. This could mean that we are in for a disruptive few weeks but how disruptive will depend on two things - how quickly and thoroughly we get the rest of the eligible population fully vaccinated, and how diligent we are in implementing other public health measures - being COVID-safe. This is why the University's approach is to ease very gently out of lockdown and keep the number of people on campus as low as possible to reduce the risk to our community.

Living with COVID

While the next few weeks are a bit uncertain, we should have a much better sense of what living with COVID is like by December. And live with it we must, as the pandemic is likely to have a few more twists in its tail before we are done. All jurisdictional health departments are looking closely at what this will mean for things like ongoing public health measures and our current Test, Trace, Isolate and Quarantine (TTIQ) approach. This has already started to change in NSW and Victoria and the coming weeks will not doubt also bring change in the ACT, with different contact requirements applying for the vaccinated and unvaccinated. What will also change is that there will be less focus on daily case numbers to inform us of local outbreaks and more on hospitalisation rates. It is a large spike in the latter that may require an increased public health response and even lockdown if the health system comes under pressure.

A picture of what living with COVID is starting to emerge overseas, but it is a very mixed bag at present. Countries such as the UK (66 per cent of their entire population is currently vaccinated) and Denmark (75 per cent) have both eased all restrictions (in July and early September, respectively). The former had another large peak and cases remain high, while the latter is also starting to see a rise, but in both cases hospitalisation rates are far less. Israel (64 per cent) relaxed their restrictions in June for fully vaccinated people but have had their highest new case wave of the entire pandemic between July and September. Hospitalisation rates have also peaked but at a lower level. This has prompted Israel to decree that full vaccination, and therefore access to certain privileges, now requires a third dose of vaccine.

But perhaps the biggest cautionary tale is Singapore, which is 78 per cent fully vaccinated. Its plans for reopening at 80 per cent fully vaccinated have experienced a huge set back. They are currently experiencing their highest peak of new cases, hospitalisation and deaths for the entire pandemic, resulting in a hospital system under pressure and reintroduction of restrictions. Of course, Singapore is not a good analogue for Canberra or many other parts of Australia. Their population density is much higher and their approach to management of COVID is much different. However, it does serve as a strong reminder that we still have more work to do.

We will continue to watch developments from overseas to shape our approach to operating in the new COVID-normal environment in 2022. While the present focus is on vaccination and whether it should be mandatory to undertake various activities, this is only one of the hierarchy of controls we must have in place to live with the disease. In fact, the ACT government has declined to use mandatory vaccination as a tool in most settings because it doesn't need to. It is not a public health requirement - more a method to encourage the hesitant. Nevertheless, ANU will be looking at whether some activities should require people to be vaccinated next year. But it will also be looking at other controls, such as ongoing requirements for public health measures, an update to our Campus Alert 'traffic light' system, ventilation requirements, how we will manage contacts and cases going forward, and options for disease monitoring.

But while there is uncertainty ahead, there is also hope that with the right settings in place and a continued positive approach to COVID-safety in our ANU community we can look forward to a much less disruptive and much more normal 2022.