Why did we drop the ball so fast on controlling covid? When will we know if it’s peaked? And how do I pandemic-proof my practice?
This is an edited transcript of Healthed’s Going Viral podcast episode with public health physician and Kirby Institute biosecurity program head Professor Raina Macintyre. The interviewer is Dr David Lim.
DL: In NSW, we’ve gone from being more or less successful in our covid management efforts to having some of the highest daily rates in the world. Why do you think this is?
RM: It’s a combination of factors. The Delta epidemic, in the middle of last year, was brought under control with standard public health measures and case numbers were coming down. And then we had the Omicron variant emerge in November, and the NSW government decided to not take that into consideration and to proceed with the NSW roadmap unchanged, which meant stopping most restrictions on 15 December. And predictably that led to a large rise in cases in a very short time. And the Omicron variable is much more transmissible than Delta. So high case numbers combined with the Christmas-New Year season, it was just inevitable there was going to be huge amounts of transmission.
DL: Can you paint a picture of what the shape of the public health challenge could look like over the next months?
RM: I suspect the only thing that will create a change in public health strategy from the government’s perspective is if the health system collapses, to a point where they’re forced to do something. Otherwise, I think they’ve pretty clearly signalled, they’re not going to do anything. And we’ve got schools about to open and I would expect to see a further surge in cases after that. So I think we’re we’re still in for a difficult period.
DL: The problem is that testing is becoming difficult to access, particularly PCRs.
RM: Yeah, it’s just a shame that the government didn’t plan for the predicted massive increase in case numbers by strengthening the testing system. The WHO has actually called on governments around the world, to strengthen testing and tracing – those are the two pillars of epidemic control – and both those things have essentially collapsed.
We really have no idea what the true case numbers are. But I think anecdotally, all of us know, just from the sheer number of people we personally know who are infected, that it’s a lot more than what the official numbers are.
When the testing systems collapsed in December, they made a decision to restrict PCR testing even further. And I think frankly, most people have just given up, they won’t even bother going to a testing centre, because they’ve heard all the stories of people being turned away. And I’ve heard anecdotally that the testing centres are pretty empty. As for the RATs, they’re still not not accessible. So while other countries are still strengthening testing and tracing, Australia has done the opposite.
DL: What is the rationale for reducing testing during this Omicron wave in the first place?
RM: Well, the government was left in this situation where they made a policy decision to remove all mitigations and thereby allow very widespread transmission. They knew from the Doherty Institute modelling that predicted as much as 200,000 cases a day that we were going to face unprecedented case numbers, they should have planned ahead and strengthened the testing system, they should have ordered the RATs last year – they should have anticipated it, they had all the information they needed, but they didn’t. They just thought life would magically go back to normal if they just lifted all the mitigations.
So I think when they were faced with that situation where the testing system was collapsing, they decided the best solution rather than strengthening the testing was to restrict it. They told everyone to take personal responsibility and get a RAT. But there were no RATs to be had – everyone was scrambling around like The Hunger Games of RATs. It was just sheer lack of planning.
DL: Is tracing still useful, and is it still practically feasible?
RM: Yes, it is. Some countries are extremely ambitious in how they’ve approached it. And I think Australia falls amongst the least ambitious countries. There was no ambition to get people vaccinated early, there was no ambition to speed up the booster – what’s the point of everyone having their third dose booster after the Omicron wave is peaked and gone? In spacing out kids’ doses by eight weeks and sending them back to school at the peak of the pandemic?
This is a virus that persists in the brain after the acute infection, it persists in the heart. Are we going to see epidemics of neurocognitive disease and cardiac disease in decades to come in young people? We don’t know. But we do know that the virus affects almost every organ and persists in the body after the acute infections. I’ve seen a study out of the US that showed more than twice the risk of insulin dependent type one diabetes in children following covid.
We can all deny it, and a spin all kinds of narratives to minimise it, but the knowledge is there. Those who choose to find that knowledge know that this is still a dangerous virus.
DL: There are so many people out there saying it’s a mild disease. How do you respond to these sorts of conversations?
RM: So globally, we’ve had four waves of the pandemic, and in every wave, people have said the same thing: Everyone getting infected will create herd immunity, and it’ll be over. Well, it’s not true, is it? You have countries that have had multiple waves are still having waves.
The problem with this pandemic is we have seen an anti-science agenda becoming mainstream. We now see doctors and health officials propagating stuff that is straight out of the anti-vaxxer playbook telling people it is necessary to get infected. Then backtracking when people start having covid parties.
I’ve worked in vaccines for 25 years and been dealing with the anti-vaccine lobby for that long, and having measles parties, chicken pox parties, that is core to the anti-vaccine movement. And here we have public health officials, doctors propagating science disinformation, it’s really quite terrifying.
It’s true that that Omicron is not as severe as Delta, but Delta was twice as severe as alpha, right. Omicron is probably similar to the original Wuhan strain. So this is still a very serious virus. It’s not like influenza. I have worked in influenza research for 30 years, I have followed every severe influenza season in Australia since 2003, and I can tell you, you don’t have 20, 30, 40, 50 people dying every day when there’s an influenza season, you do not have ambulances ramped to such an extent that people having a myocardial infarction cannot get an ambulance for five hours, you do not see tents put up in the carpark to treat patients, you do not see nearly 3000 people a day in hospital, you do not see 200 plus people in ICU on a given day.
DL: If I was a lay person, I probably wouldn’t know how to tell spin from fact now.
RM: Yeah. And the problem is, it’s coming from politicians, it’s coming from doctors, it’s coming from public health officials. There’s others who are just trying to be more objective and scientific, who generally pay a pretty high price for that – we get attacked a lot and shouted down. And it’s not just an Australian phenomenon. In the US in the first year of the pandemic, we had a political leader who was promoting drinking bleach and taking hydroxychloroquine and all kinds of anti-scientific nonsense.
DL: People have been told to exercise personal responsibility. What does that mean in the scope of public health strategy? Has it ever worked?
RM: For rich people, yeah, you can buy your own oxygen, you can have an oximeter, you can get your RATs, you can set up a hospital in your own home. But for the ordinary person out there living in a multi-generational family in one small apartment, there’s not that many options. It’s essentially another way of saying the government’s not going to do anything for you any more, it’s everyone for themselves.
DL: It seems getting Omicron does not protect you against reinfection. Do you have any figures for reinfection?
RM: A booster will give you much better protection. If you’ve had infection and you’ve been vaccinated, also you get a good response. But if you haven’t been vaccinated you’re very likely to get infected again.
DL: What do you think about fourth doses?
RM: The vaccines we have at the moment were developed against the Wuhan strain, which pretty much died out in March 2020. So what we’re dealing with now is phylogenetically very far removed from the original strain. So what we need is an Omicron targeted booster, which both Pfizer and Moderna are making.
If we’re going to have a fourth dose, it really should be matched to the predominant variant of concern.
DL: What’s the data on the new drug Paxlovid [nirmatrelvir-ritonavir] in preventing hospitalizations?
RM: It looks highly effective. Molnupiravir looks reasonably good as well, but Paxlovid looks more efficacious. Remdesivir still works as well, but not as well as these other two drugs.
DL: Why is it on every one of these issues that we are always on the back foot, or have taken a relatively relaxed position till the last moment?
RM: Go back and look at press conferences from early 2021: “It’s not a race”, we’ll just wait and see what happens in other countries. Those words have been repeated over and over again, every step of the way.
DL: We keep hearing now that we’ll soon be over the peak. What does that mean?
RM: There are two issues there. One is that we don’t know, because the testing system’s collapsed. So we don’t have an accurate gauge of what the true case numbers are. The only way we can more confidently say the peak has passed is when we see a sustained decline in the hospitalisations, bearing in mind that they will lag cases by one to two weeks. So when we’ve seen a good two weeks of continued sustained decline in hospital numbers, yes, we can say it looks like it’s passed.
The second thing is we’re having schools opening in a week or so. There’s going to be another surge after that. I think if we’ve passed two weeks after the opening of schools and numbers are still going down, okay, good, I was wrong. But you’re looking towards the middle of February, I think, to really get a handle on what effect the opening of schools has had.
We’re all sick of it, we all just want this to end, but the virus has thrown up substantial mutations pretty much every six months. What’s actually happened is not what was expected by the virologists, it’s mutated actually at a much faster rate than influenza.
We need a variant-proof pan-coronavirus vaccine. There’ll also be variant vaccines that have two or more antigens in them – Omicron and delta, for example.
DL: Do you have any final messages for our GP listeners?
RM: If you haven’t had your third dose, get it as soon as possible.
You should be wearing an N95. Everyone working in the practice should be wearing their N95, because it’s absolutely clear that a cloth mask or surgical mask is not enough against Omicron.
Another thing is safe indoor air. I went into a general practice to get my booster and the windows were closed, and there were windows that could be opened, and I said to the GP, have you tested the ventilation in here? And she was just clueless. I said, you need to open that window or you’re going to get infected, but she just didn’t seem to think that was an issue. A carbon dioxide monitor is the way to measure that ventilation. It’s a proxy for how much of other people’s breath you’re breathing in, and you can buy them relatively cheaply – they start at about $30 on Amazon. Or you can put an air purifier in – they start at about $300, they can go up to about $1000, but they make a dramatic difference in clearing the virus.
I think we’re going to be dealing with this for a while still, it’s definitely worth pandemic-proofing your practice.
DL: When you say for a while …
RM: I think at least a couple of years, maybe longer.
But there’s hope on the horizon. Definitely there’s good drugs, there’s going to be better vaccines, there’s going to be a matched Omicron booster very soon. And it’s worth holding out for that. It is a serious infection, it has not mutated into a common cold, and we do have to try and prevent it in ourselves and in the people we look after. But there’s also reason for hope.
