A much more optimistic position on COVID-19

By Dr Dion Martley, FRNZCGP

In March 2020, New Zealanders experienced one of our most dramatic peacetime events in the face of a perceived deadly pandemic. The stage was set with frightening imagery from Wuhan, China being broadcast across the world as doctors scrambled to assess the risks and spread. Many observers thought western democracies would not consider Chinese-style lockdowns, because of their constitutions and the values placed on personal freedoms.

Dramatic images from a bad outbreak in Italy and advice and modelling from the Scientific Advisory Group for Emergencies (SAGE) in the UK, created a template for a lockdown that was reasonable and safe. At the time, waiting seemed a lot more dangerous because it could mean our health services being overwhelmed and possible deaths. In the face of panic, there was no time to do a further cost-benefit analysis and the previous pandemic plans and principles were largely shelved.

Most New Zealand GPs were very relieved, at that time, to get the call to work remotely where possible, with routine and urgent care continuing in a safe way.

We have now moved to a new state of knowledge and preventive capacity, and the paradigm is changing rapidly in a favourable direction. In addition, a significant portion of this pandemic has likely now run its course in most parts of the world.

For a start, very much more is known now about COVID-19. It is not a highly lethal Ebola-type infection, or like the Spanish flu that killed young and old alike in much greater numbers. It is more like a slightly more dangerous flu-like viral illness, which circulates in a continuous manner with seasonal peaks, and is likely to continue to do so, like many viruses before it.

Mathematical modelling that was used by SAGE to predict events in 2020, and that led to lockdown advice, used estimates of death rates up to two percent; very scary. Fortunately, in the end, it has been very much less than that. 

The initial advice was based on a strong principle of precaution. The modelling used was based on assumptions that few people had any immunity at the start. In addition, at the beginning, the extent of very mild and asymptomatic cases was unknown, which made it difficult to calculate the actual case fatality rate. Further research has shown that a far higher percentage of people (perhaps 20-30 percent) were immune or not susceptible at all by mechanisms of cross immunity to other prevalent coronaviruses, T-cell immunity, and genetic factors. 

We also now know that COVID-19 strongly and very asymmetrically strikes the elderly, and those with certain medical conditions - most deaths being in those over 70, with the average age of death around 83 years. This means policies, and now vaccination, can strongly and promptly focus on protecting these groups. These are the same susceptible groups who often suffer at the end of their lives with respiratory and circulating viral infections. It is vital that vaccine offering is rolled out as fast as possible in these groups.

Thanks to the remarkably rapid development of several effective vaccines, which are already appearing to strongly reduce mortality, we are now in a very different and much more optimistic position to soon return to life as we knew it. 

We have a very good model to observe in the UK, now slightly ahead of us, with respect to both safety and effectiveness, which will hopefully provide advanced insights that help inform and facilitate our ongoing response in New Zealand.

A deeper understanding and a cool-headed recalibration to the true level of risks is essential - particularly as this has not varied as significantly as perceived from previous baseline mortality risks. 

There now needs to be a more vigorous and open public debate about how to reliably diagnose and deal with future pandemics, including information dissemination, because what is happening now largely contrasts with previous pandemic plans.

A debate about risks and perspectives (and realistic contextualisation of the risks) is also needed. 
Our future depends on further integrating essential global talent and connecting strongly with the world again. Many New Zealanders have now been involuntarily separated from loved ones overseas for going on two years.

We now have relatively ‘straightforward’ path out of this situation by offering informed, consented vaccination with a strong focus on susceptible groups, who will derive the greatest benefit. The vaccines are very likely to give many years of useful immunity. 

I believe it is reasonably foreseeable that fully-vaccinated New Zealanders will soon travel freely in and out of New Zealand, without restriction, once adequate vaccination levels are achieved, the vulnerable are well protected, and all adults have been offered vaccination

Naturally, the usual public health advice to stay home if you are sick on return, remains more important than ever. Rapid self-administered saliva-based tests if validated may provide a further safety net.

Government policy could also consider requiring visitors and New Zealanders to be vaccinated prior to returning as an alternative to mandated isolation. This would reduce the impact of personal and family costs and reduce the impact on the economy and essential national workforce, which is constraining economic wellbeing. Increasing numbers of tourists, visitors and immigrants are themselves likely to have been vaccinated in their own home country, further reducing risks, and mitigating this issue and facilitating alternative safe policies.

Perhaps more importantly there will need to be ongoing debate about policies for dealing with similar pandemic events. Former pandemic plans have always stressed the importance of carrying on with normal life as far as possible.

To close I would like to quote Sir Jeremy Farrar, director of the Wellcome Trust and a member of the Scientific Advisory Group for Emergencies (SAGE) speaking to the Daily Mail in June. 

“There is a danger of not opening up and this infection is now a human endemic infection. It’s not going away,’ he said. ‘Humanity will live with this virus now for ever. And there will be new variants. This year, next year, the year after, there will be new variants – and we will have to learn to cope with that. ‘Lockdowns are awful. They are a mark that you haven’t been able to control the virus in other ways. They have very profound consequences on mental health, on education, on job opportunities particularly affecting people on lower incomes. Societies can’t stay in that mode for ever.”

Sources of expertise and perspective

Prof Michael Levitt-Interview on unherd
Nobel Prize winner and full of humility and an open ability to admit how he may have been wrong.
Important point on how excess mortality and its timely calculation should be the future key metric.
 
Prof Jay Bhattacharya-Interview on UnHerd
Stanford Professor of medicine / public health. 

Prof Sunetra Gupta-interview on Spectator TV
Oxford theoretical epidemiology professor - a brilliant and calm intellect. 

Dr Simon Thornley - public health specialist Auckland University 
Excellent list of references at end of rapid response in BMJ. His points, as below should be the basis of further debate
a) modelled overestimation of covid death
b) overestimation of infection fatality rate/proportion (currently 0.05% in Singapore) and factors/debate how this differs from determination methodology for influenza for the same metric.
c)determination of death ascertainment documentation and accuracy /validity 
d)understanding and research on past /present prevalence and a cost benefit analysis of harms and benefits of NPIS ( non-pharmacological interventions=lockdowns).