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During 2020, there was some debate about whether Australia should pursue a Covid-19 suppression or elimination strategy, with much of the focus on what was feasible and sustainable. Having boarded the elimination bus, I hope to alight at some stage in 2021 to take a seat on the protection bus.
The goal of 2021, as we move from a maximal suppression or elimination strategy to a vaccination and protection strategy, should be to reach a position whereby we can return to a life similar to pre-Covid times without risking major public health burden related to Covid-19. There are several key issues to understand, and strategy signposts along the way, during a year that hopefully will maintain Australia’s place as a leading country in the global pandemic response.
The welcome news of the Australian vaccine rollout from February brings the first signpost. The first groups of people to be vaccinated, including hotel quarantine and border workers, frontline healthcare workers, aged care and disability staff and residents, will presumably receive the Pfizer-BioNTech mRNA vaccine which has 95% efficacy in prevention of symptomatic disease (Covid-19) and for which Australia has a contract for 10m doses (enough for 5 million people). Subsequent groups, including the elderly, presumably will receive either this vaccine or the AstraZeneca/Oxford vaccine, which appears to have lower efficacy (60-70%), but which, like the Pfizer-BioNTech vaccine, appears to prevent almost all severe Covid-19. Importantly, the AstraZeneca/Oxford vaccine will be produced locally by CSL, has less stringent storage requirements; and a contract for around 54m doses is signed. A contract has also been signed for 51m doses of a further vaccine from Novavax, which looks promising in early phase trials, but we are still waiting on final safety and efficacy data.
There has been recent concern, particularly following the identification of strains with likely increased risk of transmission from the United Kingdom and South Africa, as to whether these and other vaccines will impact spread. Preliminary data from another mRNA vaccine (Moderna) trial indicated reduction of all Sars-CoV-2 infections (with and without symptoms) from week two to week six (two weeks following second dose), with an impact even after the first dose. This is incredibly promising, given continued rapid spread globally and need for further protection in settings such as Australia. Furthermore, those who develop vaccine breakthrough infections may be less infectious, as they are less likely to be sick and may have lower viral levels.
Enhanced transmission risk of new strains or reduced vaccine efficacy against them could mean a higher proportion of the population require vaccination to achieve herd immunity and thus control of Sars-CoV-2 spread. But even a less optimistic scenario whereby there was some ongoing community infection but high vaccine uptake in vulnerable populations (particularly the elderly), would markedly reduce risk of major disease burden from Covid-19. A couple of key assumptions are important in this relative optimism. Under this scenario, there would be ongoing cases among unvaccinated populations, and some vaccine breakthrough, but low numbers of severe Covid-19 cases and deaths. Numbers in the latter categories are, however, likely to be higher than in recent months in Australia under highly successful elimination-type strategies.
Getting the Covid-19 balance right during 2021 will be a key public health priority. An elimination-type strategy has been pursued because case numbers can increase exponentially, with small uncontrolled clusters leading to widespread community spread as we saw in Melbourne last winter. Thus, major restrictions, including lockdowns, have been required in different Australian jurisdictions.
Presumably, the proportion of the population vaccinated will be the major determinant for a move away from an elimination-type strategy, however public health advice is likely to be cautious.
Thus, if we approach the next winter with a minority of the population vaccinated, even if a large majority of vulnerable populations are vaccinated, similar levers will be pulled in response to increasing case numbers.
But a time should arrive during 2021 when these levers are not reached for as readily, with the understanding that some infections will occur. Testing and contact tracing will continue in relation to these outbreaks, with enhanced national cooperation in these activities. Furthermore, optimisation of vaccination in particular settings or populations will be facilitated if very high levels have not been achieved.
Before the end of 2021, once Australia has completed its vaccination rollout, but clearly before high-level global vaccination coverage is achieved, international travel restrictions should be eased. There will be enormous variation across countries in relation to travel and entry requirements. In terms of people coming to Australia, either returning residents or international travellers, hotel quarantine may only be required for those without demonstrated vaccination. In the context of very high-level Australian vaccination and demonstrated impact of vaccination on transmission, there should be limited need for “vaccine passports” or hotel quarantine.
The major goal for 2021 should therefore be rapid vaccine rollout, including all vulnerable populations by winter, and an easing of requirements for pursuing an elimination-type strategy. By New Year’s Eve we may not have completely reached Covid “After Times”, but we should be celebrating their dawning.
Source: The Guardian
Keyword: Just how ‘normal’ 2021 will be hinges on Australia’s Covid vaccination uptake | Coronavirus