The Perils Of Covid Complacency




Every COVID-19 headline from the other side of the world is a warning for us here — the writing on the wall if we continue to be complacent about controlling the pandemic. Yes, new infections are on an overall decline in the US. And yes, more people are fully vaccinated. But our defensive shield against the virus is still quite weak, and what’s happening across Asia and Australia reminds us that the virus’s weapons are improving.

Until very recently, countries like Australia, China, Singapore, and Taiwan had their pandemics completely under control. New COVID cases were down to the single digits and their cities and economies had been reopened for nearly a full year. But in each of these countries, new outbreaks have emerged, ones that have proven dangerous enough to lead to new lockdowns, with schools shutting down and restaurants and other public gathering places closed.

The first signs of trouble started brewing in Singapore in early May, a country with some of the most stringent COVID-19 restrictions in the world. Within the country, cases were well contained. When they occurred — which was rarely — new cases were quickly identified, immediately isolated, and everyone who had come into contact with the person infected was asked to quarantine, under penalty of law. Travelers to the country were also subject to mandatory quarantines, in government-supervised hotels where they were required to test negative multiple times before being allowed into the community. 

But the one place they overlooked was the airport itself, where travelers from high-risk countries arrived and rubbed shoulders with airport staff before being ferried to quarantine. Those airport workers, many of them vaccinated but some of them not, dined in the public food court alongside other airline staff, passengers, and local Singaporeans who often visited the airport for its food, gardens, and entertainment attractions. While these containment measures may have been enough to keep the virus at bay throughout the last year, when confronted with new highly transmissible variants, they proved a poor match.

A fully vaccinated 88-year-old airport worker was the first to test positive for COVID-19, having been infected by the highly infectious Delta variant, which was recently linked to the huge outbreak in India. That single infection expanded into an outbreak that saw up to 40 new infections per day and forced the lockdown of the entire country — another circuit breaker to buy the country time to identify and contain all those potentially exposed to the highly infectious virus.

Meanwhile, in Taiwan and Australia, similar stories were unfolding. Taiwan had been extremely successful at keeping the virus from entering the country — for more than a year, the country had kept new infections near zero and had successfully contained new cases at the border. But those low case counts bred complacency. There was little testing done within the country itself, limited surveillance, and no rush to roll out the vaccines. In April, confident of their success, Taiwan changed the rules for the airline crews on arriving flights, allowing them to quarantine for just three days instead of 14. Within the month, cases went from single digits into the thousands, with airline crews bringing the virus into local bars. This time, it was the Alpha variant that managed to sneak in, a variant with mutations that are known to disable the first line of our immune defenses, giving the virus more time to multiply and spread. By May, Taiwan too was forced to start shutting down public venues, nonessential services, and limiting gatherings to all but a handful of people. Cases have now spread to the chip factories, causing a global shortage which has hit everything from cars to consumer electronics. 

Australia enacted a much more forceful lockdown in the face of its own breakthrough variant, this one brought in not by airline staff but by a passenger dutifully following hotel quarantine rules — a Melbourne man quarantined on the same floor as another traveler who eventually tested positive for the highly infectious Kappa variant. Though the two individuals had no direct contact with each other, they opened the doors to their hotel rooms within 30 minutes of each other, a seemingly innocuous event that has led to more than 300 potential sites of exposure and more than 17,000 people potentially exposed to the virus. Genomic sequencing confirmed that both individuals had the same strain of the virus. A similar event occurred earlier in April where two families quarantining in rooms next to one another were found to share the same viral sequence, after briefly opening their doors 30 minutes apart.       

The lockdowns unfolding in Asia and Australia should be a warning to us all that we cannot be complacent in the face of these new variants. It will take a single infection to spark a renewed outbreak across our country, one that could lead us back into the lockdowns of 2020 that we are already struggling to recover from.

Many assume our higher vaccination rates will help prevent this from happening, but there are a few flaws with this thinking. First, less than half of all Americans are fully vaccinated, meaning the majority of Americans are still at risk today. Additionally, the case rate among the unvaccinated seems to still be hovering at around the same rate as it was in January, when we were seeing upwards of 200,000 new cases a day in the US. While thankfully the total number of new infections is now significantly lower — though not nearly as low as it was in places like Singapore, Taiwan, and Australia — the case rate among the unvaccinated reminds us that the virus, and these new variants, are still circulating widely within our midst. Even in vaccinated individuals breakthrough cases can occur and as we saw in Singapore and Australia those cases can be patient zero in a new outbreak. Those with compromised immune systems will also not receive the full benefits of vaccination and will be left vulnerable with other public health measures in place.             

With Covid-19 cases declining to more manageable levels in the U.S. now is a critical time to adopt the lessons of other countries to keep cases at those levels or lower and avoid the trap of complacency. First, we need a return to basics, a public health strategy that has been proven to contain outbreaks; test, trace and isolate.            

To make long-term testing for Covid-19 sustainable and to encourage compliance, we need to continue to invest heavily in mass rapid testing that can be done at home across the country. Tests need to be free and widely accessible. This needs to be accompanied by public health messaging that encourages the public to get tested if they have symptoms or are exposed, even after vaccination. One of the initial cases in the most recent Australian outbreak, experienced symptoms for over 10 days before getting tested, mistakenly believing Covid-19 to no longer be a threat in the country. Hospitals in Taiwan stopped aggressively testing people for Covid, even those with a fever. In February, Taiwan was administering just 0.57 virus tests per 1,000 people in mid-Feb.        

Contract tracing has largely been a dismal failure in the U.S. and a recent study showed that 2 of 3 individuals with COVID-19 were either not reached for an interview or named no contacts when interviewed. A mean of 0.7 contacts were reached by telephone by public health authorities, and only 0.5 contacts per case were monitored, a lower rate than needed to overcome the estimated global SARS-CoV-2 reproductive number. We witnessed how effective contract tracing and quarantining was in containing and extinguishing Ebola in West Africa in 2014 and 2016. Yet we failed to apply these hard-won lessons in the U.S. 

Australia did not have a strong contact-tracing system from the outset, they learned the perils of complacency the hard way. A weak contact tracing system was one of the triggers that led to the second wave of Covid-19 cases in Melbourne in August 2020. This surge resulted in a 112-day strict lockdown. However, when restrictions began to ease, contact-tracers had adopted the Japanese practice of backward-tracing contacts for the previous 14 days, and the Vietnamese practice of quarantining first- and second-order contacts. This meant that the majority of cases in a recent outbreak in Melbourne were already in isolation when they tested positive.     

Public health departments in the U.S. have been under-resourced through most of the pandemic to trace the astronomical case numbers. But now, as cases reach a more manageable level, is the perfect time to invest in contact tracing to keep cases at those levels or lower.     

Yet as previously stated, the virus is constantly evolving and mutating. We need to be tracking these changes so we are prepared to act responsibly. Yet between December 2020 and April 2021, the U.S. has sequenced about 0.3% of individuals testing positive for Covid-19, with wide variation between states. By contrast, the United Kingdom has consistently been sequencing 10% or more. The low rate of sequencing provides an incomplete picture and puts us at risk of missing new variants with more transmissible qualities. We need to dramatically ramp up genomic sequencing efforts and create better coordination between labs across the country.    

Finally, one of the most important lessons we can take from this pandemic is to be prepared to act quickly and swiftly for the most effective result. Australia is known to act swiftly based on incoming data whether it be snap lockdowns, being among the first countries to implement drive-through COVID-19 testing clinics in March 2020, or quickly changing policies from home isolation to hotel quarantine, when it was clear some returned travelers were not complying.  

A new study has highlighted how locking down quickly and responsively in a high-income country like Australia yields significantly better health and economic results than a “wait and see” approach that ends with a delayed lockdown 21 days later or unmigitated spread.         

A co-author of the study Professor Quentin Grafton compared Australia’s lockdown strategy with the early strategy of the UK.  “The UK has lost 128,000 lives to COVID-19 and in 2020 suffered its biggest annual decline, 9.9 percent, in GDP in over 300 years. By comparison, Australia’s GDP is now higher than it was just before the pandemic and has, to date, suffered less than 1,000 fatalities.” As difficult as it may be, the UK would be wise to delay their planned reopening and lifting of all restrictions as Covid-19 cases have steadily been increasing in recent weeks.         

Co-author Professor Tom Kompas stated that the study demonstrates “elimination of community spread in Australia is best for both health and economic outcomes. There is no question about this.”

The study examines different scenarios. In one model, early mandated suppression in Australia was highly effective at both ‘flattening and shortening’ the curve. The total number of active cases peaks at approximately 4,850 cases, with 100 deaths and 6,650 total cases. With a 21-day delay mandated suppression strategy, the number of active cases peaks at 241,000 and the number of deaths increases to 9,074. In the scenario of unmitigated spread, with no restrictions, the total number of cases is nearly 16 million, with a peak of 5.7 million active cases. Fatalities without control are roughly 260,000. 

Victoria’s recent lockdown is a perfect example of this policy in action. To many other countries, 23 cases would seem insignificant, but at the time of announcing the lockdown, the Victorian government knew from contact tracing that the exposure sites were at 150 and counting, some including nightclubs and bars. Naturally, as time passed, those cases increased but all were already isolated, preventing further community transmision. After two weeks, the “circuit breaker” lockdown was lifted, with some public restrictions still in place.                           

It is understandable that many do not want to comprehend the reality that Covid-19 will likely remain endemic. They are weary and fatigued, after immeasurable trauma and over a year of constant risk calculations. But the reality is, even as we celebrate our successes with vaccination, we cannot become complacent. We must take the lessons of other countries and implement them into our public health strategies. The cost of lives and livelihoods will be far too great if we do not.


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