Health Review 2021: The year of the variant

Year two of the Covid-19 pandemic and the virus dominates our lives as much as ever.

If 2020 was the year of the virus, 2021 has been the year of the variant. The coronavirus that first emerged in Wuhan, China two years ago has changed faster and more radically than almost anyone thought it could. By doing so, it has deftly remained in circulation despite lockdowns, masks, vaccines and anything else humans could throw at it.

For Ireland, that meant successive waves of cases driven by the Alpha and, later, the Delta variant, both of which dwarfed the first surge we suffered back in spring 2020. The end of the year has brought another contender, the heavily mutated Omicron variant, to further undo progress made.

The Alpha variant that first spread from the south of England hit us hard, and at the worst possible time, from Christmas on. Cruelly, it took advantage of the cross-generational mixing that takes place over the festive period; families united over Christmas and the virus spread easily to the most vulnerable. Deaths soared in January and February as the country awaited the mass rollout of vaccines.

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No amount of head-scratching could explain how Ireland ended up with one of the highest Covid-19 incidences in the world while also having the highest proportion of vaccinated people in its population

It was far from the “meaningful Christmas” Taoiseach Micheál Martin had promised. Recriminations soured the air, mostly centring on the Government’s decision in early December 2020 not to follow to the letter Nphet’s call for greater restrictions.

In truth, the Alpha variant was the fuel that drove the fire, but by the time the first variant case was identified here, on Christmas Eve, it was too late to stop the carnage. Perhaps a quicker appreciation that Alpha was in Ireland and how this changed the rules of engagement would have moved the dial on the debate more quickly on the debate around restrictions.

January and February were new low-points of the pandemic. There was none of the novelty that surrounded the first lockdown in spring 2020, and plenty of the same grim daily toll of hospitalisations and death.

The schools were closed again and travel restrictions were back in earnest. At one point last January there were 12 times as many Covid-19 cases as during the peak of the first wave, and 50 per cent more patients in hospital.

An icy St Brigid’s Day came and went and all we could do was wait and wait for the enforced separation of the lockdown measures to work and for the curve to bend back downwards.

Only the promise of vaccines sustained us in those dark days, but even these seemed far off as their rollout faltered early on. Messaging got mixed, supplies were delayed, promised consignments dematerialised.

Eventually, though, the bottlenecks were unblocked, the programme ramped up and the public responded with a world-beating ardour. By late autumn, well over 90 per cent of Irish people aged over 12 had been vaccinated, more than anywhere else in Europe.

They say pride comes before a fall; certainly, hubris is the enemy of anyone forecasting the future of Covid-19. By summer 2020, Ireland had almost squelched the virus, only for it to come roaring back in the autumn. We had the lowest incidence in Europe in November 2020, and the highest incidence for a while in January. New infections occurred over the summer as society opened up cautiously, so that at one point Ireland had seven times as many infections as Germany relative to population.

It came as little surprise, therefore, that our incidence started breaking records again, towards the end of the year. And yet that was just weeks after Ireland was chosen in the Bloomberg Covid Resilience Ranking as the best place in the world to be for a pandemic. Around the same time, National Public Health Emergency Team officials were hailing the "near-elimination" of the virus among vaccinated people, one of many predictions that looks foolish now.

The same pattern played out internationally as countries that had had a good pandemic experience endured sticky patches, and others improved after bad starts.

Vaccination seemed to change everything – and nothing. We ended up with more, not fewer, cases because of the variants

Germany, for instance, went into panic mode towards the end of 2021 as soaring cases threatened to undo its achievements earlier in the pandemic. Sweden, while never doing as well as its Nordic neighbours, seemed to escape the worst effects experienced by countries that had much harder lockdowns.

Even New Zealand and Australia, which had minimised Covid-19 harms through severe travel restrictions, eventually had holes poked in their defences by the extra transmissible Delta variant. Both countries have had to rejig their zero Covid approaches as the virus mutates and the pandemic’s lifespan stretches from months into years.

Vaccination seemed to change everything – and nothing. We ended up with more, not fewer, cases because of the variants. As billions of jabs were put into people’s arms across the world, we learned that the vaccines don’t stop transmission of the virus, and that they have a limited shelf-life.

But while their effectiveness wanes quickly in preventing against infection, they have held up rather better against serious illness. In Ireland, the risk of a person requiring admission to ICU was almost 30 times lower in November compared to January, before we had vaccines.

No matter how bad other aspects of the pandemic got, there was always comfort to be had from examining the way deaths have fallen away since people got jabbed. The graph shows a medium-sized bulge in spring 2020, a towering spike last January and, now, a barely perceptible rise in the curve.

Part of this is also down to better care and new treatments for the sickest patients. Covid-19 will always be a serious illness for a small minority, but the development of antiviral pills and other innovative treatments holds further promise.

No amount of head-scratching could explain how Ireland ended up with one of the highest Covid-19 incidences in the world while also having the highest proportion of vaccinated people in its population. At one point, Co Waterford was reported as having 100 per cent vaccination among adults while also having the highest county incidence figures.

It didn’t help that we never succeeded in getting our numbers down over the summer. That one-third of businesses didn’t bother checking the Covid-19 vaccine pass. Nor did it help that we have an open border with Northern Ireland and proximity to the UK, which has had one of the highest caseloads and deaths in Europe and the lightest and shortest lockdown.

The official explanation was that we started high, endured Delta earlier than others and were more likely to suffer spread because of our younger population, which at that point were not vaccinated.

Towards the end of this year, ironically, the UK was doing comparatively well, considering how open its society has been for months. By that stage, the virus has either killed or infected so many people that its potential for harm had been blunted. Omicron may yet upend that narrative.

Despite our increased protection against the virus thanks to vaccines and past infection, Covid-19 spread like never before. By sheer dint of numbers, it found the vulnerable, such as the unvaccinated, immunocompromised people and those with waning vaccine immunity. The “force of infection” grew, and although a smaller proportion than before translated into serious illness the hospitals still filled up.

As winter approached and cases surged, it didn’t take long for the Irish health service to hit the panic button. Normal service was paused in many hospitals as staff were redeployed to treat Covid patients. While any health service would struggle to cope with such a rapid surge in infections, the main pinch-point was a lack of ICU beds. It was as if little had been learned from previous bad winters when hospitals housed hundreds of flu patients.

By the end of the year, two groups accounted for most of the Covid-19 patients in ICU: older vaccinated people with breakthrough infections due to waning immunity; and unvaccinated people of varying ages. Of the latter group, a disproportionate number are from eastern Europe and other regions with higher levels of vaccine scepticism.

We were told from the start to "follow the science" but many of the scientists spent this year arguing among themselves

For reasons that are yet unclear, pregnant women are more susceptible to the virus now that it has mutated. More than 35 expecting mothers ended up in ICU during the year, compared to one in 2020, and none of them was fully vaccinated. A number of stillbirths were attributed to Covid-related infection of the placenta.

The debate around Covid turned, if anything, more fractious than it had been at the start. Spring lockdowns were generally tolerated in the aftermath of the spike in deaths and serious illness at the start of the year, but frustrations grew.

We were told from the start to “follow the science” but many of the scientists spent this year arguing among themselves. Internationally and in Ireland, positions grew ever more entrenched between those who believe we have to “live with Covid” and the “zero-Covid” lobby, while a minority espoused “shielded protection” of the most vulnerable over public health restrictions.

Depending on who you listened to, you could hear diametrically opposing views from experts on issues as diverse as ventilation, masks and transmission among children.

Children, in particular, became the focus of heated debate as cases soared among primary school pupils. At the start of the pandemic, they were falsely accused of being “vectors” of the disease; now they were demonised for spreading infection. It wasn’t their fault they couldn’t be vaccinated, or that they lived with adults who were free to socialise in cafes, bars and nightclubs. Having twice rejected a mask mandate for younger children, Nphet then introduced one without producing much scientific underpinning. We are told the measure will be temporary, but tell that to secondary school students still wearing masks for a second year.

The less people agreed, the more shrill they became – often on social media, where doomsayers flourish. People who should know better played the man rather than the ball, attacking the credentials of those they disagreed with, often failing to see the mote in their own eye. It was no wonder the broader public tuned out.

The debate around antigen testing continued all year, before Nphet came around to a grudging acceptance of its worth. Mid-year, Nphet official Prof Philip Nolan had dismissed the tests as unreliable "snake oil", but by winter officials were tolerating their use in schools, lecture halls and manufacturing.

For all their shortcomings – inaccuracy and potential misuse included – antigen tests are cheap and rapid and if used frequently enough, they can help identify infections early.

Covid-19 has changed the world in ways we are only beginning to appreciate. Lockdowns and public health restrictions have created a vast surveillance apparatus that may be hard to stand down once the crisis is over. Divisions in society over issues such as vaccine mandates are becoming dangerously fractious; democracy feels more fragile than ever.

Worker productivity has increased, not decreased, as a result of home working. As a result, health and power has been concentrated even more in a global elite – not least among the vaccine manufacturers who were reported to be making $1,000 profit a second from their inventions. Half the world has yet to be immunised as the same companies hang on to their patents. You don’t have to be an anti-vaxxer to be concerned about these trends.

Meanwhile, the cost of the pandemic shows no sign of abating. Last spring, the Central Bank estimated Covid had cost the Irish economy almost €25 billion directly and indirectly; before Christmas, the Government had to turn back on supports for the hospitality industry after it reintroduced restrictions.

We still don’t know where Covid-19 started. The theory it might have leaked accidentally from a virus laboratory in Wuhan only received serious consideration when the name of the US president changed from Trump to Biden. That happened too late, so we probably will never know.

The public is clearly exhausted by the enduring nature of the pandemic, not to mention the fractured debate around it

What does the future hold? No one can say for certain. Vaccines work – for a while. Boosters boost – but for how long? The virus mutates – to what effect?

A game of cat and mouse seems most likely. The virus becomes more transmissible and adept at evading immunity, but its force is blunted by immunisation. Vaccines are tweaked to fight specific variants. Covid mutates further and the game continues.

Endemicity has been pushed out further and further, with various experts suggesting this crisis could last for five to 10 years. The seasonal element to waves of infection suggest the need for longer-term planning to get through winter surges.

The public is clearly exhausted by the enduring nature of the pandemic, not to mention the fractured debate around it. Disappointed too, that the optimism launched by the vaccination programme has not delivered us safely from Covid’s threat.

This year’s achievement has been the creation of a semblance of normality in society since the summer; the challenge will be to hang on to this during surges and build on it in the periods when the virus ebbs.