We are still learning to live with Covid’s ‘perfect unpredictability’

It wasn’t supposed to end like this: after new Covid, shocking Covid, long Covid and reducing Covid, do we now face the prospect of enduring Covid? With the country now in the throes of a fifth wave, it is clear this pandemic isn’t going to end anywhere near as fast as we would like.

While vaccination is blunting the worst impacts of the virus, or perhaps because of this, at no point over the past two years has there been so little clarity about the way forward.

“None of us have experienced anything like the pandemic in our lifetime, so inevitably there is some misunderstanding as to what it will bring,” virologist Prof Gerald Barry of University College Dublin (UCD) points out. “If this had been a flu pandemic, it might have been easier to predict. But with coronaviruses there is a lot of uncertainty, which has continued over time.”

In common with other experts, he doubts the ability of vaccines alone to bring this pandemic under control. “It is clear that vaccines on their own are not enough. That reality has begun to dawn on people in recent times and hopefully also on politicians. It seems to have taken a long time for this penny to drop with the people making the decisions.”

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A very high level of vaccination will protect a lot of the population from severe disease, Barry says, but it is not going to stop the virus from circulating. “Covid-19 is much fitter and more transmissible than influenza. It causes more disease and it’s a much bigger problem.”

“Without the eradication of infection in the long term, Covid will be another disease that affects humans and preys on the vulnerable, causing them injury and death,” says Prof Paddy Mallon, infectious diseases consultant at St Vincent’s hospital. “But how we get to that point, nobody knows. Nobody knows what level of protection vaccines will provide ultimately or whether the virus will change over time.”

Until this “steady state” situation is reached, Mallon says, society will have to continue living with the virus for the foreseeable future.

The problem, as he sees it, is we are “nowhere near” that steady state, with the virus continuing to circulate among the vulnerable – those who are unvaccinated or have insufficient protection from vaccination.

And these are not static populations; as time goes on, more people become vulnerable as their immunity, induced by vaccines or infection, wanes. Six months on from vaccination, a person has about 50 per cent protection against infection and 80-90 per cent protection against severe illness.

Prof Mary Horgan, infectious diseases consultant at Cork University Hospital, describes Covid as a “perfect essay in unpredictability” but is keen to stress the positives.

“We are in a better place now. Vaccines have done what it said on the can. They have reduced mortality and severe disease, and even though there are breakthrough infections, the symptoms tend to be less severe and shorter in duration.

“Because this is still a time of uncertainty it is too early to predict the direction of travel of the virus and how quickly we’ll get to an endemic state, but we will get there.”

A lot of Covid-19 end-game speculation envisages the disease becoming endemic, just as colds and flu are. But this won’t necessarily be a benign outcome, Barry warns. “Ending up with a virus that is endemic does not mean it becomes mild, like a cold. What we have now is what will continue, unless something changes.”

The pandemic could end in a number of ways, through a number of “fingers-crossed” scenarios, as Barry puts it. “First, if the whole world gets vaccinated, that might impact on transmissions and over time, in combination with natural immunity, reduce the impact of this virus.

“Second, new vaccines might be developed to block the transmission of infections or that are specifically targeted at the Delta variant.” This also could tilt the balance in favour of virus eradication.

The problem is that it is a) unlikely that the entire world will get vaccinated; and b) even if this were to happen, it would take so long that immunity levels would have fallen widely by the time the job was completed.

“The initial data on boosters is promising,” Barry does note. “But in reality, we do not know what the long-term effect of vaccines will be, so we have to accept other measures will be needed.”

Though many are understandably appalled by the spectre of yet another surge in recent weeks, across Europe case numbers are also shooting up. Our neighbours are starting from a lower base, having controlled the virus better over the summer, and many have more capacity in their health service than Ireland, andso will weather the winter more easily.

“We were already bursting at the seams during the 2018/19 winter when influenza cases surged,” Barry says. “Now put Covid on top of that and the likelihood is the health system will not be able to cope.”

Shards of positivity

There are shards of positivity among the bad news. Covid-19 deaths in Ireland have remained relatively stable since the beginning of September, at about five a day, and although both hospitalisations and intensive care admissions have risen, they may be stabilising.

That level of deaths is terrible but we accept it in the context of other diseases. What level of disease would be acceptable in the context of ever-present Covid-19?

In the UK, Sir Jeremy Farrar, director of the Wellcome Trust, has been calling for an honest debate around what level of disease and death is deemed acceptable. He has suggested that for Britain this might be about 100 a day.

“A country with a given vaccination coverage will have to accept either a certain level of death or a certain level of restrictions [or a mix],” he has been quoted as saying.

In Singapore, the health minister has compared the prospect of 2,000 Covid-19 deaths to the 4,000 annual deaths from other respiratory conditions.

Overall deaths in Ireland this year have been consistently above the levels seen in 2020 since July, according to economist Seamus Coffey. Estimates of excess mortality based on death notices on rip.ie suggest an additional 200 deaths a month, approximately.

Mallon says our current surge in cases is simply the product of the slow reopening of society in recent months. While the dynamic is slower so far than before, there is “always the potential” for a repeat of last winter.

“We’re facing a lot of unknowns leading into winter, such as the impact of being indoors. On the other hand, people are socialising in controlled environments and a lot of mitigation measures are in place.”

Ultimately, everyone is going to have to be exposed to the virus, he believes, preferably with the protection afforded by prior vaccination. This brings to mind the British government’s decision to get rid of public health measures last summer, when prime minister Boris Johnston asked, “If not now, when?”

In terms of infection, should we be contemplating “bringing it on”?

“Obviously, what the UK did last June hasn’t worked very well, as a large chunk of the population weren’t vaccinated and they had high case numbers at the time,” Mallon responds. “If you’re going to let it rip you have to be well prepared and have a high level of vaccination.”

Mallon believes “every single mitigation option” will have to be used in addition to vaccination in order to control the spread of infections this winter. Society has an obligation to do this because the unvaccinated population includes people who are unable to be vaccinated as well as those who refuse it, he says.

“We need to use every available means, collectively, to maximise the reduction of risk. Antigen testing, distancing, ventilation and mask wearing all need to be put in play for the populations most at risk of infection.”

And although children are at low risk individually, he says they need to be included in measures because otherwise they will seed infections back into wider society. “This virus spreads through the susceptible and then attacks the vulnerable,” Mallon says.

Social contacts

Public health officials have been changing their message in recent weeks in response to the worsening situation. Talk of personal responsibility has been superseded by active discouragement of social contacts.

This approach has worked in the past, with warnings by chief medical officer Dr Tony Holohan and his colleagues on the National Public Health Emergency Team (Nphet) prompting changes in public behaviour that served to slow down the spread of infections, albeit after several weeks.

There is less evidence of such “anticipatory behaviour” this time around because people are tired of the lengthy restrictions and also because the process of opening up the remaining parts of society has only just been completed.

We are now at a watershed moment for our public health system, Barry argues. “We have to recognise the system we have in place is not designed to deal with this new problem. A massive overhaul of the hospital and the public health systems is needed.

“The solution is to effectively control community transmission by building up public health so it in turn can stop cases leaking into the hospital system.”

Along with Mallon and Horgan, he advocates the wider use of rapid antigen testing. “It’s just one layer of the protection that is needed but it could be really impactful and it has been ignored for all the wrong reasons.”

But he also maintains that PCR testing is too onerous. “Where I live, I would have to drive an hour for a PCR test or it would take three hours on the bus. That’s just not practical.

“Every town and village should have a test centre, and people should be encouraged to test on a regular basis, regardless of symptoms.”

He questions why the technique of whole genome sequencing is not being used to follow up cases. Denmark sequences 90 per cent of its cases but in Ireland, where its primary use is to monitor variants, this figure is about 10 per cent.

“Sequencing provides the fingerprint of the virus,” he explains. “It allows us to track the path of the virus, to explain the cases that are currently lumped as ‘community transmission’.”

In UCD, the use of this technology showed clusters that were occurring in halls of residence on the campus, and which it had been assumed involved linked cases, actually resulted from people picking up infections off campus, independent of each other.

In this new environment of high and surging cases, Horgan advises people to conduct their own personal risk assessment around activities. “It’s better to be outdoors, or with friends who are fully vaccinated, to be in a well-ventilated space, or to attend a well-monitored event.

“And if you’re not happy about any of these, be prepared to walk away.”

Horgan was made a member of Nphet only last summer, and has worked since to develop antigen testing capacity. Now that she is “inside the tent”, she has a wider understanding of the challenges of decision-making, as opposed to sideline commentary.

“There is never certainty about Covid. For people to criticise what has or has not been done, that’s not a great space to be in. Things change so quickly; you’re trying to keep on top of it all the time. Nobody’s an expert on this virus; we continue to learn and to be surprised.

“If there was a perfect way of dealing with it, some country would have done it. Yet none has. Even in New Zealand, they’ve learned zero Covid is not possible.”

And while people are tired, she points out, “they are enjoying their freedoms, so we need to make sure those freedoms continue”.