COVID-19: What's next?

This story was originally published in the Autumn 2021 edition of Burnet's IMPACT magazine.

He has been a leading voice in Australia’s COVID-19 response and brings more than 40 years’ experience in international health to our research. Epidemiologist, Professor Mike Toole AM, shares his thoughts on what’s ahead in the coming months and years in the new COVID-world.

Here we are in the autumn of 2021 and widespread community transmission of coronavirus is a distant memory in Australia. That’s not to say that we have been COVID-19 free. 

Since November 2020, there have been clusters of cases derived from breaches in hotel quarantine in all mainland state capitals. As the vaccination program rolls out can we expect to return to some type of normality this year and how will it look?

The pandemic is truly global and has affected 219 countries and territories. Ending the pandemic would mean reducing COVID-19 to a sporadic or endemic disease. 

On 1 May 2021, two contrasting statistics were released. The number of COVID-19 vaccine doses administered worldwide surpassed 1 billion – quite an achievement given that this time last year there were grave doubts that we’d ever have an effective vaccine, let alone the approved vaccines currently being rolled out globally. 

But, on that same day, more than 870,000 new infections were reported – more than double the number recorded just two months ago. 

In this third global coronavirus surge, no region has been spared. In the Asia-Pacific region, India is spiralling out of control, reporting more than 400,000 cases daily. Pakistan, Bangladesh, the Philippines, and Thailand also have second or third waves. Closer to home, Papua New Guinea and Timor-Leste are experiencing major surges.

New variants may be the greatest threat

The longer the coronavirus circulates widely the higher the risk of more variants of concern emerging. We are all aware of B.1.1.7 (first detected in the UK), B.1.351 (South Africa), and P.1 (Brazil). 

But other variants have been identified, including B.1.427, which is now the dominant, more infectious strain in California, USA, a recent variant identified in New York, named B.1.526 and the Indian B.1.617 variant.

Variants may transmit more readily and may prolong the global caseload. Also, some variants may be resistant to vaccines as has already been demonstrated with the B.1.351 and P.1 strains.

Vaccines are still our main hope

Miraculously, 12 months since a pandemic was declared, nine vaccines are approved by at least one country, and a tenth, Novavax, is very promising. 

As of 1 May 2021, 1 billion doses of vaccines had been administered globally, the equivalent of 15 per cent of the world’s population. However, the distribution of vaccines has been highly uneven. 

Of these doses, 39 per cent have been given in the world’s 27 wealthiest countries and a further 35 per cent in China and India. 

The world’s poorest 85 countries have received just 1.3 per cent of vaccine doses. At this pace, most of the world’s population will remain unprotected at least until 2023.

In Australia, it means that borders won’t be open to tourists, international students, migrants and backpackers for a very long time. And Australians won’t be able to travel overseas as they did before the pandemic.

The vaccines have been shown to be safe and effective in preventing symptomatic and severe COVID-19. However, post-marketing studies will be required to determine the duration of protection, the need for booster doses, effectiveness in children and the impact on transmission. 

These studies have already revealed rare adverse effects in the form of severe clotting events in two of the currently available vaccines, produced by AstraZeneca and Johnson & Johnson. 

However, given the uncertainties about the duration of protection conferred by vaccines, these countries are already planning to provide annual booster doses and vaccine manufacturers are working to develop these boosters designed to protect from viral variants.

What are the potential barriers to overcome?

We have learned a lot in a year, and one of the most salutary lessons is how dangerous it is to let COVID-19 transmission go unchecked – the result is the emergence of more transmissible viruses that escape our immune responses, high rates of excess mortality and a stalled economy. 

Until high levels of population immunity are achieved, we must maintain individual and societal measures, such as masks, physical distancing, and hand hygiene; improve indoor ventilation; and outbreak responses – testing, contact tracing, and isolation. 

However, there are already signs of complacency and much misinformation to counter, especially for vaccine uptake. The outcomes of even momentary complacency are evident as global numbers of new cases once again increase after a steady two month decline.  

12 months from now – an educated guess

Given so many unknowns, how the world will be in mid-2022 is just that, an educated guess. What is increasingly clear is that there will be no ‘mission accomplished’ moment. We are at a crossroads with two end games. 

In the most likely scenario, rich countries will have returned to a semblance of normality. Businesses and schools will reopen and internal travel will resume. Travel corridors may be established between countries with low transmission and high vaccine coverage. 

In low- and middle-income countries, there may be a reduction in severe cases, thus freeing them to rehabilitate essential health services that have suffered in the past 12 months.  

The second scenario, which, sadly, makes the most sense from a national interest and economic perspective, is unlikely to occur – unprecedented global cooperation with a focus on science and solidarity to halt transmission everywhere. 

Moreover, if Australia’s borders are to reopen Australia will need to give a helping hand to our neighbours to achieve high vaccine coverage. To not do so will keep us absent from the international community for a very long time and a lot longer in a ‘pseudo’ new normal.

Professor Mike Toole AM is a key contributor to our COVID-19 research through the flagship program, Know-C19.

A former Burnet Deputy Director and Head of the Centre for International Health, Professor Toole has more than 40 years of experience in international health; medical research and clinical work; communicable disease control (including HIV), maternal and child health and nutrition, and public health in emergency settings. He has worked in-country in Thailand and Somalia, spent 10 years at the prestigious Centres for Disease Control and Prevention (CDC) and was a founding member of Médecins sans Frontières Australia.