The shift to managing COVID-19 as endemic

As Australia’s approach to COVID-19 turns from emergency management to treating the virus as endemic, policymakers must consider ways to reduce risk sustainably and without resorting to extreme measures, James Trauer writes.

Governments across the country continue to scale back and remove their few remaining COVID-19 restrictions, and there is a valid epidemiological rationale for this re-opening.

Things have changed dramatically over the course of the last 12 months in Australia, as it has moved from being an island virtually devoid of immunity to SARS-CoV-2 to one with substantial protection – through both vaccination and then natural infection. As the virus transitions from a pandemic to a continuously transmitted endemic infection, Australia will need to fundamentally shift its approach.

There is one important caveat: the emergence of a new variant. Depending on its characteristics, a particularly severe new variant of the virus could require a return to more aggressive interventions.

But given that this is impossible to predict, Australian governments need a plan for managing COVID-19 as endemic for years to come, while simultaneously preparing for new spikes in transmission and future pandemics. This requires a longer-term view and that they shift away from the approach of using population-wide measures to limit transmission.

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While the direct health impacts of COVID-19 have been enormous, policymakers must not underestimate the non-COVID impact of the pandemic on public health, the economy, and society more broadly. Extreme measures – including severe lockdowns – have been necessary, but it must be recognised that they have harmful consequences and are not a sustainable solution in the long term.

They have exacerbated existing health and social disparities, and affected Australians far beyond what’s measurable through indicators like hospitalisations, mental health care presentations, and lost productivity. While Omicron remains the predominant variant, policymakers could still consider some public health and social measures in response to fluctuations in case rates, such as the recent surge of an Omicron sub-variant, BA.2. However, these should generally be limited to effective and minimally intrusive interventions, such as face coverings on public transport.

The original rationale for lockdowns was to keep transmission within the capacity constraints of the health system, as Australia weathered the first wave of transmission. The success of many states in reducing transmission led to a transition to the opportunistic take-up of aggressive elimination or ‘COVID-zero’ approaches.

This was a good strategy, even in hindsight. Elimination was a crucial bridge to high vaccination coverage that averted the tragedies uncontrolled epidemics caused overseas. Given the extremely high case fatality rate of Victoria’s second wave (above four per cent) and 2.9 per cent national case fatality rate in 2020, a similar disaster was clearly possible in Australia.

On one hand, increased restrictions could well be justified in the face of future waves, particularly if the epidemic appears to be heading towards overwhelming health service capacity.

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However, during the summer Omicron epidemic, a large proportion of Australians were likely infected and health services were stretched, but this did not overwhelm health service capacity to the scale that governments had feared in 2020. Therefore, social restrictions are now difficult to justify for a virus with the severity of Omicron in a setting of high vaccination.

To understand what a future of endemic transmission looks like, first consider that this still implies high levels of transmission.

For the four circulating endemic coronaviruses, the average age at first infection is three to five years, and nearly everyone has been infected by the age of 15. This could imply five to 10 million infections per year in Australia in coming years.

In this context, while the rate of infection could be somewhat mitigated by social restrictions, elimination is rarely now considered a viable strategy.

Restrictions that would protect a significant proportion of the population from infection entirely would have to be so severe as to be unsustainable. Viewing things in the long-term is crucial here – while some restrictions would reduce transmission, most people alive today would still have repeated exposures throughout their lives, restrictions or no restrictions.

Of course, social restrictions are not the only way to manage COVID-19. Severe outcomes from COVID-19 are strongly associated with identifiable risk factors, so vaccination programs should be linked to programs such as aged care, primary care, diabetes clinics, Indigenous health, and antenatal care.

This once-in-a-century pandemic should therefore stimulate renewed investment in health care, medical research, air quality, and improved ventilation. Given the current levels of transmission in the community, these measures could also do much to prevent COVID-related morbidity.

Governments should build sustainable programs linked to existing care pathways, and strengthen the health system to ensure greater capacity to respond to surges.

As Australia shifts to treating COVID-19 as endemic, it must learn to rely primarily on vaccination and natural immunity to manage the effects of the virus, not widespread restrictions.