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On how Delta has changed the endgame for the pandemic


Lockdown vs Delta. Day by day, New Zealand is learning whether a Level Four lockdown can confine and eventually defeat the Delta variant. Yes, the number of cases keep on increasing – but the increase (so far, cross fingers) is linear, and not exponential. So far for example, the cases are not near to doubling daily - as they can do when a virus infection is raging out of control. The trouble is, such an explosive rate of increase can take off from any of the clusters or mini-outbreaks already identified. That’s why we have lockdowns.

Here, as in Britain, there are calls for us to abandon the elimination strategy, and “learn to live” with the virus. That euphemism means accepting a given date of death and serious illness as the price of renewed social and economic activity. There are several things wrong with that kind of thinking. For one thing – under this country’s elimination strategy we are already seeing a strong economic recovery, such that the Reserve Bank is called on to intervene, and dampen down the fires of inflation. Secondly, those self-described economic realists tend to be nimbyists. Meaning: the death and illness they advocate as the inevitable price of progress tend to exclude themselves, and their loved ones. Basically, for the “we have to live with it” crowd, it generally comes down to a COFO argument: Covid For Others.

Until Delta arrived, the elimination strategy had been seen as consistent (in the medium term) with a gradual opening of the borders. Elimination has always been a tool, not a goal. It is not the same thing as eradication. Elimination buys time until the vaccination rates can increase to the highest possible point. Earlier, we had supply problems in getting sufficient Pfizer doses for the country’s mass vaccination effort, and this slowed down the rollout. (Pfizer prioritised more urgent situations elsewhere.) If the October deliveries happen on the scale promised, those supply worries should be finally behind us. We may even start getting the Novovaxx vaccines we’ve ordered. These may comprise the third” booster” does.

While high levels of vaccination are our best line of defence, full vaccination is not the same thing as foolproof vaccination. In this past week alone, we’ve seen evidence of this. A fully vaccinated nurse at Middlemore got Covid. So did a fully vaccinated young New Zealand cricketer on a tour of Bangladesh. Such “ breakthrough” infections have always been known to occur, but they’re rare. An extensive US research study by the Kaiser Family Foundation says as much

The rate of breakthrough cases reported among those fully vaccinated is below 1% in all reporting states, ranging from 0.01% in Connecticut to 0.54% in Arkansas… Almost all (more than 9 in 10) COVID-19 cases, hospitalizations, and deaths have occurred among people who are unvaccinated or not yet fully vaccinated, in those states reporting breakthrough data

To put the picture another way. The Kaiser research found that “Almost all (more than 9 in 10) COVID-19 cases, hospitalizations, and deaths have occurred among people who are unvaccinated or not yet fully vaccinated, in those states reporting breakthrough data.” Last week though, findings from more recent data from a Mayo Clinic study (as yet npot peer reviewed) and based on studies of outbreaks in Florida in July, indicate that the Moderna vaccine is more effective in preventing infection than the Pfizer vaccine, hitherto seen in New Zealand as being the gold standard:

The [Mayo Clinic] study found that in July in Florida, where COVID cases are at an all-time high and the delta variant is prevalent, the risk of a breakthrough case was 60% lower for Moderna recipients as compared to Pfizer recipients. Similarly, in Minnesota last month, the authors found that the Moderna vaccine (also known as mRNA-1273) was 76% effective at preventing infection, but the Pfizer vaccine (known as BNT162b2) was 42% effective.

This data is pretty sobering. It indicates that the Pfizer vaccine may not prevent infection even in a majority of cases, but it will safeguard against the most severe consequences of that infection:

The authors of the study found that both vaccines "strongly protect" against severe disease; the difference appears to be more about whether people get infected at all in the first place.

While not invalidating the value of vaccination, the rare breakthrough cases underline the extent to which the Delta variant has raised the stakes. As MoH director-general Ashley Bloomfield has been saying all week, it is as if we’re dealing now with an entirely different virus.

Onwards, to normalcy

As a result, we’re having to reset our expectations of what the journey to relative normality is going to require - not just of the government or of individuals, but of entire communities. That’s mainly because the patterns of infection and vaccination are not the randomly distributed outcomes of millions of individual choices. They are the lumpy, uneven result of shared beliefs, social networks and joint activities - like going to parties and to sports/concerts, or attending church. Delta loves a crowd. Yet because of the rate at which it reproduces across a community, it isn’’t dependent on them. That’s why lockdowns, while not impotent against Delta , are less effective at suppressing its transmission.

Before Delta arrived, the path forward had looked difficult, but more do-able. The original plan had looked roughly like this : by year’s end, a sizeable majority of us will have been vaccinated, and this could theoretically have enabled the borders to be gradually opened up, perhaps on a regional basis and/or one or two business sectors at a time. The first step in that strategy involved a pilot programme of a limited number of Kiwis going overseas and coming back in – and this would test how well we can cope, before opening the borders further, one step at a time. Maybe we could then try a few hundred more international students. Maybe a plane load or two of international visitors. Gradually, we would learn how ably our defences could cope.

Delta now threatens that scenario. That gradualist strategy seemed more viable when the virus had only a limited reproduction number ( RO) of only (at worst) maybe 2 or 3 people. By using elimination techniques, we had a reasonable hope of getting the transmission figures down to 1, or better. Delta however, has an RO of eight or nine. This makes that previous strategy less feasible. The success (or otherwise) of the current lockdowns will tell us whether it is still possible to confine Delta, or not- and at what cost.

This isn’t simply a New Zealand problem. Around the world, Delta is problematic – to the point where it threatens any strategy based solely on full vaccination, masks, and other preventative measures. Vaccination remains the most crucial step in minimising infections, hospitalisations and death. Yet on their own, such measures won’t enable us to declare victory and throw open the borders. That would be an invitation to disaster. Many, many deaths, hospitalisations and long Covid illnesses would ensue, on a New South Wales scale or worse. (The border opening hawks need to being asked which members of their own families they regard as being expendable.)

Eventually though, these strategies ( elimination vs openings) will begin to converge. Since total eradication is not an option, there will be a point (in the medium term) where the elimination strategy will cease looking like an end in itself. It will start to dovetail with a suppression strategy for a virus that will by then have gained a foothold within the community That situation is still quite some time in the future. In the meantime, the vaccinations wil buy us time to shore up other defences and bolster the capacity of our health system to manage the virus, as it eventually becomes endemic within the community. As the pandemic reporter Ed Yong pointed out in his latest report on Covid, published in Atlantic magazine:

Here, then, is the current pandemic dilemma: Vaccines remain the best way for individuals to protect themselves, but societies cannot treat vaccines as their only defense. And for now, unvaccinated pockets are still large enough to sustain Delta surges, which can overwhelm hospitals, shut down schools, and create more chances for even worse variants to emerge. To prevent those outcomes, we need to take advantage of every single tool we have at our disposal… These should include better ventilation to reduce the spread of the virus, rapid tests to catch early infections, and forms of social support such as paid sick leave, eviction moratoriums, and free isolation sites that allow infected people to stay away from others.

Overseas, infectious disease modellers – like Adam Kucharski of the London School of Hygiene and Tropical Medicine - are warning that countries can expect to experience an ‘exit wave' surge in infections as the border precautions are lifted. Obviously, that potential for harm will have to be minimised. Logically, what it suggests is that “opening the borders” is going to require more government intervention and funding, not less.

Could there ever be a bilateral agreement among the two major parties in New Zealand on this ? Because if we to avoid considerable suffering, the safe and gradual opening of the borders will require – for example, from a long list - government subsidises to provide better ventilation in workplaces, supermarkets and public buildings; it will require new infrastructure, such as purpose built isolation centres; it will require greater investment in ICU capacity. ( Hospitals will need the extra capacity to manage chronic levels of Covid cases in future.) It will require firms and state agencies to deliver more generous sick leave provisions; it will require government to impose rent freezes and eviction moratoriums.

Is there likely to ever be a political consensus on such matters ? Hardly. Such policies would probably be ideological anathema to the political right. Some Kiwis are already sharing anti-government conspiracies, and are fretting and demonstrating against the government mask mandates and the lockdowns being imposed. In a wolf whistle to the conspiracy minded, National has used the term one party state, as if we are already subject to the jackbooted excesses being enacted by the minions of Ardernism.

It is really hard to sympathise. Such reactions are an insult to people who really do have to endure a one party state. The measures so far are only First World problems, especially when compared to what many Third World populations are going through while they lack any meaningful access to vaccines. Meanwhile, the fringe right (aka the Act Party) is already bearing the austerity drum again and demonising government borrowing - even though such borrowings have never been more necessary, cheap and affordable. In reality, we are going to need to borrow more to invest in the infrastructure required to manage Covid safely within the community. Border openings can’t be done safely, on the cheap. New South Wales shows us that.

Elimination, and suppression

Elimination and its basic tools – vaccines, masks, testing, contact tracing, genome sequencing, social distancing etc – look like being with us, indefinitely. In time, these techniques will become tools within a suppression strategy – which will be about Covid management, not eradication. If anything, the population seen to be at risk will expand. That’s because before Delta arrived, Covid was largely seen to be a disease of the old and the vulnerable. In future though, the very young are going to be included. Ultimately, we are probably going to be including Covid vaccination among the vaccination package commonly given at birth, or soon afterwards against measles, mumps and rubella.

As Yong says in his Atlantic piece, while children are less likely to become seriously ill with COVID-19, more than 400 have already died in the U.S., and many others have developed long COVID or the inflammatory condition called MIS-C.

Being fully vaccinated will reduce the risk personally, to friends, family and co-workers, , and to the community at large – but it won’t eliminate it. I’ve already mentioned the (low) incidence of “breakthrough” infections among the fully vaccinated. If infected, fully vaccinated and asymptomatic people can still transmit the disease – but the research indicate that the transmission phase is relatively brief, as the body’s defences find and neutralise the invader.

Finally…. We’re probably going to hear a lot more of the word” endemicity” in the coming months. Transparently, we have to plan for when and how, Covid becomes endemic in the community. Delta, largely because of its rates of transmission, has put paid to the early hopes of reducing Covid to the point where it would be of relatively negligible concern. Instead, as Yong says, the pandemic is likely to end “when almost everyone has immunity, preferably because they were vaccinated or alternatively because they were infected and survived.. The new coronavirus will become endemic—a recurring part of our lives…It will be less of a problem, not because it has changed but because it is no longer novel and people are no longer immunologically vulnerable.”

Covid endemicity will become the norm, but for many ( but not all) it will be by then a less deadly threat. Yong again :

If SARS-CoV-2 is here to stay, then most people will encounter it at some point in their life…. as my colleague James Hamblin predicted last February. That can be hard to accept, because many people spent the past year trying very hard to avoid the virus entirely. But “it’s not really the virus on its own that is terrifying,” Jennie Lavine, an infectious-disease researcher at Emory University, told me. “It’s the combination of the virus and a naive immune system. Once you don’t have the latter, the virus doesn’t have to be so scary.”

Think of it this way, Yong concludes : “SARS-CoV-2, the virus, causes COVID-19, the disease—and it doesn’t have to.” For now and for maybe always, repeated vaccination and anti-viral medicines will be the best tools we will have to disconnect the two.

Footnote One: Jonathan Liew, the insightful Guardian columnist who is thinly disguised as a sports journalist, has recently written about the unusually high incidence of anti-vaxx sentiments among elite sports people. ( Tennis anti-vaxxers like Novak Djokovic and Stefan Tsitsipas are just the tip of the iceberg.) Liew puts some of it down to the social isolation of top athtletes – they’re young, impressionable, and their training downtime gives them a lot of solitary time on their hands to roam the Net. For top athletes, their body is also a precious instrument, and fount of their success. Over the years, they have built up a lot of faith in their ability to control their bodies, and to be suspicious of any potential threats to its optimal functioning. New Agers, another centre of ant-vaxx sentiment, are equally reluctant to allow any pharmaceutical outsider into their bodily temple.

That being the case …surely, other top athletes could play a very valuable peer-to-peer advocacy role in promoting vaccination. Vaccination is not a partisan political issue. Therefore, why can’t we use the All Blacks and the Silver Ferns to promote vaccination, given their ability to reach the Maori/Pasifika communities where vaccination rates are relatively low? Some people who won’t listen to Chris Hipkins or Ashley Bloomfeld, just might listen to Richie McCaw, or to T.J. Perenara.

Footnote Two : Want a really good example of how politicians twist the Covid research to serve their own ends? In Australia, modelling by the Doherty Institute showed that the number of Covid cases had to be reduced before a vaccination -based strategy could be effective. As the Australian Broadcasting Corporation noted, New South Wales governor Gladys Berejiklian chose to use the Doherty data to open up, and promote a “ learn to live with Covid” message. Using the same data, Victoria’s premier Dan Andrews said it confirmed the necessity to get the case numbers down and vaccination levels higher, before thinking of opening up any further.

Berejiklian : " As the Doherty report says, once you get to 80 per cent double dose and you have to open up, everyone will have to learn to live with Delta. In New South Wales, we are learning that earlier than others."

Andrews : In Victoria, Premier Daniel Andrews said the only way to ease restrictions would be to have "cases down, and vaccination up" [Andrews] said…the modelling from the Doherty Institute that underpins the plan required "very few cases" to be circulating.

For what its worth, the Doherty Institute said that Andrews was correct, but that the Covid cases didn’t need to be brought right back down to zero.

Afghanistan postscript

US President Joe Biden is being hammered politically for not persevering with the failed policies of his predecessors. Biden is also taking flak for not rescuing every US citizen, (including those Afghans with US travel visas) that were in-country at the time that Kabul fell. Yet in April, the US Embassy had sent out an advisory message warning Americans to leave Afghanistan. In May, it sent Americans this reminder to get out now. The Embassy warning included this paragraph:

The Embassy reminds U.S. citizens that on April 27, 2021, the Department of State ordered the departure from U.S. Embassy Kabul of U.S. government employees whose functions can be performed elsewhere due to increasing violence and threat reports in Kabul. The Travel Advisory for Afghanistan remains Level 4-Do Not Travel due to crime, terrorism, civil unrest, kidnapping, armed conflict, and COVID-19. Commercial flight options from Hamid Karzai International Airport (HKIA) remain available and the U.S. Embassy strongly suggests that U.S. citizens make plans to leave Afghanistan as soon as possible. Given the security conditions and reduced staffing, the Embassy’s ability to assist U.S. citizens in Afghanistan is extremely limited.

Hard to see that it's Biden’s fault that they stayed, and got in harm’s way. Where Biden does deserve criticism is in the failure to evacuate Afghans now in peril because of their previous links to US/NATO operations. In the US, Australia, the UK and New Zealand, a very narrow definition of responsibility has been adopted. Only if you were directly employed as an official contractor might you – and your family - qualify as candidates for evacuation. If you were merely a sub-contractor or an informal employee, tough luck. Needless to say the Taliban aren’t interested in the technical details of the contractual relationship.

So far, the NZ government is escaping any backlash for its abandonment of most of the people that our presence in Afghanistan have now put in mortal danger. The Hazara in Bamiyan were already a persecuted minority, long targeted by the Taliban ( who are Sunnis) because of their heretical Shia religion – which alone should qualify them as valid candidates for asylum, under the Refugee Convention. They would have been better off if our PRT had never gone there.

Our efforts have been belated, and token. Only weeks ago in a terse one page letter, Immigration Minister Kris Faafoi refused to offer assistance to Afghans begging New Zealand for help. We have since sent a Hercules to help bring out some people at risk – but how many? The photos this week would suggest very few. On that point, the official version yesterday is laughably self-serving : “For security and safety reasons” [yeah right] the actual number of evacuees is not being released.”

How many Afghan evacuees are we accepting for permanent location here? Originally, Boden was asking allies to accept some Afghan evacuees only on a temporary basis, until the paperwork cleared them for transit/entry to the United States. This week that has still seemed to be the case. Evacuees were reportedly to spend three to four days at the Europe transit stops before they were to move oe. The plan is to move 1,500-1,800 people per day to Dulles International Airport outside Washington.

Of those destined for a new life here in New Zealand, what extra allocation of government funds will we devote to their resettlement, and how will this influx affect our official UN refugee programme quota? Will there be scope for New Zealand citizens to help sponsor the resettlement needs of some of these Afghan families, along the lines that Canada implemented with its intake of refugees from the civil war in Syria? Luckily for the government, the lockdown has been taking the spotlight away from a failure for which we – and all NATO partners to a greater and lesser degree – share a collective responsibility.

This week’s Spotify music playlist is available here. Context, and background info on the music and the artists is available here.

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