Letter From Australia: A Never-Ending Pandemic?

Australia has faced a trajectory of COVID-19 unlike that seen in other nations. The first Australian cases occurred in January 2020 among tourists from China, yet most regions of Australia then had prolonged periods of almost complete absence of COVID-19 transmission. After 20 months of the pandemic, with a population roughly 10% that of the United States, Australia had a little more than 80 000 infections and 1128 deaths, whereas at the same time, the United States had more than 41 million infections and 666 407 deaths (1). This pattern continued until mid-2021, when major cities experienced transmission of the Delta (B.1.617.2) variant and recent large outbreaks of infection, which may foretell a different future. Of course, “large” in Australia is relative to zero—the current outbreaks in Sydney and Melbourne mean 100 to 1000 cases per day. We reflect on the successes and challenges of Australia's pandemic response and suggest lessons that can be learned.

There is much Australia has done very well through the course of the COVID-19 pandemic. Combined with the geographic advantage of an island nation, government approval requirements for international arrivals and departures since March 2020 successfully limited overseas-acquired infections. In recognition of neighboring New Zealand's similar success in avoiding COVID-19, a binational travel “bubble” was established, providing some relief to the airline and tourism industries and personal benefit to the many Australians born in New Zealand (2). In addition to travel restrictions, early availability of diagnostic testing, effective contact tracing, and strict adherence to quarantine for returned travelers or exposed individuals all prevented sustained community transmission. When transmission has been detected, “lockdowns,” social distancing, and mask wearing in public spaces, workplaces, and secondary schools (students aged ≥12 years) were rapidly utilized. These approaches led to the reduction and cessation of several outbreaks (3). This has required emergency legislative powers to reinforce public health measures but has been coupled with general community support. A measure of this has been reelection of every state government that has enacted these policies. Australia has also invested in several strategies to support the mental health and associated socioeconomic risk factors during COVID-19. These have included additional government-subsidized mental health appointments, temporary government-supported telehealth (in place of face-to-face) appointments, and targeted financial support for individuals and businesses with pandemic-related income loss (4).

Nevertheless, Australia has experienced some challenges. The net result of the general absence of community transmission has been relative complacency toward risks for acquiring disease and low levels of vaccination compared with the rest of the world. This has led to a highly susceptible population. There was also considerable public fear regarding fatal adverse events associated with the AstraZeneca Vaxzevria vaccine. Among 9.6 million doses of Vaxzevria, 125 cases of and 8 deaths from thrombosis with thrombocytopenia syndrome related to the vaccine were confirmed (5), risks which were widely publicized both in the media and by some public health officials. Furthermore, official advice on which age groups should receive the Pfizer Comirnaty mRNA vaccine in preference to the AstraZeneca vaccine changed over time. This created difficulties because the AstraZeneca vaccine had been produced in large quantities in Australia. In addition, a locally developed vaccine was withdrawn from clinical trials because of its proclivity to cause false-positive HIV antibody results (6). These issues left Australia largely reliant on importation of vaccines, resulting in supply issues, combined with a common public desire in all age groups to “wait for Pfizer,” supplies of which are only now readily available. Australia has therefore lagged behind most other developed nations in achieving vaccination targets. By mid-September 2021, only 36.0% of the Australian population had been fully vaccinated, compared with 53.7% for the United States and 65.0% for the United Kingdom (1). State departments of health have recently begun to mandate COVID-19 vaccination for workers in clinical settings (7).

Negative psychological effects of COVID-19 have not escaped Australia, even with few infective cases and only short-term or nonwidespread lockdowns. For example, 1 in 5 Australians report their mental health is “worse or much worse” than before COVID-19 (8), and mental health service use and crisis line contacts have increased over the period, although the effect on suicide is not yet clear (4). Lockdowns, which have been particularly prolonged in Melbourne and to a lesser extent in Sydney, may explain some of the collateral psychological as well as economic damage. An additional factor may be the restrictions on international travel, a favorite pastime for Australians. For example, the substantial proportions of Australians born in the United Kingdom, India, and China (3.8%, 2.8%, and 2.4%, respectively) have not been able to be with family and friends from their birthplace since early 2020, and they have no known date for when this will again be possible (9). Furthermore, business-related disruptions have ensued with Australia's trading partners, including China, Republic of Korea, the United Kingdom, and the United States (10). Even the New Zealand travel bubble has been intermittently modified and is currently suspended, due to outbreaks in both countries. Some community resistance to public health measures is developing, with recent small antilockdown demonstrations in affected cities, suggesting limits to public goodwill and compliance.

What can be learned from Australia's experience with the COVID-19 pandemic? It has been particularly illustrative because it has represented a model of how community transmission can be largely prevented or, when it occurs, to be completely eliminated (3). The low case numbers and deaths related to COVID-19, and the relatively unrestricted lives of Australians in states where COVID-19 transmission is close to zero, are testament to the success of these measures. We have learned that early action is important, with public health measures tightened as soon as outbreaks occur, and then adjusted against the moving tide of case numbers, vaccine supply, and community behavior. Although such measures do not avoid the inevitable, they do buy time to vaccinate. At the same time, vaccination messages must be strong and clear to convince a population with little disease to come forward, and a ready supply of a range of vaccines is important to mitigate risk. Travel bubbles are possible between nations with close relationships and similar levels of diseases and approaches to disease control; however, these must be regularly adjusted in response to disease patterns and vaccination status. While Australia's story has been different, and there is still good reason to hope that much severe disease and many deaths can be avoided, like the rest of the world, it is creeping toward the same goal of a highly vaccinated population and an eventual return to a “new normal.” That's if we can find our passports.