We flattened the curve. Now let’s end the pandemic

As we experience the pain of so many lives lost and the fatigue of what feels like an endless year of restrictions, it can be hard to appreciate the progress that has been made in developing solutions to the Covid-19 pandemic. We’ve come a long way since late January, 2020 when the SARS-CoV-2 outbreak was first declared an emergency by the World Health Organization. We now have multiple safe and effective vaccines, reliable diagnostics, a better understanding of transmission dynamics and better clinical care.

Still, the next six months are crucial to ensuring we can open up our societies and economies, while also driving Covid-19 infections to very low numbers and keeping them there. The current priority for many governments is less about how the pandemic ends globally and more about how they continue managing this crisis domestically. But if we want to see an end to this crisis, we must reframe this thinking.

This much is clear: restrictions and harms go hand-in-hand. Worldwide, many business owners have suffered a challenging time through lockdown cycles, while children and young people have been isolated from their friends and educational environments with in-person schooling limited in many places. Health workers are experiencing rising mental health issues as well as burnout from an exhausting year on the front-line.

What Covid-19 has laid bare is that every country has struggled to manage this virus, with difficult trade-offs necessary. The Scottish Government has committed to a Four Harms framework to assess policies’ impacts upon population health, society and the economy. Countries worldwide should also evaluate restriction ramifications to adopt judicious policies as the world attempts to thwart the pandemic once and for all.

While the initial ambition of many rich governments across the world was to “flatten the curve” — meaning to keep patient volume within healthcare capacity — with greater understanding of SARS-CoV-2, it is clear that proactively working toward elimination is better from both an economic and a public health perspective. We now have tools that make this possible.

In 2020, many low- and middle-income countries recognized the limits of their healthcare systems and pro-actively worked to suppress transmission using traditional public health measures such as testing and tracing, border controls, public handwashing facilities, bans on mass gathering and good guidance on public health hygiene.

Countries such as Vietnam, Thailand, Senegal and the state of Kerala in India have done remarkably well in the first stage with non-pharmaceutical interventions. In the next stage of the pandemic, low- and middle-income countries must also have access to vaccines and larger testing capacity in order to suppress infections without the need for harsher lockdown measures.

A recent study of health care workers in Scotland suggests that vaccines can reduce viral transmission — a promising sign for decreasing hospitalizations and pressure on healthcare services. The study found that those with two doses of the vaccine were at least 54% less likely to pass the virus to others.

This means governments can be more ambitious, and aim to use vaccines following the measles model — that is, build up population immunity through vaccination and suppress the virus to the lowest possible levels by quickly managing outbreaks as they arise through robust test, trace, isolate and support policies.

Rich countries are in a privileged position given their access to vaccine supply. As of Monday, Scotland has already vaccinated over 48% of its adult population — including health and social care workers– and aims to vaccinate the entire adult population by July 2021. This is a clear ambition for all countries of the world: to start vaccinating those groups most at risk of hospitalization and death as well as those working in hospitals and social care settings.

Covid-19 vaccine trials are also taking place in children. If deemed safe and effective, in parts of the world, vaccines could be considered for kids in the fall. While it is tempting to want to release all lockdown measures quickly, patience will be key for allowing the vaccines to do the necessary heavy lifting.

Reintegrating people into society too early could trigger another wave of cases in younger people under 50, and this would inevitably hit those from deprived and disadvantaged backgrounds the hardest.

But this also doesn’t mean the world must stay in lockdown forever. It is a careful balance of opening up cautiously while keeping covid case numbers low. These are the key factors to be mindful of if we want to reach an end to the pandemic while reopening our communities across the world.

Opening public spaces

The well-being of children is a priority, and with it, the reopening of in-person schooling worldwide. Organized, group, outdoor activities and hospitality can then follow, before finally moving to more mixing indoors.

We know the riskiest settings are indoor, poorly ventilated and crowded places where people gather together to socialize. We should remain cautious of these environments. This is particularly important for those countries with limited access to vaccines and testing capability.

Testing

Testing is an important complement to vaccines — to identify cases and also for surveillance. Both traditional PCR and rapid testing are helpful in identifying infected individuals who then need adequate financial and practical support to isolate and not infect others.

Wastewater testing is also a vital tool as an indicator of prevalence of disease in a community and to guide mass community testing to find individual cases of infection. After successful piloting, Scotland has invested £2.3 million ($3.18 million) in consolidating wastewater testing across the country, ensuring broader pathogen surveillance not only now but for future threats, too.

Similar programs are being implemented in the US to detect Covid-19 outbreaks on college campuses and the European commission has recommended that all member states adopt wastewater monitoring systems. Low- and middle-income countries, too, should be supported by the World Bank to make this kind of infrastructure investment as part of their core capacity building for future outbreaks.

Viral genomic sequencing

As vaccinations proceed and more selection pressure is exerted on the virus, the other critical component of a longer-term response is comprehensive genomic surveillance.

Given the rise of SARS-CoV-2 variants such as B.1.1.7, genomic sequencing is vital to quickly identify new variants and track their impact on transmissibility, health outcomes and vaccine effectiveness. It can also ensure that testing mechanisms can adapt through the development of variant-specific testing and inform future vaccine programs.

Recognizing the importance of this viral genome analysis, some nations are making investments in genomic sequencing. Scotland, for instance, has committed £13 million ($18 million) with the intent of sequencing the genome present in every positive case detected. Denmark has undertaken a large sequencing effort, allowing it to track the rise of new variants within the country. This is important legacy infrastructure for other current and future pathogens — whether to fight future flu pandemics or to monitor preexisting communicable diseases.

Global interconnectivity

While it is understandable that countries continue to manage the current crisis and attempt to limit the impact on their own populations, we need to recognize global interconnectivity and improve global health security.

By mid-2021, wealthy countries are aiming to vaccinated roughly 70% of their populations, according to the World Health Organization Director-General Tedros Adhanom Ghebreyesus. Meanwhile, less than 20% of low- and middle-income countries will be covered.

It is for this reason that we need to form a coalition of countries to commit to vaccinating the world and creating supply chains for key medical interventions like oxygen and dexamethasone, a steroid that has shown promise in reducing the risk of death for patients with severe cases of Covid-19.

This coalition is already forming: President Joe Biden has committed to giving vaccine doses to other countries after Americans are prioritized and Norway has committed to donating extra doses to low-income countries. The UK has committed £548 million to the COVAX initiative — a multilateral program to provide vaccine access to 180 countries — making it one of the program’s largest sponsors. Other nations, too, have made commitments to COVAX.

This approach is vital, as we are already seeing the risks posed by new variants, such as those that originated in South Africa and Brazil, if uncontrolled transmission takes place. Concern about how this pandemic is affecting other parts of the world is essential — both morally and pragmatically.

The future of the pandemic is unclear, but what is clear is that we must both apply the major scientific advances and extend the warm embrace of cooperation to ensure that we leave no parts of the world behind.