Three countries that were leading the world in the fight against covid-19 now appear to be losing control, with cases rising in Australia, Japan and South Korea.
Their new waves are being caused by a combination of the delta variant, lapses in vigilance and low rates of vaccination, say experts, but do not fundamentally change what we know about how to get the virus under control.
Australia, Japan and South Korea were recently praised for their covid-19 control strategies, ranked among the five best of 37 rich nations. Along with Iceland and New Zealand, they were judged to have taken the right measures at the right time and consequently produced the best possible outcomes for health, economic growth and civil liberties, according to an analysis published in .
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All five decided to pursue an , which entails mass testing and tracing, supporting people to isolate, border surveillance and swift and stringent lockdowns when needed. This cannot actually eliminate the virus but keeps a lid on it. Australia has only reported one covid-19 death in the whole of 2021 thus far.
“I don’t think the elimination strategy is unravelling,” says Jeffrey Lazarus of the of the Barcelona Institute for Global Health in Spain, who was a member of the team that did the analysis of the 37 nations. “ I think it’s the reality of a very transmissible, very contagious virus that’s becoming even more transmissible, and a low level of vaccination.”
As of the end of June, Australia had fully vaccinated just 6 per cent of its total population, compared with 60 per cent in world-leading Israel. The main problem in Australia is supply, says at the University of New South Wales in Sydney. Australia had pinned some of its hopes on 51 million doses of a vaccine being developed at the University of Queensland, but early trials failed after the vaccine provoked an immune response that could have resulted in a false positive HIV test. There is also some vaccine hesitancy caused largely by the Oxford/AstraZeneca blood clot risk, says Dore.
Japan has fully vaccinated only 13.8 per cent of its population and South Korea 10.4 per cent. Both have . In Japan, which is preparing to host the Olympic and Paralympic Games starting on 23 July [see box], case numbers are creeping up again after falling back from a fourth (fairly small) wave in May 2021.
All three countries now have the delta variant in circulation. Two doses of the approved vaccines are highly effective at preventing severe disease from this variant, but single doses are not. “We have very reassuring data already in the real world that the original vaccine works very well against delta,” says Andrew Pollard, director of the Oxford Vaccine Group at the University of Oxford. The UK currently has a wave of the delta variant but double-vaccinated people are showing good levels of protection, he says. A recent analysis from found that double vaccination with the Pfizer/BioNTech vaccine is 96 per cent effective against hospitalisation, and the Oxford/AstraZeneca vaccine 92 per cent. The single-shot Johnson & Johnson vaccine .
“The elimination strategy still holds but you need to impose it very quickly,” says Lazarus. However, public compliance and support for stringent measures is waning, he says. “The idea that you shut down society when you identify half a dozen cases in an Australian city… it’s getting harder and harder to maintain the population on board.”
Going forward, the world needs to decide what suppression or elimination strategy to pursue, says Lazarus. Total eradication of the virus is unlikely but there are other tried-and-tested options on the table. One is “elimination as a public health problem”, which the decided to aim for with leprosy in 1991. That basically means accepting that the disease will circulate but treating cases aggressively. The other is “elimination as a public health threat”, which is being pursued globally for and essentially means suppressing transmission of the virus as much as possible. “We haven’t worked that out yet for SARS-CoV-2,” says Lazarus.
Meanwhile, Iceland and New Zealand continue to perform well. Iceland has not reported a new case since 25 May and New Zealand has been in single digits since a small spike in April.
However, the elimination strategy cannot be pursued forever. “Countries that have adopted this elimination approach are facing a different challenge and a significant challenge,” says Graham Medley at the London School of Hygiene & Tropical Medicine, who is also chair of the UK advisory group. “They will fully vaccinate before they open up I’m sure, but when they do they will be in the same position that we [in the UK] are now, only slightly worse because they won’t have the immunity developed from natural infection, and so New Zealand [for example] is going to have to have an epidemic at some point unless it wishes to keep its borders closed forever.” This is referred to as an “exit wave”.
“It’s absolutely the truth,” says Dore. Given the increased transmissibility of the delta variant, it is almost impossible to achieve herd immunity through vaccination alone, he says. “You have to shift your public health goals,” he says. That involves accepting some naturally-acquired immunity from infections. “The virus will continue to circulate globally for many years to come so you cannot cut yourself off from the world. At some stage there will have to be a wave of cases though with relatively low numbers of hospitalisations and deaths.”
But Lazarus says this is a risky strategy. “I don’t think they should be letting the virus run rampant, there will still be lives lost.” He says he’s not suggesting that elimination countries need to go back to strict lockdowns, but could keep up some elimination strategies while gradually easing restrictions. “I think there’s still a lot of basic things they can do,” he says.
Should the Olympic games go ahead?
The International Olympic Committee has put measures in place to achieve a . There will be no spectators from abroad, physical distancing is mandatory and athletes will be tested before they arrive and every day while they are there. Stadia will be open for domestic spectators but only at 50 per cent capacity and singing and chanting will not be allowed.
Nonetheless, “the decision by the International Olympic Committee and Japan to forge ahead with such a large scale international event raises many infection control, health security and ethical challenges,” says at the University of Newcastle in New South Wales. Japan is currently reporting about 1500 new covid-19 cases a day and rising, and is hence unlikely to be able to deliver a covid-proof Olympics later this month, he says.
One concern is that vaccination for competitors is encouraged but not mandatory. Another is that the testing requirements for entry into Japan are fairly lax. For example, – which are generally less sensitive than tests for viral RNA – will be accepted and there is no requirement to prove that the test was done in a lab that has been certified for quality assurance.
Thousands of competitors from countries where covid-19 is rampant will descend on the Olympic village and mingle. The village is supposed to be a bubble but there will inevitably be contact between athletes and local workers providing transport, cleaning, security, catering and covid-19 testing. Every day up to 11,000 competitors from all over the world will congregate for a test.
Around 60 per cent of Japanese people want the games to be cancelled. According to Dalton, signs in the windows of Tokyo’s Tachikawa Sogo Hospital capture the public mood. They declare: “Medical capacity has reached its limits. Stop the Olympics!”
