Comment: SARS-CoV-2; the unwelcome guest

When SARS coronavirus 2 (SARS-CoV-2) burst onto the scene, it arrived as an uninvited guest at the party, sneaking in with genuine invitees. Our indifference gave way to a sense of foreboding as SARS-CoV-2 reached into our lives. More than a year into the pandemic and the uninvited guest has become the constant companion who elbows past family, friends or close colleagues, and is incapable of recognising when it’s time to go.

We have learned so much about the behaviour of this virus that you would have thought we would have sent it packing by now, but no, there is still no end in sight. All our predictions of pandemic decline have been frustrated by this insubordinate coronavirus.

Our best pandemic models have wide confidence limits that broaden the further out you care to go. There is no recognisable vanishing point. On the contrary, the unpredictably recurrent epidemic waves appear to favour divergence as SARS-CoV-2 continues on its erratic evolutionary path. The evil logic of this virus favours accumulation of transmission-enabling features where the pandemic is already at its most intense, resulting in the generation of new variants. The molecular biology that brought us this insight also gave us the vaccines on which so many now pin their hopes. Sadly, the challenge of COVID vaccine delivery to the global population has exposed fault lines in vaccine supply, distribution, delivery and acceptance. Social distancing, public health restrictions, border closures, sanitiser and personal protective equipment are likely to remain with us for some time to come as we strive for that elusive herd immunity.

If we take an evidence-based approach to mapping out the next six to twelve months in pandemic time, it is reasonable to consider the fast and slow extremes, the most likely and most dangerous outcomes. From recent experience in the USA, where vaccine rollout has been rapid and comprehensive, suppression of epidemic spread is plausible in a matter of months. However, this may fall short of the near elimination achieved in New Zealand and parts of Australia through favourable geography, stringent border controls, quarantine and other public health measures. Continuing a global fast track assumes similar rollout in low- and middle-income countries that lack the public health infrastructure of wealthy countries. The coordination of disease prevention on this scale will be a monumental task but has to be given serious consideration because the alternative is very unattractive.

So what of the slow path to pandemic’s end? Some have suggested five years or more, but this is only an informed guess. It could be longer, if repeated stop-start controls provide SARS-CoV-2 with the evolutionary bottlenecks that encourage transmission enhancements, vaccine escape mutations and diagnostic test evasion. At a strategic level, a methodical and therefore slower approach would start with pockets of disease elimination which are then expanded until they join up.

The most likely path for the COVID pandemic will probably be the consequence of vaccination bias that favours wealthy countries, and wealthier people in lower-income countries. The vaccine-advantaged will surround their disease-free havens with border controls, quarantine and ever-improving vaccination regimes. The most dangerous course will be a protracted series of pandemic waves due to new variants of concern, arising in populous newly industrialised countries such as the BRIC group. No amount of vaccine imperialism will stop further waves of vaccine-escape COVID from burning through well-heeled communities with a strong attachment to freedoms they lost to SARS-CoV-2.

The first few weeks of the pandemic saw a cessation of ineffectual peacetime bureaucracy, interdisciplinary communication, pragmatic decision-making and rediscovered community cooperation. There is a pressing need to rediscover that common language and sense of purpose. SARS-CoV-2 is able to change its fundamental behaviour faster than public administration can adapt. Agile administration is a step in the right direction, but if we want to put a confident date on the end of the pandemic, we need to use microbiology’s moment on stage to re-engage everyone outside coronavirology, from vaccine refusers to exhausted politicians. The conversation must start with what life beyond the pandemic will look like before we can move onto how we might get there. Only then will we be confident that the end is nigh.

Tim Inglis

The University of Western Australia (M504), 35 Stirling Highway, 6009 Perth, Australia

[email protected]

@scrimgeourONE

Tim Inglis is a UK-trained medical microbiologist, who migrated via Singapore to Australia, and Deputy Editor-in-Chief of Journal of Medical Microbiology. His work on emerging infectious diseases in Western Australia has emphasised capability building in regional, rural and remote locations where pathology support is lacking. Currently, much of his time is taken up on COVID laboratory activities, and if it weren’t for the pandemic, he would be working flat out on new methods for rapid diagnosis of systemic, drug-resistant infections in regional Australia. In his spare time, he enjoys trail running and looking after a smallholding.

What parts of your job do you find the most challenging?

The part of the job I find most challenging is finding the patience needed to handle public-sector administration!

What advice would you give to someone starting out in this field?

Our discipline is in the spotlight: do micro, think global.