We (really) need to talk about reopening…

Australia has been one of the world’s COVID-19 success stories, with a total of just over 30,000 cases and 910 deaths. That’s in large part due to the early move to shut our borders. But after more than a year in the ‘fortress’, frustration is growing among experts who have been calling, for months, for a reopening plan.

“We went into it to protect the population until we had other means to reduce the severe illness and deaths associated with the infection,” says Professor Catherine Bennett, chair in epidemiology at Deakin University, Melbourne. “But we put so much effort into holding the walls that we now don’t know how to sit back and let the virus in. And knowing what that path looks like and when we can do that safely is a critical conversation to have.

“We have created a bit of a dilemma. We find ourselves thinking this could be sustainable. And even if it was, all the costs of being isolated will become increasingly obvious as the rest of the world continues to open up.”

Recent announcements that Australia won’t consider borders reopening until sometime next year, and state premiers pushing to cut international arrivals as outbreaks ripple across the country, have amplified concerns.

But with the federal government facing an election before too long, are our leaders looking at the scientific evidence around borders reopening, or are they peeping at the ballot box?

Maybe you guys are right

Australians have widely supported the government’s zero-COVID approach. After all, it has avoided thousands of deaths. But with almost 30% of Australia’s population born overseas, unease is growing among those who have been separated from family and friends for more than a year. And yet the moment they will be able to hug their loved ones is not even on the horizon.

All the costs of being isolated will become increasingly obvious as the rest of the world continues to open up.

Over 35,000 Australians are still stranded overseas and unable to return home. The international students, skilled migrants and tourists that Australia’s economy strongly relies on are left out.

While other countries such as Singapore, Hong Kong and Taiwan are preparing to reopen their borders, moving towards the next phase of the pandemic, Australia is choosing to be left behind.

“As long as COVID is causing chaos internationally, [the zero-COVID] policy is rewarded and popular,” says Professor Ben Marais, an infectious diseases specialist at The University of Sydney. “But as the COVID wave starts to wane internationally, we are in a very disadvantaged position.”

Australian authorities have presented the public with a binary scenario. Either we can raise our walls higher and higher to keep the community safe, or we knock them down and let the virus run through the country like wildfire. But experts argue there are safe alternatives to those two options.

“The reality is that there is a middle ground, but the middle ground has become more and more politically uncomfortable,” Marais says.

In the emergency national cabinet brief held in late June, Prime Minister Scott Morrison said the government is preparing a plan. But he pushed back any conversation around reopening to sometime next year, when Australia has reached a vague “much higher levels of vaccination”.

The exact timing of that plan, and what it looks like, remain unclear.

We’ve asked some of Australia’s leading experts to help us picture some strategies Australia could be adopting right now to begin easing borders restrictions.

Vaccination is key

The global consensus among experts is that the virus will continue to circulate for the foreseeable future. It is reasonable to assume that SARS-CoV-2 will become endemic – meaning that it will continue to circulate in pockets of the global population for years to come.

“The visible disease is likely to pass, but the virus is going to be with us forever,” says Marais.

“All the other coronaviruses that have crossed the species barrier into humans are still with us, and once they’ve established themselves at a global scale, they are ineradicable.”

Eventually, we will have to learn to live with COVID-19 – a statement that horrifies many. But learning to live with the virus does not mean accepting death and devastation. Instead, with enough people vaccinated, COVID-19 will be managed like other endemic diseases – such as the common cold; the flu; or hand, foot and mouth disease.

Learning to live with the virus does not mean accepting death and devastation. Instead, with enough people vaccinated, COVID-19 will be managed like other endemic diseases.

The evidence is clear: vaccines are highly effective in reducing the severity of the disease, even against the newly emerged variants.

All the experts Cosmos Weekly interviewed agreed that we need to vaccinate at least 80% of the entire population before we achieve some kind of herd immunity. That is an ambitious target we might not be able to achieve for a long while, if ever. But before we hit such a target, there are many steps we can take, they say.

A traffic light system

One of the first steps could be to create new travel bubble – such as the one with New Zealand – with countries where infection rates are low.

This would be governed by a kind of ‘traffic light’ system, suggests Professor Mike Toole, a medical epidemiologist at the Burnet Institute, Melbourne. Low-risk countries would have a green light, while countries with increasing transmissions would have a yellow or red light.

This lights system would direct incoming travellers to different quarantine arrangements with different levels of restrictions.

Singapore is taking a similar risk-based approach. Travellers coming from countries deemed to be safe don’t need to quarantine in a dedicated facility; those coming from countries with high-infection rates must.

“At the moment, there wouldn’t be many countries that would be green,” says Toole.

The main problem with such a system is that the green light could turn red in a matter of days. Countries that have had zero COVID-19 transmission for some time could suddenly experience a resurgence of the virus. That’s happened in several countries in the past few months, including Australia, which is currently battling a series of outbreaks after weeks of normalcy.

“It’d have to be flexible,” Toole says. “You can’t just open the door and not have the ability to close it again.”

Home quarantine

Recent studies showed that full vaccination provides 60–90% infection risk reduction, and that even when fully vaccinated people do get infected, they are less likely to transmit the virus to others.

“If you’re fully vaccinated, you should be able to travel overseas now and come back into home quarantine,” says Professor Gregory Dore, an infectious disease expert at the UNSW’s Kirby Institute, in Sydney.

Dore has strongly promoted the need to move away from a one-size-fits-all approach to quarantine, to home quarantine for vaccinated travellers: “The risk is incredibly low.”

He’s estimated that the number of positive cases among vaccinated returnees in home quarantine would be minuscule. These people would be confined to their homes and tested regularly so that even if a positive case was detected, the risk of those cases leading to significant community spread would be exceedingly low: “Much lower than the risk currently coming from our hotel quarantine system,” Dore says.

In the past two months alone, Australia has experienced six quarantine breaches that have forced Victoria under yet another lockdown; then New South Wales, Queensland, the Northern Territory and Western Australia. Since April 2020, there have been 21 quarantine failures, with every 204 infected travellers resulting in one outbreak.

If you’re fully vaccinated, you should be able to travel overseas now and come back into home quarantine.

“Everything has a risk, but you just need to ring-fence that risk,” says Professor Mary-Louise McLaws, an epidemiologist at UNSW Sydney and advisor to the World Health Organization.

A vaccine passport could prove travellers have completed a vaccination course with one of the WHO-approved vaccines. Rapid-antibodies tests could also be used at airports to check the antibody levels against COVID-19 in people within minutes.

Travellers would be required a negative test within three days of departure, which is currently required for all returnees. As soon as they land, they could take a rapid antigen test, which would indicate if they are carrying the virus within minutes. Once self-isolating, they could be tested again in following days. Both Dore and McLaws think that fully vaccinated people could home quarantine for a much shorter time than 14 days.

Dore says past and current lockdowns in Australia could serve as a perfect model for what future home quarantine might look like. During a lockdown, we’re asked to isolate at home, monitor symptoms and get tested. “We have these data,” Dore says.

He says if states would provide them, researchers could extrapolate precious information that would help design a home quarantine system for incomers.

“We would also know whether any of those people who were supposed to be in home quarantine didn’t comply with the public health orders and led to subsequent community transmission,” says Dore.

Other countries that, like Australia, have pursued an elimination strategy have successfully implemented home quarantine. For example, Singapore uses its traffic light system to allow travellers arriving from low-risk countries to quarantine at home for seven days. In Taiwan, where hundreds of thousands of travellers have gone into home quarantine, authorities have recorded 99.7% compliance.

In Australia, a national review of hotel quarantine and a report commissioned by the Victorian government recommended implementing a home-based quarantine system for all international arrivals. The recommendations came at the end of last year – before any vaccine was even approved.

Fit-for-purpose quarantine

Although a transition to a home-based quarantine is favourable, fit-for-purpose quarantine facilities are still needed, says McLaws.

“Those who don’t have a home to go to need to be put somewhere safe, and the system we have at the moment is not built safely.”

That also includes travellers who are not vaccinated, and positive cases.

When we closed our border on the 20th of March last year, we only had 800–900 cases. Every single case in the community since then has been due to breaches in quarantine, and that has been due to an inability [of the government] to respond correctly.

For months, McLaws and many other experts have called for the government to fix the current hotel quarantine system. “They all ignored the warning from myself and others about airflow problems within hotel rooms,” says McLaws.

“When we closed our border on the 20th of March last year, we only had 800–900 cases. Every single case in the community since then has been due to breaches in quarantine, and that has been due to an inability [of the government] to respond correctly.”

McLaws has also stressed the need for more testing in hotel quarantine to identify positive cases faster, and to separate them from negative-case travellers. Currently, travellers in hotel quarantine are only being tested at arrival and the end of their stay.

“We’re not testing enough to move people out of hotels and away from the negative travellers fast enough,” McLaws says. “That’s a lack of duty of care.”

How many travellers have been infected with COVID-19 while in hotel quarantine is unclear, but the current arrangement poses a serious risk for incomers. “The duty of care goes both ways,” says McLaws. “The community do what they are asked, and the government must keep you safe while you are asked to be in isolation.”

Now is the right time

There is no doubt that early closures of the country’s international borders has been a successful strategy to minimise the spread of the virus and deaths in the community, says Dore. But a target for reopening must be set, he says.

“There is no excuse for not having this conversation right now.

“We have to start to get the community to understand that there is a pathway forward. People would have a sense of optimism around what the future may hold; it creates an incentive for more people to get vaccinated, and that’s really important.

“The federal government has seen state government elections being one off the back of a strong stance on community safety. They look at those surveys and think, ‘what are we to gain politically from taking what some people would describe as a riskier approach?’”

But no expert suggests throwing the gates open suddenly. Instead, these steps can be planned following the evidence and estimating the risks. “It comes back to leadership and communication,” says Dore. “It is possible to show to the community that making these evidence-based changes doesn’t increase risk and doesn’t represent harm for the community.”