To anyone who has watched and even partially understood the continued dynamic evolution of the SARS CoV-2 virus, this 4th wave comes as no surprise whatsoever. Multiple scientists, doctors, research groups and major health institutions including the WHO have warned repeatedly that the COVID-19 pandemic is not over, no matter how much we would like it to be. I personally predicted another surge in October/November back in July -and here it is. Not that I am particularly clever or that this is rocket science, it is not, and it is all there in the data for everyone to see.

COVID-19 exhibits global periodicity of about 4-5 months as well as local periodic surges, the timing of which varies according to the local prevention conditions and public behaviours. I am currently on business in Seoul this week and everyone here is wearing top quality masks indoors and outdoors- no exceptions, it’s the law.

In Australia, our politicians only pay attention to the information that suits their political agenda and business/financial interests- so a few weeks ago we stopped having compulsory isolation following a COVID infection and guess what?- infections soar again. We are not testing and tracing either. Zero COVID policies are near impossible, but common sense and flexible, informed ,and agile public health policy is possible – so why don’t we have it? We now know that multiple infections with SARS COV-2 produce cumulative long term health risks including long COVID related problems such as heart disease, diabetes and dementias, and even mild infections make a long-term difference in risks for these serious diseases.

The life expectancy of humans globally has been dialled back by about 2 years over the last 3 due to the multiple knock-on effects of COVID-19, and with it 25 years of advances in preventive medicine have been lost. Australia is behind the curve on this because of the lateness of the pandemic arrival in this country, but it appears that we are racing to catch up!

The fact is that the Omicron XBB sub-variant of this virus is one of the most infectious agents known to man, it shows significant immune evasion (previous vaccinations and infections do not stop infections) and people have not topped up their booster shots recently either.

There are new vaccines available that protect better against Omicron sub-variants than the previous vaccines- everyone should try and get a bivalent vaccine booster and these need to be more generally approved, not just to protect against the current XBB sub-variant that is ripping through the community, but against the next generation of sub-variants of unknown pathogenicity that will inevitably follow and might be potentially even more dangerous- we simply don’t know, so caution and more vaccination is the call of the day.

Oh no! Not again, or rather, not still?! We are sick of it. 

The air of pushback against ongoing restrictions was typified by demonstrations threatening violence some months ago. We eased restrictions rather than face discontent. We did not want to go the American way. We needed to open our struggling economy. 

There was a tacit acceptance that ease in other discomforts outweighed increased COVID deaths.

However, when ill, it is best to accept the illness as well as its widespread physical, psychological, and social ramifications. 

So it is not only important to vaccinate once more, but to be aware of and try to counteract complications such as fatigue, brain fog, anxiety, despair, withdrawal, frustration, anger, rebellion, paranoia, and conspiracy theories.

COVID-19 being worldwide, politicians need to be aware that much of the deterioration in world politics since the pandemic may be due to similar emotions playing out on a wider scene for similar reasons.

The Queensland Premier has just raised the state’s emergency status from green to amber, in response to a doubling of patients hospitalized with Covid over the last week and a 15% increase in cases. The amber alert requests people wear a face mask in healthcare settings, indoors if social distancing is difficult, on public transport, and if they are vulnerable or around vulnerable people. It also requests people to take a RAT every two days if someone in the household has Covid-19. Importantly, this is a request rather than a regulation. 

Australia is now in its fourth wave of Omicron infections. However, unlike the previous waves caused by Omicron BA.1, BA.2, and BA.4/5, this wave has several causes. The first is waning immunity. Many people have had their last dose of vaccine over 6 months ago, and by now have comparatively little protection against symptomatic disease. At the same time, we have little or no public health measures in place to put a brake on transmission. The removal of mandatory isolation for infectious people just as new subvariants were on the horizon really was a poor decision. These new subvariants are more transmissible than BA.5. They include BA.2.75, BQ.1 and XBB. They are better than BA.5 at getting around our immune systems, and this means that even fully vaccinated people or those who have recovered from an infection are at higher risk of infection.

This is not just a Queensland problem. We are seeing this new wave happening across the country. As of last week, the Effective Reproduction Number for Australia was 1.11, representing a 23-day doubling time for case numbers - just in time for Christmas!

ATAGI is coming under increasing pressure to allow a fifth dose to vulnerable people. The onus is now on the other states and territories to follow Queensland’s lead and upgrade their health advice, and if necessary, reimpose some public health measures, like face mask advice. Surely, mandating face masks on public transport is not that difficult!

A 4th wave of COVID-19 started in Australia towards the end of October, driven by a “variant soup” of new lineages of SARS-CoV-2 that further escape existing infection-derived and vaccine-induced immunity. Instead of single variant driving this, we have many lineages with similar properties causing this rise, although the XBB, BQ.1.1 and BR.2 lineages are likely to be most prominent in Australia.

I expect that we will see a short sharp wave, similar to the recent one in Singapore with a peak by the end of November. I also expect this to be smaller than the BA.5 wave but that we will see a considerable rise in hospitalisations and deaths, particularly in people over 65, where blood surveys show that less than half of people have a prior infection. We have seen no evidence of increased severity in international settings but age remains a key risk factor and there are many Australians still eligible for third or fourth doses who could benefit from a booster dose at this time.

The new COVID wave is a concern. It’s due to the grandchildren of omicron, a variant which has been with us now for a whole year. This tells us that the virus is running out of ways to mutate so as to evade our immunity. 

There will undoubtedly be an upsurge in cases but the new wave, I think, will be easily body-surfed by most sensible people. Taking those common sense cautions like vaccination, social distancing, masking in public places, especially if vulnerable; and if infected and also vulnerable due to age or disease, consulting your GP RAPIDLY for potential use of antivirals - these measures will together make a real difference and get those body surfers safely back to shore!

We have now entered the next phase of the COVID-19 pandemic, where instead of seeing a single dominant variant, we’re now seeing multiple variants circulating at once. These variants are highly infectious and have acquired mutations which decrease the protective immunity provided by existing COVID-19 antibodies.  What this means, is that even people who are fully vaccinated, or have already had COVID-19, are highly susceptible to infection with these newer variants.  Current COVID-19 vaccines are still effective at reducing the risk of hospitalisation, but they now have limited ability to protect people against infection with these newer variants.  Unfortunately, until a vaccine is developed that can block viral infection and transmission, we will continue to see these ongoing waves of infections. This is unfortunate, as this gives the virus new opportunities to mutate further into later variants, which in turn generates new waves of infections.

Over the month of October, many variants have been circulating within the community and have various similar changes to them. By using antibodies derived from cohorts where vaccine responses have been monitored (VIIM vaccine cohort of NSW led by Tony Cunningham), other cohorts where infection and vaccination have been tracked since the beginning of the pandemic (ADAPT led by Gail Matthews and David Darley), and pooled antibodies that can give a population snapshot of greater than a quarter of a million people, we would conclude the following:

 1- Over time the immune response across the community has continued to mature. This means that the cells that generate the antibodies that are made following vaccination and/or infection are maturing to make better versions of antibodies. So over time, our antibodies may indeed decrease, but the antibodies being made bind across variants better. That said, antibody levels do get to low levels after 6 months and we know and have observed that a booster shot increases antibody levels (including the good ones). The latter observations were using the original vaccine. Recent data with variant specific vaccines has shown that the new vaccines may help target variants marginally better but we need to consider the results are only after a short period (one month). Monitoring these responses over a longer period is key as is testing newly emerging variants. 
 
2- Whilst the sheer number of variants in the community may be of initial concern, it is likely the consequence of pressure on the virus we see in 1. The population is getting better at protecting itself against a greater diversity of variants and in response the virus needs to continue to change to try and evade them. Of the variants, many immune evasive variants have appeared in Australia and include XBB.1, BQ.1.1 and BR.2.1. The latter variant is gaining in frequency and both ourselves and others in Australia are tracking it carefully. Overall these three variants take the edge of antibody responses, whether it be from vaccines and/or infection. That is the antibodies can still bind the variants but to lower levels than previous variants. Whilst it is difficult to predict what this will look like with respect to cases emerging in Australia, increases of the variant XBB.1 in Singapore for instance resulted in a peak level of infection well below that observed with prior Omicron variants.

I am very concerned by the lack of organised and structured responses to this 4th COVID wave. I believe that a mask mandate should be in place for public spaces where people are confined, to minimise the infection rate across the community. There is now good evidence that Long COVID is a major health complication of COVID-19 infection and that vaccination does not completely decrease the risk of having Long COVID. Further, there is emerging evidence that reinfection may be associated with Long COVID risk. Long COVID is a debilitating condition which is characterised predominantly by fatigue and brain fog.

This concretely means that people with Long COVID cannot be fully productive members of society in some cases because they cannot work as efficiently as they used to, with major implications for the economy. But perhaps more importantly, with a lack of service provision and a lack of structural response across the Australian healthcare system, patients feel abandoned and are therefore at risk of developing chronic mental health issues, meaning added suffering for them and their loved ones. Overall we need a better balance between total laissez-faire and an unrealistic COVID-zero approach. We also needed a better Australia-wide healthcare response as soon as possible.

Australia is currently facing a soup of variants, with no one strain of the virus clearly dominating. However, none of these currently circulating subtypes of the virus appear to be markedly more severe than what we have previously encountered, and we now have substantial population immunity to protect us.

Overseas, several countries have passed through waves with these newer offshoots of BA.2 and other variants, usually with mild to moderate strain on their healthcare systems. So there’s no need to panic and it’s unlikely we’ll need any population-wide restrictions. However, the elderly and at-risk groups should ensure they have had all the vaccine doses they’re eligible for, and if you think you could be eligible for COVID-19 antivirals, get tested and linked into care. Australia should now be looking to longer-term sustainable measures to protect ourselves from emerging infections.