“What everyone is worried about is 1918 – Spanish flu. Fifty million deaths in a flu season. That was over 100,000 deaths a day.”
Prof Mark Walker, the director of the Australian Infectious Disease Research Centre at the University of Queensland, says Australia has had to respond to the novel coronavirus outbreak by imagining the worst that might happen.
“That’s the perspective. Right at the start of an outbreak, you can’t predict which way it’s going to go, and that’s why there has been such a strong response.”
Barely a month after the first recorded death from what is now known as Covid-19, about 1,500 people have died, almost all in the Chinese city of Wuhan and surrounding Hubei province. Flight routes have been shut down, travel bans issued, thousands of people evacuated and quarantined. As the World Health Organization’s director general calls on countries to act quickly to prevent the spark of the disease “becoming a bigger fire”, leading epidemiologists say Australia’s response has been robust, but not perfect.
In Australia, the number of cases remains steady at 15, with five people having recovered and 10 stable. The Australian government has enacted a range of measures, advising residents to avoid travel to China, evacuating Australians from Wuhan to quarantine facilities on Christmas Island and outside Darwin, and banning arrivals from China of non-citizens and permanent residents – on Thursday Scott Morrison announced a week-long extension of the initial two-week ban. Wuhan itself is in lockdown.
Recent figures coming out of China have caused confusion about the number of cases, but it will be months before the trajectory of the virus is properly understood, epidemiologists say. Current evidence suggests coronavirus has a mortality rate between 2% and 2.5%, about twice that of regular flu.
“It’s really hard making decisions in the absence of much evidence,” says Prof Allen Cheng, the incoming president of the Australasian Society for Infectious Diseases.
“You don’t want to be saying ‘I don’t think it’s going to be anything’, and then it turns out to be worse than you think.”
While researchers in Australia and globally have been mobilised to try to understand, treat and vaccinate against the virus, epidemiologists say it is the magnitude of uncertainty around the virus’s components and behaviour which has prompted extreme caution on the part of national public health agencies.
“The problem is you don’t know, so it’s best to prepare for the worst,” Walker says.
Australia’s preparation ‘a bit clunky’
Measures to deal with “the worst” are canvassed as part of the Australian Health Management Plan for Pandemic Influenza, from vaccines and antiviral medication – which yet do not exist for Covid-19 – to border measures.
Should current containment measures no longer be effective and the virus spreads more widely, the government will consider “social distancing”, which means cancelling large public events, encouraging people to work from home if possible, and closing down schools if it appears children are susceptible to the virus. Public health messaging about basic measures such as hand hygiene would also be amplified.
The plan also involves continuity preparation for businesses and hospital pandemic planning. Since the last serious outbreak, of swine flu in 2009, most hospitals have had pandemic plans in place which aim to allow them to function normally while dealing with an increased number of highly infectious patients. As in 2009, it is likely fever clinics would be established to isolate patients presenting with symptoms, and wards or spaces identified to hold those with the virus.
“Most hospitals are fairly stretched at the best of times in the middle of winter,” Cheng says. But elective surgeries may be deferred in order to free up beds. “Intensive care is probably the pressure point,” he says.
Australia’s preparation is in line with best practice, Cheng says, but the situation in Hubei province would test any government. Australia last ran a national simulation exercise for pandemic flu, testing the system’s preparedness, in 2006.
Cheng says the current system is working, but “it’s just a bit clunky. It could work better.” Rather than drawing on a network of different committees and bodies, as the pandemic plan does, he says a permanent centre for disease control would be more efficient.
“We don’t need one tomorrow. This is for the next one, and it’ll be something to review when we’re done with this virus,” he says.
Christmas Island choice ‘draconian’
The Australian Medical Association has praised the national response so far, saying Australia has been prepared and acted in accordance with international best practice, although it criticised the choice of remote Christmas Island as a quarantine facility, noting specialist teams had to be flown to the island.
Prof Catherine Bennett, the chair of epidemiology at Deakin University, says the isolation on Christmas Island or the mining accommodation in Darwin “appears almost draconian … but that’s the extra step of caution that’s protecting a lot of people, including healthcare workers”. She says there are limited places where people can go for quarantine, and without those facilities it would be harder for people to return home at all.
Outside China, she says, “we have the opportunity to try to get the gate closed, pick up any cases that come through by screening people and putting them into these 14-day holding periods to make sure they’re OK, because if it gets out into the community you’re chasing it, and it becomes a very difficult outbreak to manage”.
But Australia’s federal system has meant the response has not been entirely uniform.
Bennett says there have been inconsistencies between states in public messaging, specifically around who needs to self-isolate. “The more consistent the message is, the less confusing it is for people and the more likely they are to abide by it,” she says.
The outbreak has prompted the Australasian Society for Infectious Diseases to renew its call for the establishment of a central government body to monitor and coordinate responses to public health threats such as novel virus outbreaks.
“The main issue is that things are changing so quickly that some states may get ahead of others in terms of response,” Cheng says. “That’s always going to be a problem in a situation like this, because our knowledge keeps changing.
“I think in general the coordination has been reasonably good this time, but I think with the speed of changes and those sorts of things, there is a little bit of slippage.”
Cheng and Asid say a national body like the European Centre for Disease Control, which coordinates a Europe-wide response to emerging threats, could improve Australia’s national response.
Australia has a model for coordinating response to outbreaks – in food. OzFoodNet draws together food epidemiologists to monitor and respond to new threats to food security.
Walker says the coordination and speed of the Australian response to disease outbreaks has vastly improved, but a centralised body for disease control could be “useful” if it were backed by the states and well funded by the federal government.
“You wouldn’t be able to do that sort of thing on the cheap,” he says. “I think it’s a good wake-up call nationally. Our preparedness for future infectious diseases is really important.”
Public fear and response
Epidemiologists say that while caution is critical, so too is perspective.
Last year, more than 250 people in Australia died from regular flu. Globally, influenza kills 1,000 people a day.
“For perspective, there’s a long way to go before corona virus is as much to worry about as the flu,” Walker says.
Walker and Bennett both say media coverage has tended towards scare, and information has been incomplete. Most reported deaths from coronavirus have been among high-risk groups, including the elderly and people with other conditions. For the average person in Australia who hasn’t been travelling, Bennett says, the chance of contracting Covid-19 is almost zero.
But public anxiety remains high, and Chinese Australians have borne the brunt of it, with reports of racist behaviour towards those of Chinese appearance.
The mood prompted Australia’s chief medical officer, Prof Brendan Murphy, to reiterate that the risk is among people who have recently visited China, not the Australian Chinese community. “We are very concerned about xenophobia and any sort of racial profiling, which is completely abhorrent,” he said. “We’re talking about a relatively small number of people just because of where they’ve been, not who they are. There is no community transmission of this virus in Australia.”
Cheng, who is of Chinese ancestry, says he can understand the anxiety, but it needs to be combated.
“There are only 15 cases in Australia as best we know,” he says. The last census recorded 1.2m Australian residents with Chinese ancestry. “Clearly, most people don’t have it.”
Walker points out that infectious diseases can spring from anywhere. Australia is the origin, for instance, of Ross River virus. “We don’t want to get into a geographic blame game about where a particular disease originates. We want to mount the best and most appropriate response to prevent disease progression and spread,” he says.
China is not the enemy, but the most important ally in containing this threat, Cheng says. “If they get it under control we all need to absolutely thank China for cutting this off at the source, and they really need as much support from us as we can.”