COVID suppression vs elimination: beware of hot air!

When I started this post on 17 July I wrote:

    Much of the last week the debate has raged as to whether our aim in tackling COVID-19 should be suppression or elimination. The debate has involved short memories, the loose use of language, and a false binary. Also the notion that every country should use the same strategy.

    PM Scott Morrison will tell you that ‘aggressive suppression’ is the way to go, and that ‘elimination’ would break the economy. He also said that we need a few people getting sick and dying to keep our minds on the job.

    Scotty from Marketing did not say it quite that way, but that is what he meant.

On 15 July Katharine Murphy wrote Scott Morrison says Australia cannot shut down to contain second wave of Covid-19.

At that point Morrison was not against Victoria’s imposition of Stage 3 restrictions, and warned that a lack of vigilance could readily lead to scenes like we saw in New York:

    Morrison said lockdowns were necessary in Victoria given the significant spike in infections in the state, but “your protection against the virus is not shutting things down all the time”.

    “You have to do that sometimes, as is the case in Victoria,” he said. He said trying to eliminate the virus wasn’t the “right strategy” for Australia.

He said:

    “You don’t just shut the whole country down because that is not sustainable. I’ve heard that argument. You’d be doubling unemployment potentially, and even worse.”

    Morrison said it was impossible to achieve elimination “unless we are not going to allow any freight, or medical supplies into Australia, or any exports into Australia, or things like this – there is always going to be a connection between Australia and the rest of the world”.

No-one was talking about shutting down Australia. They were, however, pointing out that New Zealand had shut down quickly, and was reaping the economic reward of ‘snap-back’ at that time. At that time the Crossroads Hotel outbreak had just occurred. Morrison said:

    the responses by governments to the threat achieved the correct balance between suppression of the virus and allowing economic activity. Morrison said governments had to keep “tension in the cord” and he praised the efforts under way in New South Wales to contain a smaller outbreak in the state.

However, the problem was that apart from saying that all states should be like New South Wales there was never any precision about what ‘aggressive suppression’ meant. In spite of superficial agreement in the newly formed National Cabinet states clearly had their own views, not always clearly defined either, and confused by talk of ‘hotspots’, which could refer to anything from a cluster based on a hotel to a whole state.

In mid-July, Queensland was open to NSW, Victoria was in Stage 3 lockdown, and the Sydney Crossroads Hotel cluster had emerged, which was to generate a series of other clusters, so in quick succession, Queensland experienced the Logan infection, brought from Melbourne by two young women, and then Premier Palaszczuk, acting on advice from her Chief health Officer, declared Sydney a hotspot and closed the NSW border.

There is nothing wrong as such in what Morrison said in the link above, but he has failed, I think, on three counts.

Firstly, there has never been a clearly articulated national statement of what our COVID-19 target is. Given that health is a state responsibility, a nationally coherent approach always needed consensus, that is, the agreement of each participant to a concrete and clearly articulated goal, not some vaguely articulated aim.

Secondly, he has not understood his constitutional role, which in a federation was through leadership to get all the states on the same page, and then provide help and support.

By contrast, in a BBC report I heard, that is exactly what Angela Merkel has done in Germany in a similar federal system with 16 states and cities.

Morrison has provided a public running commentary on what he likes and dislikes, and in some cases has tried to direct.

Thirdly, he has played politics. Anthony Albanese has said that Morrison likes to take credit for anything good that happens with the coronavirus, and blame the states for anything bad. He has also clearly given his senior ministers a licence to attack the Labor states, as Josh Frydenberg has done repeatedly with Dan Andrews and most recently by piling into Qld Deputy Premier Steven Miles calling him “a stumbling, bumbling lightweight that no one’s ever heard of”.

Here I need to point out that in Queensland the Chief Health Officer’s responsibility for making directions in a health emergency was legislated under the Public Health Act 2005 (Qld), before Annastacia Palaszczuk entered parliament. Had she legislated to take back those powers, or ignored them, she would have been attacked for being power hungry by the LNP opposition.

The current occupant, Dr Jeanette Young, was appointed in 2005, and has now worked with four premiers on six pandemics. Palaszczuk, Young and Miles may not always get it right, but they work as a team.

I can’t find the link, but Raina MacIntyre explained the confusion of terminolgy very clearly to Norman Swan on ABC RN. From my notes she said that through the WHO the world had agreed definitions of these terms.

‘Elimination’ meant that you had cleared the virus from your country and had every expectation that it would not return in the future, usually through immunisation, and had the public health measures in place so that if it were to appear it would be quickly dealt with. Then you can apply for a certification, which I expect would be judged by a WHO panel.

MacIntyre says that, given the infectiousness of this virus, together with its ability to infect when pre- or asymptomatic, no country could ever make that claim, unless it isolated itself from all physical human contact through strict quarantine measures.

No country can do that in the longer foreseeable term, she says.

‘Eradication’ is not something any one country can do. That term only applies when all countries have eliminated it, and it survives nowhere in the wild.

MacIntyre says that the New Zealand example is irrelevant. Yes, like Australia, it is girt by sea, but no-one much goes there, or at least needs to go there. Within NZ the population is spread out, apart from Auckland (ca 1.6m). She said that New Zealand in COVID terms, was simply not comparable to Sydney and Melbourne.

She did not spell this out, but this virus loves big cities and dense populations.

New Zealand with around 4.9m people is less populous than Queensland, Melbourne or Sydney.

So on the same grounds I’m sure MacIntyre is not impressed with arguments based on the success of WA, SA, Tasmania and the Territories. She did not address Queensland directly (more of Qld later) but the point is that Sydney and Melbourne are in a different league.

The next main point made by MacIntyre is that the differences in practice between ‘aggressive suppression’ and ‘elimination’ are small – a matter of a tweak here and there, and the time period various measures are applied. Both can involve lockdowns, but living with the virus sans a vaccine is much the same under both regimes.

On July 16 The Conversation published a fine article by Anita Heywood, Associate Professor, UNSW and C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW entitled Eradication, elimination, suppression: let’s understand what they mean before debating Australia’s course.

They draw on the recognised international terminology published here by the CDC:

  • Control: The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Example: diarrhoeal diseases.
  • Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Example: neonatal tetanus.
  • Elimination of infections: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required. Example: measles, poliomyelitis.
  • Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox.
  • Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none.

Heywood and MacIntyre say that in practice:

    Elimination and suppression strategies employ the same control measures. For COVID-19, these include:

    • rapid identification and isolation of cases
    • timely and comprehensive contact tracing
    • testing and quarantining of contacts
    • varying degrees of social distancing (lockdown, banning mass gatherings, keeping 1.5m distance from others)
    • border controls: restricting entry through travel bans, and quarantine of returning international travellers
    • face masks to reduce transmission.

    The differences between a suppression strategy and an elimination strategy are the strictness, timing, and duration with which these measures are applied, especially travel restrictions.

    For example, under a suppression strategy, physical distancing requirements might be lifted while there’s still a low level of community transmission. But under an elimination strategy, these measures would remain in place until there’s no detectable community transmission.

In those terms Victoria is pursuing an elimination strategy which as Tim Colebatch points out in Covid-10: where next? (shouldn’t that be Covid-19?) no country has met. Queensland has said they want to see two successive transmission periods, that is 28 days, without community transmission. That means you don’t count returnees from overseas in quarantine, or anyone already identified as a contact and in isolation.

In NSW we find that advice from Chief Health Officer to schools assures schools that:

    These updated measures will assist us to achieve the NSW Government’s aim of eliminating community transmission in NSW…

To state Qld’s goal another way, they want no new cases popping up in the community that are not already under control for 28 days. Such cases are becoming rare in NSW. I think Qld and NSW goals are not so different and could be achieved before Christmas.

In order to get there, however, it is not helpful for the PM and the NSW premier to simply demand that Qld health authorities perform to the NSW standard.

If that is too strict, we might look at Taiwan, where with a population of 23.8 million it has had only two days with more than five infections since 20 April, with a maximum of seven.

Morrison has said that we need to live with the virus. Indeed we do, the question is at what level?

I have compared our 7-day running average of new cases with other countries we might learn from, making the adjustment to reflect their level of infection in terms of our population.

Elmer Funke Kupper in Infections are just the new normal published on 6 July put a very rational case for opening our internal borders and living with infection rates of 100-200 per day, comparing us with Germany, which at that time had a 7-day average in our terms of around 80. Our average back then was 109. This is what happened here:

We were at 109 per day back then, rising fast, peaking at 552, and are now down to 19.

This is Germany:

In early July they were about 117 per day in our terms, but are now in a disturbing uptrend now at 554, which is about 7 times where they were at their lowest point in early June.

Kupper was going to lock away our older folk, and was taking a very rational view across the spectrum to derive net deaths from all causes including influenza and suicide.

Germany has the advantage of having fewer large cities than we have, and an apparently a strong health system, but suffers from porous borders in the Shengen Area, and hard winters, where the virus thrives especially as activity moves indoors.

Health decisions will never be made entirely on rational grounds. If they were we should consider emulating China, which has been hugely successful in extinguishing outbreaks and keeping infections low. Europe in general is entering a new crisis period, especially in places like France and the UK, where the new case loads are 4,630 and 2089 per day respectively in our terms, and climbing fast.

Two countries that are numerically fairly stable at present are Sweden and the USA, where the new case load converts to 920 and 3,190 per day respectively in our terms.

Europe and the US provide patterns of infection that we would regard as failure. We need to find our own solutions in our own circumstances, being as rational and scientific as possible, but also within a social setting with its own characteristics.

In Australia we have two large cities and high urbanisation generally. Apart from state capitals we have two hub cities, Canberra and The Gold Coast, which create transmission pathways from everywhere to everywhere.

We also have more casualised labor than most comparable countries, with no sick leave, especially in the health and aged care systems, which are especially vulnerable to the virus. Our institutional aged care system is in fact scandalously neglected. This image from a Raina MacIntyre lecture illustrates the problem from Victoria’s experience:

MacIntyre points out also that we are simply not up to speed in using masks as a frontline tool for the public, or in our health system. On occupational PPE she posts this image, which contrasts health workers with cleaners about to disinfect a gym where there was one infected case:

A further factor is population compliance. MacIntyre points out that masks tend to be made compulsory in public settings only when there has been a lockdown. Mask-wearing increased noticeably in Brisbane when we had the recent scare, but now is becoming rare again. If they were made compulsory now with so little virus around, I doubt there would be high compliance.

Generally, though, according to a QU academic who studies the issue, Australians are 80 to 90% compliant to restrictions. He contrasted this with the English, who he said were only 20% compliant.

So enforcement is also an issue, one where China provides an example we would not follow.

I’m inclined to think that public expectation together with economic necessity will prize borders open by Christmas. South Australia’s recent opening, I would hazard a guess, was in part motivated by a 90% reduction in tourist activity, and the need to co-operate with NSW and Victoria in fruit harvesting. WA is currently looking at a shortage of 1,000 workers, many requiring heavy machinery licenses, to harvest and move their grain crop. The Courier Mail reports that backpacker availability to work on farms is expected to reduce from 220,000 to 20,000 next year.

As to opening up internationally, Tim Colebatch’s article says:

    The idea of setting up a travel bubble among relatively Covid-free countries within our region ought to be a winner. While new case numbers are exploding in Indonesia (4634 yesterday), the Philippines (2180) and Nepal (1497), much of Asia is reporting little new activity. Last week, for example, the growth in the total caseload per million people was zero in China, Taiwan, Vietnam and Papua New Guinea, one in Japan, two in Australia, four in New Zealand and the Maldives, and five in Sri Lanka. Most of the South Pacific remains Covid-free. Why not open the doors to safe neighbours?

    Unfortunately, there are lots of reasons why. It might happen with New Zealand, maybe the South Pacific, possibly even Japan. But there are obvious political problems for Australia in negotiating an opening with China in this environment. And if we don’t open up to China — or it refuses to open to us — we risk another Beijing tantrum if we open up to Taiwan.

    In other countries, the data can’t be trusted…

New Zealand, China and Taiwan are the cleanest prospects. South Korea and Japan have new case loads of 44 and 87 per day in our terms, with the trends in the right direction. Vietnam and Thailand may also be worth consideration.

Looking forward to vaccine, Raina MacIntyre says that the promised efficacy of 50% will fall short of herd immunity which requires at least 70%. A survey reported in the CM says that 80% of Australians are willing to be vaccinated. This article which identifies Byron Bay as the anti-vaxxer capital of Australia suggests that 91 to 95% will be required.

MacIntyre says that cures are being widely researched, but so far there are none. The importance of cures in disease control is exemplified by diarrhoea.

Control of this virus is going to require continual effort and readiness for the foreseeable future.

Here are some links I gathered but didn’t use:

21 thoughts on “COVID suppression vs elimination: beware of hot air!”

  1. For Australia, suppression vs elimination is a bullshit argument for the next few years. Until we get herd immunity an elimination in Aus can be overturned by just one contaminated person entering the country undetected. (If nothing else, the second wave in Vic demonstrated how easy it is to start the next wave.)
    The point we have to reach is the stage where the next wave can’t take hold. If you like it is form of herd immunity that doesn’t simply depend of enough people being immune. “Herd immunity”
    1. Simply having enough people immune. AND/OR
    2. Have enough strategies in place at all times to give defacto herd immunity. (Ex: Less people immune but keep mask rules in place.)
    3. Have strategies that can be quickly restarted as soon as a new case appears. (Ex: Allow mask free but insist ready to roll again if there is a new case.) AND/OR
    4. Keep on developing additional strategies, particularly ones that do low economic and social damage. (Ex: Faster testing.)

  2. I think we are able to effectively clean the virus out, so IMHO we should, and then your:

      Have strategies that can be quickly restarted as soon as a new case appears. (Ex: Allow mask free but insist ready to roll again if there is a new case.)

    Plus keep on developing additional strategies, especially your example of faster testing.

    I’ve heard of a few possibilities for instant testing, but haven’t seen any links yet.

    As things are with nil cases in Qld the performing arts are starting up again, with government help. Qld ballet has already given a performance in Toowoomba.

    Tickets are available for daytime orchestral concerts later this year, which my wife has signed up for. Mask-wearing mandatory.

    WA is planning a folk festival, which may be a world first.

    Most countries, however, are in trouble right now, which is a worry for all.

  3. The Morrison government is now harassing Dan Andrews, pointing out that Victoria’s level of infection is now similar to that of NSW, post the Crossroads cluster in Aug-Sept.

    I thought it was touch and go as to whether NSW contained that attack. Prof Chant, who designed the Victorian path out of COVID says if they opened up now there would be a 41% chance of the state having >100 cases per day within a month.

    Of interest, I’ve just seen a broker forecast for Suncorp (I have no shares). They have flat earnings in 2021, and and a flat dividend. This is brilliant compared to other banks. For 2023 the broker forecast is an increase in earning per share of 12%, and through restoring a more normal payout ratio, an increase of dividends of 52%.

    My hunch is that the forecast is optimistic, because they take treasury forecasts on the economy as gospel. However, they give the reason for Suncorp’s outperformance as “we believe this correctly reflects SUN’s skew towards Queensland, which has not been as adversely affected by COVID-19 as other states.”

    As far as I know, the “we” would refer to Sydney-based analysts.

  4. From Nine newspapers, 11.08am Victorian time:

    Andrews rules out eradication in wake of Mikakos tweet

    By Rachael Dexter

    Premier Daniel Andrews has denied the Victorian government is chasing an eradication strategy.

    In response to today’s low numbers, Jenny Mikakos – who resigned as health minister over the weekend – tweeted out this morning that “we are well on the way to eradication”.

    (This was the twit:

    I am saddened to see more lives lost, my sympathy to their families. But I’m so pleased to see how low the numbers are. I’m so proud of Victorians and so grateful for the sacrifices made to get us to this point. We are well on the way to eradication. ❤️)

  5. Brian: “Victorian coronavirus hotel quarantine inquiry hears no single person or decision caused scheme’s failure” and then goes on describing the difficulty of setting up quarantine in such a short time. (This is in line on my comments re the commentators inability to understand the challenges and why a “gotcha” analysis is completely inappropriate.) https://www.abc.net.au/news/2020-09-28/covid-19-hotel-quarantine-inquiry-hears-final-submissions/12709782
    A telling quote: “The inquiry previously heard that 90 per cent of the infections in the state’s second wave could be traced back to a family of four who served their quarantine period at the Rydges on Swanston hotel.”
    It goes to show just how little it takes to launch another wave and why our planning and research should assume further waves and perhaps spur some effort planning for future waves.

  6. Ambi, Ms Mikakos loose use of the term ‘eradication’ possibly indicates that she never had a clear grasp of what they were dealing with.

    John, I agree completely. Prof MacIntyre said what is different about this one was not so much how infective it was, it’s not as infective as measles, for example. Rather it is the sneaky way it infects invisibly pre- and asymptomatically through aerosols and droplets.

    That youtube I linked to (sent to me by bilb2, thankyou kindly) has a lot of information about the diverse ways it spreads through airflows.

    What we don’t know is how big the viral load has to be to cause an infection, and, similarly, how much virus asymptomatic people have to have before it gives them any kind of immunity.

  7. Today some expert epidemiologists are commenting again that they would have thought Andrews could open more quickly.

    Andrews is working in the real world. He only gets one shot at this. He can’t afford to fail.

    Apparently Morrison piled in again, saying Victoria should do what NSW has done.

    Then we are told that what NSW has done is world class, which does appear to be the case.

    What Morrison is doing is saying that any young athlete who puts their mind to it can run 400 metres like Cathy Freeman without going through the years of training and competition she did.

    Andrews did well IMO by telling him that he would more profitably spend his time talking about something else.

    We have to understand and work within our limitations. The reason NZ locked down initially was because they knew their system could not cope.

  8. I’ve heard our CHO Dr Jeanette Young say that she liked the sewerage being produced in the Northern NSW bubble.

    Not exactly what she said, but apparently NSW is monitoring the sewerage, and it’s clean as far as the virus is concerned. She said that one in 10,000 could be picked up by the monitoring.

    AMA are saying that the vaccine won’t be implemented in Oz until the end of 2021, going into 2022.

    Meanwhile research has shown that only 27% of Australians with a cold or other symptoms are getting themselves tests.

    Victoria is implementing workplace testing where it matters.

    Elsewhere COVID aged care deaths could have been “avoided” if response was faster, Brendan Murphy admits.

  9. A professional health officer would never publicly express a preference for interstate sewage, over the local product, Brian.

    Whatever her own, private thoughts might be.

    🙂

    (Grandsons have taught me to better savour a really fine poo-poo joke.)

  10. In Victoria, Mr Plod and the Health bods use sewage testing to find out which suburbs are using more ice.

    Though why anyone would flush ice cubes down their dunny is a complete mystery to me.

  11. Aged care news ***

    The aged care royal commission has called on the government to fund extra staff to ensure nursing home residents locked up in COVID quarantine can receive visitors.

    And the commission says Medicare funding should also be provided for mental health services and allied health in aged care during the pandemic to prevent further deterioration.

    In a special report to parliament, the commission levelled criticism at the federal government for not having a COVID-19 plan specifically for aged care during the pandemic, and proposed it establish a permanent national aged care advisory body and publish a national aged care plan.

    The commission held a separate session in August on COVID-19, during which counsel assisting accused the government of “hubris” over its handling of aged care during the crisis, which has so far claimed the lives of more than 670 people in aged care.

    In a subsequent submission, the government flatly rejected that allegation and said government officials had worked extremely hard from the early days of the pandemic to protect those in care.

    But the commission’s special report found there was confusion among providers about who was in charge.

    “Confused and inconsistent messaging from providers, the Australian Government, and State and Territory Governments emerged as themes in the submissions we have received on COVID-19,” the commission’s special report said.

    “All too often, providers, care recipients and their families, and health workers did not have an answer to the critical question: who is in charge? At a time of crisis, such as this pandemic, clear leadership, direction and lines of communication are essential.”

    – from “The Oz” online

  12. Do we want to suppress???

    Nine newspapers:

    US President Donald Trump, who announced he has tested positive for COVID-19 on Friday, rarely wears a mask, our North America correspondent Matthew Knott reports.

    Trump has belittled his re-election challenger, Joe Biden, for routinely covering his face. He has also resumed holding large campaign rallies at which thousands of his supporters gather, shoulder-to-shoulder, few in masks.

    Most of the events are held outdoors at airports but two recent events – in Arizona and Nevada – were indoors, a setting that public health experts say raises the risk of virus transmission.

  13. Plenty of Blame to Go Around

    from “The Australian”

    Former Victorian Health Minister Jenny Mikakos has blamed Daniel Andrews’ subversion of Cabinet processes for the hotel quarantine program’s failings.

    In an explosive final submission to the inquiry published on Friday, Ms Mikakos said the haste with which the program was set up saw “usual Cabinet processes subverted” with the Premier, through the Department of Premier and Cabinet, giving responsibility for the scheme’s design and implementation to Job Minister Martin Pakula’s department.

    She said ordinary decision-making mechanisms, lines of accountability and reporting had been supplanted by the Premier’s introduction of the Crisis Council of Cabinet, which replaced ordinary Cabinet Committees and processes, and reorganised key aspects of the Victorian public service.

    Ms Mikoas said the fact that no Cabinet or Cabinet Committee process was engaged for the setting up of the Hotel Quarantine Program is “the root cause of some of the issues which have been ventilated before the board in the course of this Inquiry.

    “In particular, the failure to follow ordinary Cabinet-led decision-making processes is the cause of the differing views which have been given by witnesses as to who had overall responsibility and accountability for the Hotel Quarantine Program,” she said.

    She said the lack of process might also be a “cause of the obscurity” as to who decided to engage private security guards.

    “Had the Hotel Quarantine Program been the product of a Cabinet or Cabinet Committee decision, these issues would not have arisen. More importantly, such a process would have enabled differing views and potential risks and weaknesses with the program to be identified and addressed prior to its establishment,” she said.

    She said he features of the program identified as critical to its failure – hotels, inadequate cleaning, and the use of private security guards – remained the responsibility of Mr Pakula’s department until July when the program was moved to the Department of Justice and Community Safety.

  14. To a naive outsider, this sounds like what an ex-Minister says, after maintaining a spurious solidarity for months, then being placed carefully under a bus.

  15. Ambi, to this outsider it looks as though setting up hotel quarantine was seen as relatively routine, and not requiring any cabinet consideration.

  16. Perhaps so, Brian.

    Here in Victoria we are finding that our hindsight is becoming sharper with every passing day.

    We’ve had plenty of special practice this year:

    The George Pell appeal in the High Court
    The Witness X Royal Commission (the High Court was scathing about our Police force’s actions)

    Restrictions in Melbourne; reset as second restrictions.

  17. Brian: “Queensland achieves 28 days without coronavirus community transmission as NSW border decision expected at end of October. ” https://www.abc.net.au/news/2020-10-09/coronavirus-queensland-cases-border-reopening-nsw-decision/12743084.
    Gladys was completely pissed off with Qld behaviour. Gladys problem is that she is a very logical, competent woman who knows when she is being fed crap.
    Meanwhile the Davidson’s struggle with keeping up with Qld border rules deju. Needs to be sorted out by someone with the brain and knowledge re Northern NSW to sort it out in a politics free way.

  18. John, Gladys B is being fed crap by her health minister Brad Hazzard, who started the latest round with very personal and abusive comments about Palaszczuk on radio.

    This discussion really belongs on the thread COVID-19: Hotspots and opening borders.

    Have to do stuff today. Will try to give some links later.

    The short answer is that I was right, ScoMo didn’t like what the chief health officers agreed to on hotspots and didn’t take it to National Cabinet.

    Hazzard didn’t and still doesn’t know what his CHO agreed to, doesn’t know and doesn’t want to know how the system works in Qld, just makes sh*t up and thinks it appropriate to go in for megaphone diplomacy and public shaming through the media.

    Palaszczuk is campaigning and has left Steven Miles to carry the can. Miles would do better if he dampened the matter down and closed it off rather than return serve, because, contrary to what Hazzard thinks, this issue does not play in Palaszczuk’s favour politically.

    Meanwhile the default position is that the border will open on 1 November. Dr Young confirmed that as still being so. Depends on what happens in the next little while.

    Living with the virus isn’t going well in Europe and north America, with Germany and Canada both in trouble along with other countries, many doing worse.

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