As Australia moves towards expanding access to a fourth dose of the COVID vaccine, some health leaders are urging governments to do more to promote a vaccine-plus strategy.
They want to see stronger messaging around the importance of a range of other actions, including the wearing of high-quality masks, ventilation, social distancing, isolation and staying home when unwell.
They are also advocating for more effective communications and engagement strategies to encourage uptake of the third dose at a time when health services are preparing for the next big COVID wave to hit.
During multiple media interviews over the past week, Federal Health Minister Mark Butler stressed that more than five million Australians are overdue for their third dose, while 40 percent of people over 65 haven’t had their fourth dose.
In an open letter published in the BMJ in January, a group of public health experts, clinicians and scientists called for a vaccines-plus approach to be adopted globally.
“This strategy will slow the emergence of new variants and ensure they exist in a low transmission background where they can be controlled by effective public health measures, while allowing everyone (including those clinically vulnerable) to go about their lives more freely,” they wrote.
They cited a statement by the Director-General of the World Health Organization (WHO) Dr Tedros Adhanom Ghebreyesus on 14 December 2021.
He said: “I need to be very clear: vaccines alone will not get any country out of this crisis. Countries can and must prevent the spread of Omicron with measures that work today. It’s not vaccines instead of masks, it’s not vaccines instead of distancing, it’s not vaccines instead of ventilation or hand hygiene. Do it all. Do it consistently. Do it well.”
OzSage has also advocated for a vaccines-plus strategy, with its 23 June statement saying that this approach, including safe indoor air, masks, testing and tracing, will reduce transmission, and substantially reduce the disease burden of COVID-19 and long COVID
Croakey asked a range of health leaders for their views on why Australian governments have not engaged more proactively with the vaccines-plus messaging, especially when the recent milestone – of Australia recording the 10,000 death from COVID – and growing concern about new Omicron strains have brought many opportunities for media interviews.
Many factors involved
Professor Brendan Crabb Director & Chief Executive Officer, Burnet Institute
“Stating the obvious, as things stand there is a clear reluctance to do anything to control COVID that is perceived as a restriction. And effectively everything other than vaccination is (wrongly in my view) considered a restriction.
Understanding where that comes from is more the realm of psychologists and political commentators than it is of public health experts – Psychologist Stephen Reicher’s piece in The Guardian just a day or so ago is a good example this.
For what it’s worth, from my infectious disease/public health expertise point of view, I can offer a few reasons for the reluctance of our leaders to strongly advocate for public health measures, even when the key measures themselves (vaccines, clean air, masks and testing) are accepted, sensible, and up-to-date as they are in this Victorian update today.
Firstly, we continually underestimate the impact of COVID on health and society.
For example, we fail to connect the dots between the major disruption we see to the wider community (for example, struggling emergency systems, health systems more generally, travel chaos, school disruptions, tight labour markets) and the fact that so many people are sick with COVID, hundreds of thousands of Australians at any one time. It’s been like that pretty much all year and it likely will be for much of the rest of the year.
And we totally ignore the impact of long COVID despite the growing awareness of its significance even with omicron, and of the exacerbating cumulative impact with multiple infections. The in-between, “goldilocks” nature of SARS-COV2 infection, where severe disease rates are high but not always high enough to command strong policy response, is linked to this. It has dogged the response from the beginning. If it had been “worse” it’s likely it would have been shut down in early 2020.
Secondly, of the ‘plus’ tools we do have, each faces obstacles; masks seem to have become a symbol of control in a sort of culture war that Stephen Reicher describes above. As a result, if they are recommend at all, it is as a matter of personal preference as for example the Queensland Premier said today; airborne transmission is simply not embraced strongly enough; hard to find a mention of it on the Federal Government website, for example.
In my view, along with the lack of appreciation of long COVID, failure to accept and mitigate airborne spread is the biggest failure of the Australian response (amongst several strong successes). Dogma and professional pride are key reasons for this this, as described well in this piece. And testing suffers from a few obstacles, not the least of which is knowledge that if you’re positive you are required to isolate for seven days. As this recent Kirby serological survey showed, we are probably only detecting around half the number of cases that are out there, at least that was the case earlier in the year/
Whatever the reasons, the reluctance to strongly advocate for the ‘plus’ in vaccines-plus has cost us dearly, with caseloads that are so large that they overrun and mask the remarkable anti-severe disease effect success of vaccination, which remains the core pillar of the response.
As a result we are now looking down the barrel of a series of new variants and all the damaging health, healthcare, business and societal impacts that goes with that.”
Politics undermined public health responses
Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of Melbourne
“For most of 2020 and 2021 Morrison Government ministers undermined state action on public health measures. They opposed state border closures. They opposed mask mandates. They opposed lockdowns. They dog whistled support to anti-vaxxers. All of this undermined a state’s social licence to act.
Then Prime Minister dichotomised the choice either the heavy hand of government or freedom. Lockdowns or nothing. Mandates or personal responsibility.
This is the Liberal Government’s ongoing legacy – a weakening of the public health role, and a weakening of the public’s health.
More nuanced approaches – including campaigns to mask up indoors, or indeed a mask mandate – are seen as part of the heavy hand despite the deaths we are seeing today.”
National leadership needed
Dr Tarun Weeramanthri AM, President, Public Health Association of Australia
“Reaching 10,000 deaths in Australia from COVID-19 is an unwelcome milestone. The new Federal Government is continuing with national cabinet arrangements and has promised a reset of national policy.
Nearly all good public health strategies have a number of complementary elements, each of which needs to be implemented properly. So the reset should consider not just boosting COVID-19 and influenza vaccine delivery and uptake, but also other measures such as mask wearing, ventilation, testing and staying home when sick.
Most importantly, as a country we need to know what we are trying to achieve, and what the measures of success are (health, social and economic). We should be collecting national data about health care worker absenteeism for example, and ambulance and hospital demand pressures.
Currently, each state and territory is making their own policy decisions, but is this enough?
We need someone to speak to a national story of what we are facing, what we are doing, and why. The next wave is here, and we need to hear from the lifeguards.”
Dr Chris Moy, Vice President, Australian Medical Association
“Part of the problem of where we’ve ended up is because of the election; the election created this illusion that it was over. Neither leader wanted to emphasise COVID because it was perceived as negative.
We’ve had increasing numbers and deaths, it’s been like a frog being boiled slowly; there’s been community denial about the numbers of people getting sick and dying.
Now we are in this predicament of overloading the hospitals with another wave coming in; it’s hard to change gear because you have to take the population with you.
At the moment we have a situation where we are almost solely managing the pandemic just with vaccines and antivirals with very, very minimal public health intervention such as masks.
There is also the issue of trying to bring the community along, going into reverse, with a population that’s been going the other way…it’s quite hard to bring the community with you. First up there has to be a move to try and encourage mask wearing. At least encouraging it.
We need to be doing more than encouraging boosters and antivirals.”
Professor Bronwyn Fredericks, a Murri woman and the University of Queensland’s Pro-Vice-Chancellor (Indigenous Engagement)
“There have now been over 10,000 deaths from COVID in Australia. People are still getting really sick and dying every day. Some news bulletins are reporting some of the figures in terms of hospitalisations, and ambulance wait times, while others aren’t. There is little attention by the broader media about what is happening in terms of COVID.
There also appears to be an increasing complacency in terms of mask wearing, using hand sanitiser at venues, and maintaining some social distancing in situations that might be considered a greater risk. I did notice that the last two times I’ve been grocery shopping the hand sanitisers were empty, and almost no one was wearing a mask, and there was a general lack of attention to cleaning. I wore my mask to minimise my risk and protect others.”
Boost community awareness
Leanne Wells, CEO of the CHF
“Some consumers are understandably concerned about the risks from COVID, as cases continue to surge and health professionals say they are on high alert. There is notable pressure on services, particularly hospitals. State health officials, hospital staff and patients are acutely aware of the how very dire the situation is.
Others now think that the crisis is over and have relaxed their vigilance and sense of urgency. It is important to continue with communication campaigns especially targeted at vulnerable populations. COVID fatigue is an ongoing problem and messaging should be flexible, innovative and fresh.
Wearing masks protects everyone in the community and slows down the infection rates. This particularly important with respect for those people who can’t wear masks, due to disability, physical or mental health illness or conditions but are still vulnerable to severe disease. Australians aren’t as accepting of mask wearing as a normal response and expected behaviour as in many parts of Asia.
People who are in insecure employment or housing can be in a very precarious position if they do catch COVID, as there are no COVID payments anymore, although Services Australia do provide a crisis payment. Not everyone in need will be eligible for this. When people have no choice but to work when they are sick, it is much harder for them to act responsibly.
CHF urges governments to mount some fresh and engaging community awareness campaigns about the merits of masks, and to raise awareness of antivirals and how to access them, more so if eligibility does widen as we’ve called for today.”
Federal Health Minister Mark Butler has been actively engaging with the media to raise awareness of rising case numbers and surging demand on hospitals.
“Most state governments and our advisors think that the wave that’s just starting now is going to be just as bad as the ones we saw earlier this year. Case numbers are rising already, hospitalisations are up across the country. There’s probably 800 people more in hospital than there were only a couple of weeks ago. I cannot urge strongly enough people, if you are not up to date with your vaccination, please get up to date,” he said during a radio interview on 6 July.
On masks, he said: “I don’t see any states being about to reintroduce broad mask mandates, I think they’re behind us, I think all of the health advice is if you’re indoors and you’re not able to socially distance, particularly as we head into this new wave, you should carefully consider putting a mask on if you can’t socially distance. It does provide additional protection.”
However, Adrian Esterman, Professor of Biostatistics and Epidemiology, University of South Australia, has suggested that mask mandates may be required in the face of the emerging third Omicron wave as BA.4 and BA.5 become the dominant COVID strains.
“…this third Omicron wave – along with a very severe flu season – will likely see our hospitals struggling even more over the next few weeks,” Esterman wrote in The Conversation on 5 July.
“If things get bad enough, state and territory governments might be forced to reintroduce face mask mandates in many settings – in my opinion, not such a bad thing.”
In Victoria, the Department of Health anticipates a further increase in cases – including reinfections – and hospital admissions and deaths in the coming weeks due to BA.4/BA.5. This is because the strain has a greater ability than BA.2 to evade immunity provided by vaccination and earlier COVID-19 infection.
The Department strongly encourages Victorians to remain up to date with their vaccines, in particular people eligible for third and fourth doses, and to stay home if unwell and test for COVID-19.
The wearing of masks and measures to make indoor air safer will have a significant impact in reducing transmission of the BA.4/5 sub-variants. Masks continue to be strongly recommended in shared indoor settings, if you can’t physically distance or you are with those more vulnerable to COVID-19. Improve ventilation by opening doors and windows, using fans or purifiers and gathering outside where possible.
Face masks are still required for everyone aged 8 and above in some locations, including on public transport, rideshares and taxis, and in sensitive settings such as hospitals and care facilities. They are also required by household contacts in quarantine who meet the criteria for leaving home.
The NSW Government is likewise encouraging “COVID safe behaviours”. In a statement, NSW Chief Health Officer Dr Kerry Chant said in addition to booking in for a booster, people should “exercise common sense” and wear a face mask in public indoor spaces, where physical distancing cannot be maintained.
“Face masks, hand hygiene, staying home when ill, testing yourself when symptoms present, physically distancing, all these measures are not new to us,” Chant said.
Writing in The Conversation, Professor Paul Glasziou and Professor David Henry said that compared with many countries, Australia had done well in controlling COVID, having minimised both the impact of illness and the economic burden.
But they said: “Unfortunately, Australia’s booster uptake has been much slower than the initial vaccination campaign and has almost stalled. This complacency is dangerous.
“In the past three years we have experienced the pandemic and a series of natural disasters in Australia. Fatigue and a desire to move past COVID is completely understandable but carries substantial risk.
“During winter, we must redouble our efforts to maintain population immunity through vaccine boosters combined with reasonable protective measures. Make sure your COVID and influenza vaccines are up-to-date, avoid crowded places (or wear a mask if you can’t), and avoid others if you have any respiratory symptoms.”
Other experts have suggested there is significant room to improve the Federal Government’s $11 million advertising campaign, which urges Australians to “take on winter” by getting COVID boosters and influenza vaccines, as well as promoting COVID vaccination for children.
Nothing that “vaccine fatigue is high”, they said: “For all the dollars spent, evidence from social and behavioural science should be reflected in the messaging to ensure the ads are as effective as they can be.”
In a briefing on 6 July, the WHO’s Director-General Dr Tedros Adhanom Ghebreyesus said that globally reported COVID cases had increased nearly 30 percent over the past two weeks. Four out of six of the WHO sub-regions saw cases increase in the last week.
In Europe and America, BA.4 and BA.5 are driving waves. In countries like India a new sub lineage of BA.2.75 has also been detected which the WHO is following.
Compounding the challenges are a number of factors: testing has reduced in many countries. This obscures the true picture of an evolving virus and the real burden of COVID.
New treatments, especially promising new oral antivirals, are still not reaching low and low-middle income countries, depriving whole populations that need them.
He also said that as the virus evolves, vaccines protection – while is still really effective at preventing serious disease and death – does wane. Decreasing immunity underscores the importance of boosters, especially for those most at-risk
Each wave of the virus leaves more people with long-COVID or post-COVID condition. This obviously impacts individuals and their families but it also puts an extra burden on health systems, the wider economy and society-at-large, he said.
See Croakey’s archive of articles on prevention