Introduction by Croakey: From Monday 11 July, Australians aged 30 and over will be able to have a fourth dose of a COVID-19 vaccine, although it will only be officially recommended for adults aged 50 to 64, in addition to the groups who were already eligible.
Federal Health and Aged Care Minister Mark Butler says an additional 7.4 million people will become eligible to receive a fourth dose, as a result of the Government accepting updated recommendations from the Australian Technical Advisory Group on Immunisation (ATAGI) updated its recommendations.
The ATAGI statement (7 July) says a surge in COVID-19 cases from Omicron BA.4 and BA.5 subvariants is expected to worsen in coming months and that increasing the uptake of winter booster doses in those most at risk during this time is anticipated to play “a limited, but important role in reducing the risk from COVID-19 to individuals and pressure on the healthcare system”.
The statement says:
“Based on first principles and currently available evidence, reaching a higher level of coverage of the COVID-19 winter booster dose in older adults, including those aged 50 to 64 years, is likely to reduce the number of COVID-19 related hospitalisations over the coming months.
“However, the impact of this expanded vaccine booster recommendation alone is expected to be limited. ATAGI advises that other public health and social measures, in addition to vaccination, will have the greatest impact against the Omicron BA.4 and BA.5 surge in infections. This includes increased use of masks and increasing the use of antiviral treatment in people diagnosed with COVID-19, including in people aged 50 years and above.”
Butler also told journalists today: “I’ve also put a strong case before the Pharmaceutical Benefits Advisory Committee asking them to expand access to these highly effective oral antiviral treatments, tablets and capsules that can be taken at home and dramatically reduce the risk of severe disease particularly for older Australians and I’m eagerly awaiting advice from that advisory committee about our submission.”
The developments come as the Australian Institute of Health and Welfare (AIHW) releases its biennial ‘Australia’s Health’ report, which contains a wealth of data on our health system and our health, including quantifying the impacts of COVID upon Australians.
In response to this report, Minister Butler released a statement highlighting some of the positive findings in the report (overall Australians are living longer and healthier lives) and acknowledging some of the negatives (out-of-pocket medical costs, long COVID, rising rates of mental illness and the persistent health and life expectancy gap between Aboriginal and Torres Strait Islander people and non-Indigenous Australians).
Below, we cross publish two related articles from The Conversation:
• ‘How has COVID affected Australians’ health? New report shows where we’ve failed and done well’. Professor Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice at the University of Melbourne, discusses how the AIHW report helps us assess both the pluses and minuses of Australia’s response to the pandemic and suggests the need for a nuanced “vaccine-plus” strategy to reduce unnecessary COVID deaths in the future, particularly among people living with disadvantage.
• ‘Access to a second COVID booster vaccine has been expanded to people 30 years and over’. Professor Raina MacIntyre, NHMRC Principal Research Fellow, Head of the Biosecurity Program at the Kirby Institute, and Professor of Global Biosecurity at UNSW, argues that much more could be done to mitigate and prevent COVID, by using a “vaccine-plus” strategy of layered measures (and read more on this approach in a previous Croakey article, ‘Another COVID wave is rolling out, so what more could governments be doing?’)
Stephen Duckett writes:
The SARS-CoV-2 virus was first detected in Australia on 25 January 2020. Within two months, the lives of all Australian were upended.
Australians were stranded overseas as external borders were slammed shut. State borders were closed to people from other states. Lockdowns severely restricted movement of the population. People watched in fascination as case numbers went up and then down.
The daily drama dragged on for months, with premiers and chief health officers fronting the media with announcements of case numbers and tightening or loosening of restrictions.
But the daily spectacle made it difficult to see the wood for the trees. Now, new data from the Australian Institute of Health and Welfare shows how Australians’ health changed over the course of the pandemic. It allows us to step back and assess what happened, and to whom.
Australia’s management of the pandemic was overall very good, leading to about 18,000 deaths averted in 2020 and 2021. This was primarily due to restricting arrivals and hotel quarantine for those who did arrive, and lockdowns when quarantine was breached, which inevitabley happened.
From late 2021, with more than half the total population vaccinated, these restrictions were lifted following the Morrison Government’s national plan, released on August 6 2021.
However, the pandemic is not over. The number of deaths in the eleven months since the plan was released is almost ten times the number than in the 18 months before.
An inequitable impact
Australia has had four pandemic waves so far. Daily deaths during the first three waves peaked at around 20 per day. The peak in the current wave is much higher, around 90 deaths per day.
Although more transmissible, the current variant of the virus is less deadly, with a death rate in April 2022 about 0.1% compared to a rate of over 3% in April 2021.
However, the number of daily new infections, some of whom will become long COVID cases, is much higher than in 2021.
Although most deaths throughout the pandemic were in people aged over 60, each of those was a shortened life. Thousands of years of life have been lost prematurely because of COVID.
Deaths did not fall evenly. Those born overseas had twice the death rate of Australian born. The death rate in cities was three to four times that in regional areas.
The bungled management of COVID in residential aged care facilities resulted in deaths in aged care accounting for three-quarters of all COVID deaths in 2020. 
The residential age care death rates in 2021 (17%) and 2022 (26%) are tragically high.
People living in the poorest communities had death rates three times that in wealthier communities.
For younger people, COVID was a disease which led to disability rather death, although this does not diminish the impact on those who suffered – and might still be suffering – as a result of the infection or long COVID.
Warning signs
Some preventive care was deferred during the pandemic, which could mean some diseases weren’t detected in their early stages, resulting in poorer outcomes.
Endoscopies are procedures where clinicians look inside the body using a long tube with camera attached, sometimes to detect cancer. Rates of endoscopies were down, suggesting some cancers may have been missed.
The rate of Indigenous health checks also took a downturn:
This may mean it will be even harder to close the gap between the health of First Nations Australians and the rest of the population.
The overall pattern about mental health is mixed, with raw numbers suggesting no statistically significant change in long-term patterns.
However, there were upticks of reported psychological distress in early 2022, and so the underlying pattern may not yet be clear.
Still a long way to go
Extended border closures led to stress on those separated from their families, and so too did the state border closures. Overall, however, outcomes from the pandemic have been good so far.
But the Australian Institute of Health and Welfare report was released in the same week the 10,000th Australian COVID death was reported. The ongoing deaths from COVID are barely reported in the media and appear to be ignored by policymakers.
The previous prime minister dichotomised potential COVID responses into lockdowns or “living with COVID”. This was never the case.
A more nuanced response – supplementing a drive to increase vaccination rates with mask mandates and density limits when required, and improving ventilation – was always part of the public health response.
Unfortunately, third dose vaccination rates are sitting at around 70% of those eligible, leaving many Australians dangerously exposed to the virus.
There should be a return to the “vaccine-plus” strategy, where we focus on lifting vaccination rates and implementing other public health measures – such as mask mandates or density limits – where required.
Otherwise we risk all the good work done in 2020 and 2021 being completely negated and more unnecessary deaths occurring, especially among the most disadvantaged.
Raina MacIntyre writes:
Australia has just expanded access to a second COVID booster to everyone 30 years and over, while recommending it only for people 50 and over. That means it’s up to people aged 30-49 years to decide whether they would like a second booster, but they will not be actively encouraged.
The promise of COVID vaccines as a means to completely ending the pandemic was short-lived. Just as vaccines matched to the original strain of the virus were being rolled out in late 2020, multiple new variants of concern emerged, with increasing vaccine breakthrough infections.
Vaccines are not as protective against variants such as Omicron and also wane in protection, which is why we have seen continued waves of infection even in highly vaccinated countries. Two doses do not protect against infection with Omicron, especially if you had the Astra Zeneca shot, so high booster rates are essential.
The strong messaging we received in 2021 about being “double-jabbed” being the end of the road, left many people unaware a third dose was essential. Compared with a stunning 95% of people 16 years and over having two doses, only 70% have had three doses. Yet even the protection of a third dose wanes, even against severe infection and death. But this can be restored with a fourth dose.
Some countries, such as the United States, have recommended fourth doses to anyone over 50 for some time, while Australia has had restricted access, until now just for people over 65.
Why we need a fourth shot
Australia has essentially used a vaccine-only strategy to control COVID since late 2021. Masks and other measures such as QR codes have been largely abandoned and testing is expensive – many cannot afford a regular supply of rapid antigen tests, and PCR tests can cost an individual more than $100. Antivirals are only available to restricted groups, unless you can afford $1,200 for a private prescription.
Meanwhile, more than 10,000 people have died in Australia, the majority within the supposedly “mild” Omicron wave in 2022 when we were given the message the pandemic was over.
Many of these deaths and hospitalisations could have been prevented by using extra, layered measures to reduce transmission. The crippling of the health system, disruption of workforce, schools and airports, and the burden of long COVID are other reasons to try our best to reduce case numbers. Repeated reinfections should also be prevented, as they increase the risk of death.
A fourth dose becomes even more crucial when we have no other plan – no mask mandates, no mandated indoor air quality standards nor universal, affordable access to antivirals. It will save lives and reduce the load on our health system.
The BA.5 Omicron subvariant is now taking over, and has even more “escape” from current vaccines. But a fourth dose will help.
Ideally, we would have vaccines matched for Omicron, but these may not be available in Australia for many months, during which time many more lives will be lost from the BA.4/5 wave. Even the original vaccine will still provide better protection with a fourth dose compared with only three doses.
Could too many vaccines be bad?
Some argue about “original antigenic sin” (or “immune imprinting”) as a problem with repeated doses of COVID vaccines – as in, they think after repeated doses the vaccine’s effectiveness will be reduced. However, this reflects a misinterpretation of what original antigenic sin means – it means the first time you are exposed to a virus or vaccine, the body remembers that first time when it subsequently encounters something similar. But this immune memory can lead to either a blunted or an enhanced response.
The concept arose around influenza, but even that, which has been studied far more than SARS-CoV-2 (the virus that causes COVID), is not conclusive or necessarily detrimental – and we still recommend repeated flu vaccines every year.
There is no evidence of original antigenic sin being a problem for COVID boosters – studies show significantly better protection from four compared to three doses. In people with weakened immunity, even five doses continued to boost the immune response. When we have better matched boosters, it is likely they too will be offered, but holding out for these for an unknown period of time will result in preventable deaths and chronic illness.
What about younger adults?
ATAGI did not recommend fourth shots for under-30s reportedly because of the low risk of myocarditis following vaccination in young males – but the risk of myocarditis is far higher after COVID infection than after vaccination, and even if that argument held, what about young women?
Omicron causes excess mortality in all adults, even younger ones, so the benefits of expanding access to a fourth dose to everyone 18 years and over would likely outweigh any potential risks.
Health workers miss out yet again, with no specific allowance for them and many being under the age of 30. This will not help the exodus of burnt-out health workers, many of whom got infected in the line of duty.
Meanwhile, we are bracing for a massive wave of BA.4 and 5, predicted to be as bad as the last peak early in 2022. In the absence of other public health measures such as masks, and if a vaccine-only strategy is continued, expanding fourth dose eligibility is the only way to mitigate the next COVID wave.
Much more could be done to mitigate and prevent COVID, by using a “vaccine-plus” strategy of layered measures.
See here for the archive of Croakey’s COVID-19 wrap
