Introduction by Croakey: Experts are sounding the alarm about NSW’s reopening strategy, with new modelling showing the state’s approach could result in prolonged ‘code black’ periods in intensive care units, and others warning that the plan signals an end to a national approach.
Two articles below explore these concerns. In the first, Nicole MacKee outlines UNSW modelling on paths to reopening; and in the second, the Grattan Institute’s Professor Stephen Duckett and Anika Stobart write of the broader risks of the NSW plan. This article was first published in Pearls and Irritations, before the release of the latest modelling.
Nicole MacKee writes:
NSW is on track for a second, larger COVID-19 epidemic with over-burdened intensive care units and compromised care over Christmas and New Year, experts say.
The independent OzSAGE group of researchers released UNSW modelling yesterday outlining six scenarios, all showing a second COVID-19 peak after the easing of restrictions.
The scenario reflecting NSW’s current proposed roadmap – with a forecast daily caseload of 1,890 cases and a two-stage easing of restrictions from 18 October when 70 percent of adults were fully vaccinated – showed a five-week period of ‘code black’ conditions in NSW hospitals over Christmas and New Year period.
‘Code black’ is defined as more than 900 patients requiring intensive care support on a single day, exhausting ICU capacity.
Compromised care
The OzSAGE group said during ‘code black’ conditions, care would be “compromised, health workers endangered, and case fatality rate expected to rise”.
Outlining the modelling yesterday, Professor Raina MacIntyre, of the Kirby Institute at UNSW, said: “If further relaxation of restrictions occur [after the 18 October easing of restrictions], NSW could face a serious situation. Once you can’t provide ICU care for people who need it, then the death rate starts to go up, and that’s exactly what we saw in Europe last year.”
She said if restrictions were eased in mid-October, it was recommended that no further easing occurred to avoid the worst-case scenario. And, if restrictions were only relaxed in November, when the 80 percent target was met, the daily case numbers would be lower and this would help to mitigate the epidemic and shift the second peak to January, the OzSAGE group noted.
“It’s really important in any of these scenarios that we keep our testing rates really high and rapid …[and] we need to scale up the rapid contact tracing capacity,” MacIntyre said, adding that widespread mask use, including in outdoor areas, would also be needed to mitigate the epidemic. “If any of these things drop, the epidemic gets worse.”
In The Conversation, Burnet Institute researchers reported on their own modelling that has shown that the strict restrictions, including curfews, introduced in Sydney’s 12 hardest hit local government areas (LGAs) in August had halved the the expected case numbers.
“Without these stricter measures we expect about 2,000 cases per day by now and about 4,000 per day by the end of the month instead of the 1,000 per day currently in these 12 LGAs,” said the authors, who have also called for a vaccine-plus exit strategy.
The prospect of extended periods of ICU overload has frontline doctors extremely worried. Writing in The Conversation, Dr Peter Wark and Dr Lucy Morgan say plans are underway to manage the expected surge in cases.
“Staff are being trained and we are preparing to get enough equipment where it’s needed,” they wrote. “The problem is this will go on for many more weeks, staff will get tired, physically and emotionally, and we don’t want this to be any worse than it must be.”
The UNSW modelling was released after Denmark last week lifted all restrictions after achieving high vaccination rates and high levels of adherence to restrictions.
Vaccination rate concerns
Also, speaking during the OzSAGE press conference yesterday, Professor Kalinda Griffiths, Scientia Lecturer at the Centre for Big Data Research at UNSW, called for no-one to be left behind on NSW’s path to reopening.
She pointed to the recent call by OzSAGE’s Aboriginal and Torres Strait Islander working group for at least 85 percent of Aboriginal and Torres Strait Islander people vaccinated before NSW opens up, with a preference for this rate to be more than 90 percent. Other Aboriginal and Torres Strait Islander groups have also called for higher vaccination targets.
“If COVID does get into [Aboriginal and Torres Strait Islander] communities, it is going to spread very, very quickly,” Griffiths said. “To date, there has been 1,574 Aboriginal and Torres Strait Islander COVID-19 cases since the start of the NSW outbreak, about 30-40 cases are being seen each day.”
Griffiths noted that before the NSW outbreak, there had been fewer than 200 COVID-19 cases among Aboriginal people nationally. “So it’s quite an extraordinary jump,” she said.
Griffiths said only 25 percent of Aboriginal and Torres Strait Islander people aged over 12 years had been fully vaccinated, and 51 percent have received at least one dose.
“The good news is thanks to the extensive efforts of ACCHOs, and also the efforts from both Commonwealth and state governments, the pace of the vaccine rollout for Aboriginal and Torres Strait Islander people in NSW has been moving quite quickly,” Griffiths said, noting that this was also the case in Victoria, but more assistance was needed in other jurisdictions.
The call came ahead of an announcement yesterday of a $7.7 million federal funding injection to boost vaccination rates in Aboriginal and Torres Strait Islander communities, and the correction of official vaccination figures after an administrative bungle had double-counted some doses.
As Victorian Premier Daniel Andrews prepares to release this Sunday a roadmap for easing of restrictions, concerns are being raised about a Federal Government data processing error that artificially inflated vaccination rates for Aboriginal people, especially in Victoria.
Linda Burney, Shadow Minister for Indigenous Australians, said critical questions had to be asked of the Federal Government.
“How did you get this so wrong?” Burney said, referring to the data processing error. She also called for the public release of data that had informed the selection of 30 Aboriginal and Torres Strait Islander communities that will benefit from the additional funding.
“I am calling urgently on the Federal Government to come clean about how the 30 communities were chosen, what the modelling was … and most importantly, to answer how you got it so wrong in Victoria.”
Stephen Duckett and Anika Stobart write:
By abandoning the national plan, NSW’s gamble to go it alone on easing restrictions for fully vaccinated people further fractures federalism … NSW initially locked down too little and too late.
NSW’s ‘Roadmap to Freedom’ announced on September 9 is a risky gamble. If NSW pulls it off – and reduces restrictions for the vaccinated without a spike in hospitalisations that its system cannot handle – then Victoria and the ACT can follow suit. But if the gamble fails, the costs will be enormous: many more deaths, further widespread lockdowns, and increased risks to other states.
Attempting this high-wire act is consistent with NSW’s COVID approach to date, trying to pull off win-win situations where health impacts are managed, but restrictions remain minimally burdensome. NSW has successes pre-Delta, but this approach has proven unsuccessful in managing the delta variant. NSW initially locked down too little and too late, discovering that against delta its contact tracing system and restrictions were insufficient to push cases into decline. And now it risks coming out too early.
NSW’s plan for reopening helps provide certainty to the community and business, and may encourage more people to get vaccinated, but it is risky, does not provide assurances that hospitals will cope, will be difficult to enforce, may unfairly discriminate against areas with low vaccine supply, and appears to signal an end to a national approach for reopening. NSW should change its plan and aim for a higher rate of vaccination before it takes its leap to “freedom”.
NSW’s plan is risky
NSW’s plan to substantially ease restrictions for fully vaccinated people once 70 percent of adults are vaccinated is an experiment that has not been modelled, and is reported to go against the advice of the NSW chief health officer, who recommended waiting until 85 percent of adults are vaccinated.
But we can confidently predict that Covid will continue to spread – and spread faster than it has been spreading – when this step is taken. Seventy percent adult vaccination translates to about 56 percent total population vaccination. Double-dose vaccination does not fully prevent infection or transmission, so delta will still continue to spread in NSW. While eased restrictions on gatherings, hospitality, retail, and events are all caveated with density limits and requirements for attendees to be fully vaccinated, it is unclear how big the risk of further uncontrolled spread and further hospitalisations will be at a time when NSW hospitals are already under significant strain and the premier herself has admitted that this has not yet reached its peak under lockdown settings.
The Doherty Institute modelling that informed the national plan did not model a scenario where the starting point had thousands of cases already in the community, vaccinated people would be exempt from lockdown restrictions, and the testing, tracing, isolation and quarantine system was not coping. It simply modelled what the likelihood of lockdowns would be with 70 percent adult vaccination, baseline restrictions, and “optimal” or “partially effective” test, trace and isolate capabilities.
Despite proposing to take a significant step into the unknown when Doherty’s modelling suggests bad outcomes – in terms of deaths and high levels of hospitalisations – are still possible, NSW has not provided guarantees that it has the capacity and infrastructure to do tracing effectively with a much higher case load, especially when vaccinated people (and likely some unvaccinated people) will have many more contacts per day.
While the NSW plan does provide some caution by stating that targeted restriction may be needed “to deal with outbreaks“, this is difficult to do in cities because essential workers need to travel outside their areas.
Struggling hospitals
NSW’s health system is already under huge pressure, including in rural areas, and this will probably increase when Covid is allowed to spread more rapidly in the community while many people remain unvaccinated.
Burnet Institute modelling of the current NSW outbreak under lockdown suggests that hospital admissions will peak in mid to late October, but NSW’s plan was never factored into this model.
And just recently, national cabinet said that “further work [was] underway to understand the surge capacity available should it be required in the transition to Phase B and Phase C under the national plan”, suggesting that NSW made its decision before this was fully understood.
In our Grattan Institute Race to 80 report, we advocated for 95 percent vaccination of people over 70, a critical contributor to keeping the number of hospital admissions and deaths down. Currently, just 52 percent of people over 60 and 64 percent of people over 70 in NSW are fully vaccinated.
Challenges ahead
Giving vaccinated people freedoms in the first stage of easing restrictions is a good way to drive up vaccination rates, and could shift about 20 percent of people who are unsure or unwilling to get vaccinated, but it needs to be carefully planned and implemented.
A lockdown is, by definition, no longer a lockdown when 70 percent of adults are exempt. It won’t be difficult for unvaccinated people to bypass the restrictions, in situations where enforcement depends on social policing, such as for household gatherings, which are known to be higher risk.
And non-compliance is likely to be higher among “vaccine refusers”. The risk of transmission from non-compliance needs to be factored into the plan and modelling for easing restrictions, but it is not clear this has been the case.
Vaccine supply issues
Some communities in NSW, particularly rural communities, are struggling to get vaccines. These communities now face a double whammy. They are at higher risk of infection outbreaks because of their low vaccination rate, and opening up before these communities have had a chance to be fully vaccinated unfairly discriminate against them.
NSW’s plan to reopen at 70 percent double-dose adult vaccination is not consistent with the national plan, agreed by national cabinet on July 31 2021. That plan clearly states that:
“Phases [are] triggered in a jurisdiction when the average vaccination rates across the nation have reached the threshold and that rate is achieved in a jurisdiction expressed as a percentage of the eligible population (16+).” (emphasis added)
Contrary to the national plan, NSW is signalling a move that in fact amounts to skipping Phase B of the plan and enacting something approximating Phase C (which was to be tied to 80 percent of the adult population) without the rest of the nation having reached either threshold. This further fractures federalism. The national plan is being abandoned in favour of a “go it alone” approach, knowing that it is not alone and increased infections in NSW will inevitably spill over into other states.
And with more vaccines being allocated to NSW to date, these states with lower vaccination coverage are vulnerable.
To better protect its residents and health system, and the residents and health systems of other states, NSW should not open up until it reaches a higher vaccination rate. This would mean waiting only another two weeks under current projections to get to 80 per cent adult coverage, or four weeks to get to 90 percent adult coverage. And it should consider children in its coverage targets, as children 12 and above are now eligible for vaccination.
In the meantime, NSW should boost vaccination rates in vulnerable groups, commission modelling of its plan, ensure its health system can cope, ramp up its tracing capabilities, and ensure equitable access to vaccines across the state.
Professor Stephen Duckett is Director, Health Program, at the Grattan Institute.
Anika Stobart is an Associate at the Grattan Institute.
This article was first published in Pearls and Irritations.
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