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COVID SNAPS: on covidiots, the high price of “freedom” and liminality

In her latest column, Professor Kathy Eagar, Director of the Australian Health Services Research Institute at the University of Wollongong, is determined to strike a positive note amid rats in the ranks, concerns about covidiots, and the toll of “freedom”.

The NSW and Victorian plans accept that the price of coming out of lockdown will be massive surges in cases and deaths, she writes.


Kathy Eagar writes:

“Nurses, midwives and carers are exhausted and frustrated as they watch protesters fight

for their right to overwhelm our health system.”

Our quote of the week is from Australian Nursing and Midwifery Federation (Victorian Branch) Secretary Lisa Fitzpatrick in response to the covidiot protests in Melbourne this week.

It is inevitable that Melbourne clinicians will care for some of this week’s protesters as they gasp for air and fight for their life. A big shout out to all clinicians watching covidiot protests, it must make you want to cry in frustration.

Word of the week: liminality

We are now in a state of COVID liminality – a waiting room between lockdown and what comes next.

Australian COVID at a glance today

Two milestones this week. NSW passed 50,000 cases since 16 June when this outbreak began and Victoria had its highest number of cases ever, exceeding its worst day in 2020.

COVID in the Illawarra

The Illawarra is now at risk. Cases are increasing at a high rate and we have had three COVID deaths this week. We had 103 cases reported this morning – 82 Wollongong LGA (only 18 linked to known cases), 14 Shellharbour (8 linked), 5 Kiama (3 linked) and 2 Shoalhaven (both linked).

Our vaccination rate is below the NSW average and is not high enough to protect us from a major outbreak.

One in every 391 people in Shellharbour has been infected with COVID in the last two weeks. So has one in every 617 people in Wollongong, one in every 1,184 in Kiama and one in every 2,382 in Shoalhaven. These infection rates are too high and COVID is now spreading down the coast.

The #VaxTheIllawarra campaign is working to improve our vaccination rates. Here is a table showing where we stand at present. These percentages are based on the ‘eligible’ population which is still calculated on people aged 16 and older. The percentage of the whole population vaccinated is considerably lower.

Make sure you support #VaxTheIllawarra if you can. None of us are safe until all of us are safe.

Click on these links to see COVID cases numbers by LGA for Sydney and for Victoria. Bingo.

COVID in aged care homes

In 2020 COVID swept through aged care homes and people in aged care, who represent less than one percent of the population, accounted for 75 percent of all COVID deaths (678 of 910 deaths). By the end of 2020, 218 aged care homes had had an outbreak, infecting a total of 2,027 residents as well as 2,238 aged care staff.

The Aged Care Royal Commission conducted a special hearing on COVID and it was scathing. While Australia had a very low population rate of COVID by international standards, our percentage of cases and deaths in aged care was one of the highest in the world. Our failure to protect our most vulnerable citizens was, quite frankly, a national disgrace.

Blame was laid, quite fairly in my view, at the foot of the Commonwealth Government for its systemic failures in funding and governance as well as its failure to respond adequately once COVID outbreaks occurred. While most of the failures were systemic, in some cases specific aged care providers were also to blame.

The situation in 2021 is much better although the picture is still not good enough. In total 87 aged care homes have had an outbreak in 2021, infecting 311 residents and 189 staff and killing 24 aged care residents. There are 47 active outbreaks this week and 172 active cases among residents. Inevitably there will be more deaths.

There are two important reasons for the improvement from 2020. The first is that aged care homes have made improvements to quality and safety especially infection control. The second reason is vaccination. While the vaccine rollout was too slow and poorly managed, more than 300,000 doses have now been administered to residents and over 80 percent of aged care residents were reportedly vaccinated by the time the latest population outbreaks occurred in NSW and Victoria. Vaccination is now mandated for all staff working in aged care and this will have also had a positive impact.

While the number of homes with outbreaks has decreased, so have the number of cases in each home.  In 2021, the number of homes with outbreaks has fallen to 40 percent of the number in 2020. Resident infections are 15 percent of what they were in 2020, staff infections 8 percent and deaths 3.5 percent.  Vaccination has definitely been a life saver in aged care. But other factors have also played a part.  A shout out to aged care providers for the improved safety they have achieved this year.

That said, people in aged care homes are some of our most vulnerable citizens. They have a right to be safe. While the situation in 2021 is much better than it was in 2020, 87 outbreaks this year is 87 outbreaks too many.

Reff round up

The Effective Reproduction number or the Reff or the RO tells you how quickly the virus is spreading. When the Reff is greater than 1.0, cases are increasing. When the Reff is less than 1.0, cases are decreasing.

ACT: 5-day moving average 15 (19.0 last week), Reff 0.81 (1.21 last week) – ACT is still fluctuating a bit but is slowly decreasing.

NSW: 5-day moving average 1,007 (1,241 last week), Reff 0.85 (0.89 last week) – I’m now quite confident that NSW has peaked.

Vic: 5-day moving average 657 (467 last week) Reff 1.27 (1.20 last week) – cases are still increasing with each 100 people infecting about 127 more. Is this increase a covidiot effect?

Qld, SA, Tas, WA, NT: moving average 0, Reff 0

While the numbers are looking promising, we need to be cautious about averages. An average does not tell the whole story. There is significant variability within both NSW and Victoria and this is masked by single statistics such as the Reff.

In NSW the Reff is continuing to fall faster in the 12 LGAs that have had severe restrictions than it is in the rest of NSW. The excellent news is that this is good evidence that hard lockdowns work.

But the bad news is that the Reff is going up in other parts of NSW. NSW has to achieve a continuing fall in cases in the 12 hotspot LGAs as well as reverse the upward trend in the rest of NSW. Doing one without the other won’t work.

The same applies in Victoria. The centre of the current outbreak in Victoria is the LGA of Hume and it accounts for more than one third of all cases in Victoria. Victoria needs to reduce cases in Hume without letting them creep up elsewhere.

How do our various outbreaks compare?

Thanks Juliette O’Brien for this excellent graph showing how our various outbreaks compare. The current NSW outbreak (the aqua line) overshadows the outbreak that sent Victoria into lockdown for many months in 2020 (the red line).

But look at the rate of increase of the current outbreak in Victoria (the purple line). It is increasing at a faster rate than any other outbreak to date.

No doubt the covidiot protests in Melbourne haven’t helped. Neither NSW nor Victoria are great places to be when the plan is to move out of lockdown in the foreseeable future.
Vaccination rates – how do we compare?

Oh look, no wonder the PM is so proud. We really are above average in the A group for our COVID vaccination rate.

After a very slow start, our vaccination rates have improved rapidly in recent weeks. That is great news.

But we are still near the bottom of rates in peer countries.

Calling last drinks: COVID in Australia is becoming an epidemic of the unvaccinated

NSW and Victoria have now both released their roadmaps to ease restrictions so that we ‘live with COVID’. Politicians from all sides have now concluded that we have no choice but to live with it. The only issue in dispute is the timing.

NSW and Victoria have been trying to control major outbreaks. But they have now both decided that we can’t get back to zero and, given this, we may as well start opening up this year. This is a real dilemma for the other states. They are living happily without COVID. ‘Opening up’ means inviting COVID into their state with the inevitable surge of cases and loss of life.

The plans for NSW and Victoria are for a staggered easing of restrictions linked to achieving 70 percent and 80 percent double vaccination rates. These percentage targets are consistent with the national plan. The NSW plan is for a faster pathway out with many restrictions easing at 70 percent. Victoria is more measured with most restrictions not easing until 80 percent. Meanwhile, the Doherty Institute has undertaken further work on the national plan and is now recommending that “cases be strongly suppressed” until 80 percent vaccination of adults is achieved.

Both state plans accept that the price of coming out of lockdown will be massive surges in cases and deaths. This is the case even at 80 percent plus of the ‘eligible’ population being double vaccinated.

According to their own plans, NSW will peak in October, Victoria in December. Both projections assume that their health systems will barely cope. The Burnet Institute has modelled the likely impact in Victoria and concluded that there is a “moderate risk of exceeding health system capacity”.

I know that both states have fall back plans at different level of pressure on the system. At their most extreme, these include the temporary cancellation of all planned surgery (even category 1 surgery for life threatening conditions like cancer) and rationing access to beds based on likelihood of survival.

Here is a table and some graphs out of the Victorian roadmap. The roadmap option that Victoria is going with is shaded in dark pink. Victoria is projecting to reach 4,500 cases a day and more than 2,000 deaths by the end of 2021.

Victoria has been more transparent with the community than NSW and NSW has not released an equivalent summary. But the NSW projection has to be a lot worse – NSW is starting with many more people in hospital and intends to open up faster.

It seems the NSW Premier wants the worst of it over before Christmas. If the projections are right, Victoria will peak close to Christmas week.

In essence, we all need to be prepared for ‘freedom day’ to come at a huge price. COVID in Australia is becoming an epidemic of the unvaccinated. While estimates vary, some are now projecting that 80 percent of those unvaccinated will eventually be infected with COVID. Internationally, almost everyone will be either infected or vaccinated before the pandemic ends.

Calling last drinks for the vaccine hesitant and for the people who haven’t got around to it yet. Anyone electing not to be vaccinated while ‘living with COVID’ will be literally putting their life at risk.

I can accept it if you decide to put your own life at risk. I can’t accept it if you do so knowing that you are also putting the lives at others at risk. Am I judgemental about this? You bet I am.

While the mouse may be dead, long live the rat

While the prognosis for this mouse is not looking good, the rat is destined to become part of our world when living with COVID. RAT stands for Rapid Antigen Test. These are tests that identify virus proteins, typically using disposable single-use devices. They are screening tests rather than diagnostic tests. They are designed to give you a result at point of testing, typically within 15-30 minutes. Some are for use by clinicians and some are do it yourself (DIY).

Most RATs are nasal (up your nose) or nasopharyngeal (further up your nose – the upper part of your throat up behind your nose) tests. But some are also opharyngeal (the middle of your throat behind your mouth) and saliva. Samples taken from your nose give a more reliable result then samples taken from your mouth. There are now also Rapid Molecular Tests (RMTs) that are designed to detect the virus’s genetic material, using small portable or table-top devices but these are for clinician use rather than DIY.

While earlier RATs had poor sensitivity (the ability to correctly identify people with COVID) they had better specificity (the ability to correctly identify people who don’t have COVID). There are now numerous RATs on the market and they vary in their accuracy. But, in general, sensitivity is still not great – they are about 70 percent accurate with people who are symptomatic and 60 percent with people who are asymptomatic. They are more accurate early in the disease. Sensitivity improves when repeated daily, as is now occurring in some workplaces. Specificity is now reported to be excellent – generally about 99.6 percent.

The Therapeutic Goods Administration (TGA) is the Australian Government body responsible for approving, monitoring and regulating all therapeutic goods (not just medicines but also vaccines, medical devices, biologicals etc). Among its other roles, it is responsible for approving COVID vaccines and COVID RATS.

The TGA has a bit of a reputation for being slow as a wet week and they were criticised for being too slow in approving COVID vaccines for use in Australia. Some hail this as evidence that the TGA is cautious and thorough, making sure we are all safe. That is undoubtedly true. But some cynics (who me?) also see the TGA as evidence of what happens when a government spends more than a decade cutting the Australian public service and rely instead on high paid consultants for advice.

Be that as it may, the TGA has to date approved over 50 point of care tests for use by clinicians only. It has not approved any DIY tests and has actually banned companies advertising COVID test kits to consumers for self-testing. The TGA argues that, because Australia has had so few COVID cases (relative to other countries), the lower sensitivity and less than 100 percent specificity of RATS will result in too many false negative and false positive results.

But the technology is improving all the time and Australia is now many months behind other countries in introducing the widespread use of both RATS and RMTs. We are also well behind other countries in not only allowing, but actually promoting, DIY testing. Both are essential ingredients in other countries ‘living with COVID’. From my perspective, we need to give priority to following the lead of other countries and introducing DIY RATS.

An example from England to illustrate what it happening elsewhere: the mother of a friend in England went to Boots the local chemist to get her script filled. She came out with her script and a packet of 10 DIY RATs. Her RAT kit was free, funded by the NHS as part of their COVID program.

Mandatory RATs will inevitably become a part of routine life in Australia. Like Singapore (see below), it will no doubt become mandatory for those who are not vaccinated.  It will also be mandatory for international travel, irrespective of vaccination status. It might also be mandated for domestic travel.

Millions of Australian women have successfully used a DIY home pregnancy testing kit and the RAT test is no more complex. I have no doubt we will all learn how to use a DIY RAT. Then we can all have a RAT in the bathroom cabinet and bring it out whenever we wake up with a sniffle.

Living with COVID in Singapore

With a population similar in size to Greater Sydney, Singapore has reached 82 percent of people over 12+ fully vaccinated, with 84 percent at one jab. Despite this, Singapore is experiencing about 1,000 cases (up from 100+ just a month ago) and a few deaths a day.

Masks are mandatory outside the home except if strenuously exercising. This will be the last measure to disappear. Vaccination is not compulsory. Everyone is required to check in everywhere they go using an app with photo ID. This app also tracks your movements via Bluetooth to identify close contacts. Don’t have a phone? You can wear a token instead. Neither the phone app nor the token is compulsory. But you cannot enter any public building without one or the other. The app also holds vaccination status.

Want to eat out in groups of five?  Prove your vaccination status or pay $50 for a RAT at the door. Don’t want to get vaccinated or tested? Then you can only eat in groups of two at hawker markets. Want to visit someone in hospital? Get vaccinated. Want to go to the gym/cinema/theatre/museum? Get vaccinated or turn up 30 minutes early and pay $50 for a RAT before you can go through the door.

Want to travel to and from Germany/Brunei using Singapore’s new travel corridor? You can but only if you are vaccinated. If you are vaccinated but get COVID you can now recover at home as long as you are asymptomatic. Everyone else is required to recover in a government facility.

via Financial Times, 22 Sept 2021

On a positive note

If you are as frustrated as I am about the danger that anti-vaxxers are now doing, try this:

Recommended reading

If interested in NSW, you can check out latest case numbers and vaccination rates by postcode here.

Here is a link to an excellent article on ‘Six Rules That Will Define Our Second Pandemic Winter’. While the pandemic keeps changing, these principles can guide your thinking through the times to come:

  1. The role of vaccines has changed (again)
  2. The proportion of vaccinated people matters, but who they are and how they cluster also matters
  3. The people at greatest risk from the virus will keep changing
  4. As vaccination increases, a higher proportion of cases will appear in vaccinated people – and that’s what should happen
  5. Rare events are common at scale
  6. There is no single “worst” version of the coronavirus.

Here is a link to the best article I have read that explains how coronavirus spreads through the air. As Australia prepares to open up, we are really not giving enough attention to ventilation. This Spanish article (which is luckily in English) explains why we need to take ventilation seriously:

I wrote in an earlier COVID update about the importance of ventilation in schools. This article explains that poorly ventilated schools are a super-spreader event waiting to happen.

Open the windows … and experience the state of liminality.


Croakey thanks and acknowledges Professor Kathy Eagar for this column, which is based upon a regular COVID update that she emails her networks, combining a mixture of evidence, observation and pithy humour. On Twitter, follow @k_eagar

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