As we ponder the health implications of the NSW Premier’s resignation and the Australian Government’s plans “to safely re-open to the world”, the health workforce faces immense pressures, in the short and long term.
“An exhausted workforce in combination with reductions in clinical training in 2021 means that we can anticipate big workforce shortages for years to come,” writes Professor Kathy Eagar, Director of the Australian Health Services Research Institute at the University of Wollongong, in her latest column.
And, she asks, what do a mountain lion, a toddler and an anti-vaxxer have in common?
Kathy Eagar writes:
“Life is what happens when you are busy making plans.”
Quote of the week comes from John Lennon – and brings words of wisdom for the COVID management team in Victoria who had no possibility of managing the biggest pandemic in a century after their efforts were sabotaged by lockdown protesters and thousands of football grand final party goers.
Word of the week:
Australian COVID at a glance
Yesterday was our worst day in the history of the pandemic – 2,419 cases in one day. Nevertheless, all governments are continuing with plans to open up. The only issue in dispute is the timing.
NSW, Victoria and ACT are still trying to get their major outbreaks under control and Queensland is now also on knife edge after six local cases yesterday and another two today.
Case numbers effectively doubled in Victoria in the last two days and, based on contact tracing so far, the Department of Health is estimating that at least 500 cases yesterday are due to illegal gatherings and house parties over the AFL grand final long weekend.
Until now, Victorian cases have been concentrated in the northern and western suburbs of Melbourne. Not anymore. Football fans have now spread COVID through the whole of Melbourne and into the regions.
That football match will be the cause of numerous cases and deaths in the weeks to come. A new category of covidiot.
How is the health system coping?
Every district in NSW is on code red and it won’t be long until Victoria is in a similar position.
There are a total of 1,514 COVID cases in hospital in NSW, Victoria and the ACT today. They include 299 people in intensive care, 165 of whom are on a ventilator.
Allowing for turnover, this is equivalent to 54 x 30 bed wards. These are not additional intensive care units and wards. They are existing units and wards that are now being used for COVID patients. And the people delivering the care are not new staff who have magically appeared.
These 54 ICUs and wards are staffed by thousands of existing staffing and by staff redeployed from elsewhere in the health system. Community health services, palliative care units, rehabilitation units, surgical units and many other services are being closed or reduced to free up the workforce to care for COVID patients.
The average time in hospital for non-COVID patients is three days. In contrast, COVID patients need care for weeks. The opportunity cost is that thousands of other non-COVID patients are not getting the surgery, treatments and care they need.
The system impact will be felt for years. Not only will patients with long COVID need extensive rehabilitation, we are now hearing daily reports of patients with other health problems not getting the care they need. This includes delays in diagnosis and in treatment for life-threatening conditions such as cardiac conditions, cancer and diabetes and people not getting the rehabilitation they need after conditions such as a stroke.
But the major long-term impact is likely to be on the workforce. We are at risk of moving into 2022 with an exhausted and stressed workforce.
Based on international experience, some will leave the health sector completely burnt out and swearing never to return. An exhausted workforce in combination with reductions in clinical training in 2021 means that we can anticipate big workforce shortages for years to come.
Per capita case rates
Here are two excellent graphics by Travis Picker showing per capita COVID case rates in the last two weeks. Only the top LGAs by case numbers are included.
One in every 185 people in the NSW LGA of Canterbury Bankstown has been infected in the last two weeks, down from one in every 106 people a fortnight ago.
Wollongong has moved in the opposite direction. One in every 362 people in Wollongong has been infected in the last 2 weeks, a big increase from one in 959 in the previous fortnight.
Most top LGAs in Victoria are heading in the wrong direction – they are moving to the right.
One in every 76 residents in Hume has been infected in the last two weeks. The South Gippsland region is doing best – just one in every 10,400 residents has been infected in the last two weeks.
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: 52 cases today. 5-day moving average 27 (15.0 last week), Reff 1.23 (0.81 last week) – ACT has been fluctuating around 1.00 for weeks but the picture is now getting worse, not better.
NSW: 864 cases today. 5-day moving average 851 (1,007 last week), Reff 0.88 (0.85 last week) – NSW has peaked
Victoria: 1,143 cases today. 5-day moving average 1,044 (657 last week) Reff 1.38 (1.20 last week). Professor Adrian Esterman, a Reff guru, estimates that, without the additional 500 cases caused by people getting together for the AFL, the Reff for Victoria would be 1.18 instead of 1.38. Between covidiot protesters and football fanatics, Victoria hasn’t stood a chance of controlling this outbreak.
Qld, SA, Tas, WA, NT: moving average 0, Reff 0
Vaccination rates – how are we doing?
After a very slow start, vaccination rates are improving rapidly. But, as can be seen in the map below (thanks Citizen Science), coverage is very uneven.
This map is a nice illustration of a core idea: Risk = Likelihood x Consequences.
Vaccine hesitancy occurs when you overestimate the likelihood of an adverse vaccine reaction and underestimate the consequences of remaining unvaccinated.
Vaccine take-up reflects an assessment that the likelihood and/or consequences of being infected with COVID outweighs any possible vaccine side-effects.
The Melbourne Institute of Applied Economic and Social Research has been tracking vaccine hesitancy for months and produces a regular Vaccine Hesitancy Report Card. As can be seen in these graphs from their latest report card, vaccine hesitancy has been decreasing week by week since about May. These graphs show reported hesitancy by age group.
The younger you are, the more hesitant you are. Incidentally, women are much more likely to be hesitant than men. I was quite surprised by that.
Vaccine uptake is increasing and the major reason is clearly supply. We now have enough vaccine for anyone who wants it (although access and distribution issues remain problematic in large parts of the country).
But the other reason is the decline in vaccine hesitancy. This decline is due to two factors. I suspect that the minor factor is that the likelihood of an adverse vaccine response has actually diminished. But the much bigger factor is that the consequences of remaining unvaccinated have now become amplified.
Australia should have no trouble achieving a 90%+ vaccination rate. But even 90 percent will not achieve herd immunity.
Still can’t decide? Hopefully this helps:
An update on Rapid Antigen Testing: long live the rat
Last week I included a post on Rapid Antigen Test (RAT).
This week the Minister for Health has announced that he is pushing the regulator – the Therapeutic Goods Administration – to approve DIY Rapid Antigen Testing by 1 November.
Coming soon to a bathroom cabinet near you – a DIY RAT.
COVID, kids and schools
I have been monitoring the international evidence on schools and COVID throughout the pandemic and in a previous COVID update I questioned why Australia was paying so little attention to ventilation and air quality.
In particular, there is strong international evidence that HEPA filtration systems can significantly reduce airborne coronavirus participles. They work at school, at home and in other venues of course.
Since them, NSW and Victoria have both announced return to school plans and dates. It is great to see Victoria putting a strong emphasis on air quality.
The Victorian plan is aptly called “Three Vs”: Ventilation, Vaccination and Vital COVIDSafe Steps”. Mind you, given this is Victoria, isn’t that “Four V”?
The Victorian plan includes $190 million to purchase 51,000 air purifiers to be rolled out to all government and low-fee non-government schools in the coming weeks and months.
The goal is to remove coronavirus particles from higher-risk areas including class rooms, staff rooms, sick bays, music rooms and other high traffic areas.
They are also providing $25,000 grants to more than 2,000 schools for shade sails to create more outdoor learning spaces.
NSW schools are now set to return ahead of schedule (and ahead of Victorian schools) and it was reported yesterday that they went to tender last week to purchase 10,000 purifiers.
This is happening in parallel with an audit of school classrooms that NSW did not begin until two weeks after it announced its back-to-school plan and that is yet to be complete.
Given that Australia doesn’t actually make air purifiers and they will need to be imported, it looks like we are soon to see yet another race to procure the supplies we need. Oh dear!
On the upside, the purchase of 10,000 purifiers would suggest the NSW Department of Education is making progress. Earlier this month one departmental executive was reported as saying that “no one with any scientific or medical qualifications” had recommended the use of HEPA filters. Really?
The photo below demonstrates how schools were kept open during the Spanish flu, this time in summer.
The most important action we can all take to improve ventilation is to open the windows. I hope that NSW schools have a lot of windows as I suspect they will be waiting a while for HEPA filtration systems.
On the larger issue of kids and COVID, the evidence has not changed. Only a small percentage of children become seriously unwell and an even smaller percentage die from COVID.
But a small percentage of a large number of infected children is a lot of children. We need to do everything possible to protect every child.
Deaths during the first year of the pandemic
September is an exciting month. Not only is it the beginning of spring. It is also the month that the Australian Bureau of Statistics (ABS) produces its annual mortality statistics. I look forward to it every year.
The ABS has been monitoring deaths during the pandemic and looking for evidence of ‘excess mortality’, either because of the pandemic’s direct or indirect health effects.
Direct effects are deaths from COVID. Indirect effects are deaths from other causes that may relate in some way to the pandemic. These include deaths due to social factors (such as changes in rates of suicides, traffic accidents, drug and alcohol poisoning) and deaths due to difficulties accessing essential healthcare (such as missed or delayed diagnosis and/or treatments for conditions like cancer and heart attacks).
Comparable countries are collecting similar data to assess the impact of COVID internationally. Based on these data, The Economist has estimated that, while there have been 4.8 million COVID deaths globally, there have been around 18.5m excess deaths so far. This graphic is from The Economist.
Unpacking these issues for Australia in 2020 is compounded by the severe bushfire season in the first half of the year.
Key findings from the ABS on cause of death data for 2020 are:
- COVID-19 was the 38th leading cause of death (898 deaths).
- In 2020 there was actually a decrease in mortality in Australia. Australia was one of only a handful of countries where the death rate fell. The 898 deaths from COVID was more than offset by reduced deaths from other causes.
- The five leading causes of death stayed the same as in previous years but, after adjusting for changes in population size and age, the death rate in all five decreased – ischaemic heart disease, dementia (including Alzheimer’s disease), cerebrovascular diseases, lung cancer and chronic lower respiratory diseases. These conditions all had declining death rates prior to COVID and that did not change in 2020.
- Deaths due to respiratory diseases fell by 24 percent – the largest recorded fall in the last 10 years. Deaths from influenza and pneumonia fell the most, dropping 46 percent from 2019. Only 55 people died from flu in 2020, down from 1,080 in 2019. Closed borders, social distancing and masks prevented enough respiratory deaths to offset the additional deaths caused by COVID. The flip side is equally true. ‘Living with COVID’ will inevitably mean that deaths from flu and pneumonia will revert to their pre-pandemic levels.
- Rates from suicide, drug overdoses and car crashes all decreased. No one was predicting the suicide rate to decline but it has so far kept declining in 2021 as well. The fall in drug overdoses is linked to reduced access (with the borders closed and reduced social movements) and car crashes declined because we all stayed at home.
- Alcohol-induced death rates increased by 8.3 percent. This needs no explanation.
As can be seen clearly in the graph below, age-standardised death rates (SDR) have been slowly falling over the last decade as life expectancy continues to improve.
Contrary to expectations, the trend continued in 2020. The overall number of deaths is stable as improved life expectancy is offset by population increases. There were 161,300 deaths in 2020 or about 440 a day. This is consistent with previous years.
As part of its work measuring changes in patterns of mortality during COVID-19, the ABS released yesterday provisional deaths data for the first six months of 2021.
They reported that counts of deaths were above historical averages for each month of 2021 but that age-standardised mortality rates were below historical averages for each month of 2021 so far. I hope you find this fascinating. I certainly do.
Normalising COVID
While death is inevitable, we need to be wary of the way that politicians, the media and the community are now normalising hundreds of COVID cases and double digit death numbers each day. I worry that the numbers are just rattled off as though they have no meaning.
We need to be clear that dying from COVID is not a normal death and we cannot simply dismiss every death by explaining that the person had underlying health conditions. The Doherty Institute is projecting that, as we open up with an 80 percent adult vaccination rate, we will have more than 200,000 cases and 761 deaths in the first six months.
Every one of those numbers represents a person, a family and a community impacted by COVID.
COVID is not like the flu. COVID is not like old age. And it’s not like dying in a car accident or of cancer. I have heard all of these analogies and they are being used to justify walking away from attempts to mitigate the spread of COVID.
Dying from COVID is not normal or inevitable. It is many times more lethal than the flu. And COVID deaths are anything but peaceful, as death mostly is for people fortunate enough to make it to very old age.
The normalisation of multiple COVID deaths every day will make us complacent. In doing so, normalisation will result in even more deaths and will diminish us as a society.
Looking ahead
Do you find it difficult to reason with some people?
If so, this challenge is for you. Pick one of the following – an anti vaxxer, a toddler or a mountain lion. In 200 words or less, convince them to obey social distancing rules, wear a mask and/or get vaxxed.
Recommended
‘Relying only on vaccination in NSW from December 1 isn’t enough – here’s what we need for sustained freedom’. An excellent overview by Professor Raina MacIntyre and colleagues. Essential reading if in NSW.
Tracking COVID-19 vaccine hesitancy across Australia using Taking the Pulse of the Nation (TTPN) Survey data.
For nerds, an interesting webinar on “The Recognition of Airborne Transmission of Infectious Diseases” hosted by the International Society of Indoor Air Quality and Climate:
“My patients in Melbourne tell me how they caught COVID, and the reasons leave me sad and frustrated”. An empathic reflection from a clinician on the frontline by Kate Gregorevic
PostScript
Thinking of a career change? A late vacancy has arisen and applications are now open for appointment as Premier of NSW…
And one last bit of advice…
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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