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COVID SNAPS: on the inverse care law, protecting children, a date for your diary – and fingers crossed for Christmas

The inverse care law is clearly evident in how the pandemic is playing out, writes Professor Kathy Eagar, Director of the Australian Health Services Research Institute at the University of Wollongong, in her latest column.

She also writes that adults have a responsibility to protect young children by making sure every adult in their life is vaccinated and that their school has fully implemented an air quality plan.

“Keep in mind that 15 percent of the Australian population are too young to be vaccinated and they depend on the rest of us to keep them safe,” she says.


Kathy Eagar writes:

“When the COVID announcements were made, they’d say ‘Very sadly, three people have died’, then it was ‘Very sadly 70 have died’.

Now they don’t say ‘Very sadly’. One thing we know about humans is our emotions are stirred by images, they’re not stirred by numbers.”

Our quote of the week comes from Professor Robert West, University College London, quoted in The Guardian.

Word of the week is ‘Pandademic’. On average a Panda feeds for 15 hours a day. This is the same as an adult at home under quarantine, which is why we call it a Pandademic.

We reached an Australian COVID milestone on 21 October: more than 150,000 cases and 1,500 deaths. Australia now has a case fatality rate of one percent.

The case fatality rate is down from three percent in 2020. This is because the proportion of cases and deaths in aged care homes has decreased from 2020.  People in aged care represent less than one percent of the Australian population but deaths in aged care accounted for three-quarters of all COVID deaths in 2020.

Here is a summary of the COVID state of the nation on 21 October.

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. Thanks Prof Adrian Esterman for his daily calculation of the Reff.

ACT: 13 cases. 5-day moving average 25 (38 last week), Reff 0.6 (1.14 last week) – getting there but it is taking so long.

NSW: 345 cases. 5-day moving average 301 (399 last week), Reff 0.87 (0.72 last week) – the Reff is up a little on last week but cases have more or less plateaued.  It is unclear whether this is early evidence that easing out of lockdown is starting to increase case numbers. Watch this space, we are not out of the woods yet.

Vic: 2,189 cases. 5-day moving average 1,965 (1,814 last week) Reff 0.98 (1.03 last week) – the Reff is stable just below 1.00.  Victoria continues to hover just below its peak. Fingers crossed.

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

Here is a table of case numbers for NSW districts since the outbreak started in June 2021 (thanks @DeadInLongRun). NSW had over 65,000 cases and 487 deaths in just 18 weeks.

The last column shows the numbers for the week starting 10 October. Total numbers are less than a third of what they were at the peak (5 September).

Illawarra is looking more in control the but Hunter is not. Murrumbidgee is also of concern now. More broadly, cases are declining rapidly in Sydney but not so in the rest of NSW.

See COVID cases numbers by LGA for Greater Sydney, Regional NSW and for Greater Melbourne. NSW LGAs are much lighter. Sadly, Greater Melbourne is now Bingo.

Magic vaccination rates

Here is the latest update on vaccination rates for NSW statistical areas.

NSW has the highest vaccination rates in the country and the increases from week to week are still really impressive. Regions are listed from highest (Baulkham Hills and Hawkesbury) to lowest (Richmond-Tweed). I have also included the 70 percent and 80 percent thresholds.

These are percentages of people over 16, not the whole population.

Seventeen areas are at 80 percent or better, up from seven last week. Only two areas are still below 70 percent, both on the north coast of NSW.

The north coast is well below where it needs to be for communities to be protected in the months ahead. First Nations peoples are particularly at risk. So my heart sank earlier this week when I was sent this invitation for an event at Tweed Heads.

Indigenous leaders across Australia have been vocal in urging their communities to be vaccinated and have stressed that it is safe and culturally OK. Yet the message is clearly not being heard in some communities. This invitation is a depressing sign of the vaccination challenges still ahead.  It is a challenge that communities really must win.

This is particularly the case because, as I have commented previously, plans to move out of lockdown and open our borders are proceeding with the implicit understanding and acceptance by governments that some people are going to be left behind.  Sadly the people promoting vaccine rejection are making this even more inevitable.

On Julian Tudor Hart and the Illawarra region

Here is a table of COVID case rates and vaccination rates for Illawarra postcodes.

I have also included the ABS Socio-Economic Indexes for Areas (SEIFA) score. This is a composite measure of socio-economic advantage and disadvantage. It is based on Census data and uses measures such as household income, education, employment, occupation, and housing to classify each Census collection district. The most disadvantaged postcodes have a SEIFA of 1. The most advantaged postcodes have a SEIFA of 10.

The postcodes within each LGA are sorted in the table based on the percentage of residents who have been infected with COVID since 16 June 2021.  Guess what, people living in the most disadvantaged postcodes have the highest rates of COVID cases. It is a straight line relationship.

Within Wollongong LGA, the rates vary from 2.3 percent of the residents in postcode 2502 (Cringila, Lake Heights, Primbee, Warrawong) being infected with COVID through to 0.1 percent in postcode 2515 (Thirroul through to Clifton).

We saw the same pattern in Sydney, with the highest rates in the south west and western suburbs. The pattern is not quite as clear for vaccination rates but it is still there.

Better off areas have the highest vaccination rates and the lowest COVID rates. And worse off areas have the lowest vaccination rates and the highest COVID rates. But the high case rate is not caused by the low vaccination rate. Or vice versa.

The underlying factor driving both is differences in socioeconomic status. These differences drive differences in health literacy and result in vaccine inequity. People with better health literacy were quicker to understand the importance of vaccination, were less likely to be ‘vaccine hesitant’, were better able to navigate booking systems and appointments and were more likely to work in jobs that gave them flexible time off to be vaccinated.

This combination of factors means that people of higher socioeconomic status got better access to vaccination.  Whoever would have thought it?

The Illawarra is a micro case study of Julian Tutor Hart’s 1971 ‘inverse care law’.  Gee, I wonder if Julian saw COVID coming?  So now we have an ‘inverse COVID law’.

‘Real world’ data on the effectiveness of the vaccines

With Australia well on the way to having one of the highest COVID vaccination rates in the world, the obvious question is how well the vaccine works. This question is being increasingly asked as we move out of lockdown with plans to open up our borders.

Vaccine goes through rigorous testing for safety and efficacy prior to approval. Once approved, all vaccines are monitored for both safety and effectiveness once in routine use.  There are 4 key tests of real world effectiveness:

1.     How well does the vaccine prevent mild (symptomatic) COVID?

2.     How well does the vaccine prevent severe (sick enough to go to hospital) COVID?

3.     How well does the vaccine prevent you from dying?

4.     How well does the vaccine prevent you from infecting someone else?

The table below summarises the current evidence about each of these questions. It is a lay summary only, not a systematic review of all of the available evidence and the purpose is a high level scan rather than an in-depth analysis.

There is quite a lot of variability in the actual numbers but that is because there is a lot of variability in how vaccines are being rolled out. Effectiveness varies by dosing schedule (the closer the two doses are together, the less effective it is), age, underlying heath conditions and so on.

In summary though, the evidence is clear. All three available vaccines do what they are meant to do. They are all excellent at keeping you alive, which I must say I found quite reassuring (and much better than the alternative).

They are also excellent at preventing you becoming sick enough to go to hospital. They are effective at preventing mild COVID, but effectiveness against mild COVID isn’t as good as against severe COVID.

They also reduce transmission. Vaccination significantly reduces the chance you will pass COVID on to others in two different ways. The first is that vaccine dramatically reduces your viral load – so, even if you do get infected, you have less virus in your system to exhale over other people. The second is that vaccine greatly reduces the time you remain infected and contagious, so there are fewer days when you can infect others.

Calculating a precise measure of transmission reduction is almost impossible as it is influenced by lots of other factors – season, viral load, symptomatic or not, indoors or not, ventilation etc.  For these reasons, the best measure is transmission reduction in families. The results are clear. The more immune people in your family, the less risk an unvaccinated family member has of getting infected. If even one person in the family gets a single jab, it helps to protect unvaccinated family members.

Vaccination is already having a significant impact in preventing severe illness in the current Victorian outbreak.

Professor Michael Toole from the Burnet Institute has calculated that the hospital admission rate in Victoria is down to 3.5 percent of active cases with just 0.4 percent requiring ICU.

The NSW outbreak, which ran four weeks earlier than the Victorian outbreak, had a hospital admission rate of 13 percent with three percent requiring ICU. The difference can be attributed largely to vaccination. The NSW outbreak ran just ahead of a major improvement in vaccination rates whereas the Victorian outbreak is running far enough behind. With only 3.5 percent of cases being sick enough to be in hospital, I am expecting the fatality rate in Victoria to fall well below one percent.

But no vaccine is 100 percent effective. Effectiveness wanes with time and we are all going to need booster shots.

The best guarantee of safety is to combine double vaccination with a double dose of common sense (oh dear!). Wear a mask in crowded, poorly ventilated spaces, get tested at the slightest symptom and keep your social distance.

Keep in mind that 15 percent of the Australian population are too young to be vaccinated and they depend on the rest of us to keep them safe.

Living with COVID

While over 80 percent of people over 16 in NSW are fully vaccinated, only half of people under 40 are fully vaccinated. This is a NSW Health graph of cases in the last week.

COVID is now a pandemic of the unvaccinated. Protect young children by making sure every adult in their life is vaccinated and that their school has fully implemented an air quality plan. Plus masks for older children.

I am expecting vaccination of children 5-11 years to begin in the next few months and be done in time for school in 2022. Now we just need to get through the next few months.

Rare syndrome affecting children

Cases of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS) – a novel post-infectious systemic hyperinflammatory syndrome – are now being reported in children in Australia and internationally.

PIMS-TS is rare – it occurs in less than 0.5 percent of children who have had COVID. But it generally occurs in children who were previously healthy.  It typically occurs two to six weeks after infection with COVID. The median age at onset is nine years and it is more common in boys, those of ethnicities other than Anglo-European, and obese children.

Signs and symptoms include, but are not limited to, persistent fever, rash/conjunctivitis, and hypotension/tachycardia and/ or shock. Vomiting, diarrhoea and abdominal pain may also be prominent. The majority of cases test negative for COVID.

PIMS-TS can be very serious. Myocardial dysfunction requiring ICU admission occurs in at least half the patients.  Coronary artery aneurysms occur in about 15 percent.

Early recognition is essential. If you have a child who has had COVID and who displays these symptoms, don’t muck around. Take them straight to the Emergency Department and tell the ED triage nurse that the child is post-COVID.

Thinking ahead to Christmas

Everything is looking good for Christmas reunions with family and friends. Chris Billington (@Chrisbilbo), the analyst who does the superb graphs I’ve included below, has been pretty spot-on through the whole pandemic. And his colour scheme is great!

The maroon line is actual cases each day. The pink line smooths the cases until now. It then projects cases between now and the end of the year.

But Chris Billington makes the important point that this is the projection with no adjustments for what might happen now that the outbreak restrictions are being lifted in all three jurisdictions.

Our vaccination rates are high enough now that we should be fine as long as people are sensible. It’s looking good at this point with the virus reproduction rate stable or actually decreasing in all three jurisdictions. Fingers crossed.

Recommended reading

Looking for the perfect Christmas gift?  I recommend herd immunity for all the family.

Hot off the press: the more immune people in your family, the less risk that unvaccinated family members get infected. If even one person in the family gets a single jab, it helps to protect everyone else: Association Between Risk of COVID-19 Infection in Nonimmune Individuals and COVID-19 Immunity in Their Family Members.

Why Sydney’s COVID numbers didn’t get as bad as the modelling suggested.

Australia’s pandemic modellers are remodelling: ‘I’d give us a credit so far, but I’d like a high distinction,’ says Professor Margaret Hellard, a deputy director of Melbourne’s Burnet Institute.

Why we must not allow COVID to become endemic in New Zealand. As New Zealand switches from elimination to suppression, those who argue that COVID-19 will become endemic and part of our lives either do not understand or ignore what this would actually mean.  Many of us in Australia feel exactly the same way.

For your viewing pleasure: Want to be an anti-vaxxer but not sure where to start? This one is for you, from Sammy J.

So close: an anthem for the COVID generation.

A date for your diary

You will need a vaccine booster shot about six months after your second jab. So put a reminder in your diary now. I am expecting bookings for the general public to be opened up by the end of November.

Are you exhausted by COVID and thinking that a career change might be in order? If so, look no further.

Meet Mary Smith, a “knocker-upper”. Mary earned sixpence a week shooting dried peas at windows to wake people for work in East London (circa 1930s).

Many thousands of people are now out of the habit of rising early to get to work. They will no doubt struggle to return to the office.

Plan your next career move and become a modern-day “knocker-upper”.

Not quite ready to move out of lockdown and get back into the hustle and bustle but don’t know what to say?

“I can’t go out because of the virus” sounds weak, whiny and boring. My advice on how to handle this awkward situation is below.


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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