With Victoria set to ease public health restrictions this week and the “Premier of Sydney” catching many by surprise with plans to drop quarantine for fully vaccinated international travellers, what will be the price of policies touted as ‘living with COVID’? What will they mean for health equity?
“Commonwealth, state and territory government planning is proceeding with the implicit understanding and acceptance that some people are going to be left behind,” writes Professor Kathy Eagar, Director of the Australian Health Services Research Institute at the University of Wollongong, in her latest column.
Kathy Eagar writes:
“I’m reminded of the culture shift that occurred at the turn of the century. With universal literacy, soldiers gained voices, and lost their taste for dying for causes they didn’t hold dear. This will be the first plague where victims have voices. History will judge us all.”
The quote of the work comes from Anon (@MIsbelPerth).
The word of the week is scamdemic. In the worldview of conspiracy theorists and their followers, a pandemic that either does not exist or is not as serious as governments and health experts claim. Some see it as a hoax. In this version, COVID-19 does not exist at all or is no worse than a mild bout of flu.
Seriously, who could believe such nonsense? And who would judge any government capable enough to fake a whole COVID pandemic? In your dreams.
Fact of the week: NSW schools have more than 650,000 windows. They need to be opened to improve school air quality and thus protect teachers and students.
I wonder how many of them actually open?
Australian COVID at a glance
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: 35 cases today. 5-day moving average 38 (34 last week), Reff 1.14 (0.86 last week) – ACT continues to play snakes and ladders but opened up yesterday regardless.
NSW: 399 cases today. 5-day moving average 399 (591 last week), Reff 0.72 (0.75 last week) – the Reff and cases are decreasing nicely. The next week will tell what impact easing out of lockdown is having.
Vic: 2,197 cases today. 5-day moving average 1,814 (1,599 last week) Reff 1.03 (1.21 last week) – yesterday was the highest number of cases ever reported in Victoria. But the Reff is down close to 1.00 and there are glimpses that Victoria is at, or near, its peak. Fingers crossed. (See link to today’s announcement on restrictions easing at 11.59 pm on 21 October).
Qld, SA, Tas, WA, NT: moving average 0, Reff 0.
COVID curves with snakes and ladders
NSW has well and truly peaked with cases down by two thirds of what they were at the peak. Victoria is a month behind NSW and seems to be near its peak.
Being a month behind NSW, Victoria actually had a higher rate of vaccination than NSW had at a similar point in their outbreak.
The graph below compares NSW and Victoria based on the number of days since the start of each outbreak. While Victoria has a higher peak of cases, look at the Victorian death rate. The Victorian death rate is significantly lower than the NSW death rate.
Source: Professor Mary-Louise McLaws, Professor of Epidemiology, UNSW
This is the best Australian population evidence we have at this stage that vaccination works. Well done Victoria, while it must feel very miserable, there is a glimmer that things are getting better
See the COVID cases numbers by LGA for regional NSW, and for Greater Sydney, and for Victoria. NSW LGAs are generally getting lighter, Victoria’s are still dark. Bingo.
International comparison of vaccination rates
Australia had a very slow start with vaccination. We were one of the last high-income countries to get going and we took a while to gather speed.
But we have been doing very well in recent weeks. That said, we are still below most other countries in the OECD.
The graph below shows percentage of the total population vaccinated in OECD countries, not just those over 16 years. We are not there yet.
The magic of 70% and 80% double vaccination rate
Here is an update of a table I included last week on vaccination rates for NSW statistical areas. This week I have added the percentage increase from last week.
Increases of 5.1% to 8.7% in one week are really impressive. Regions are listed from highest (Baulkham Hills and Hawkesbury) to lowest (Richmond-Tweed). I’ve also added the 70% and 80% thresholds. These are percentages of people over 16, not the whole population.
Seven areas are already at 80%. They are all in Sydney. Nine areas are still below 70%, all but one in Sydney. The first easing of restrictions occurred at 70% and the next (now expected within days) will be at 80%.
The Premier and Government of Sydney is doing a great job.
And here was I thinking all these years that NSW stood for Newcastle Sydney Wollongong. Silly me. Forget the N and forget the W. We are now just S.
Vaccination’s two roles – stop infection and stop spread
Vaccine has two important but different roles. The first is to stop you getting infected or, if you do, to stop you becoming critically unwell and dying. The second is to stop you passing on the virus to someone else.
The three vaccines currently available in Australia do both of these quite well. But they are not 100% effective at either.
Real-world effectiveness data on hospitalisations and deaths following vaccination (currently Pfizer, AstraZeneca and Moderna) show vaccines are between 71% and 98% effective at preventing severe illness requiring hospitalisation and 88% to 97% effective at preventing death.
But efficacy reduces over time and we are all going to need booster shots.
Real world data on transmission rates is similarly positive. But transmission data are much harder to interpret because transmission is influenced by multiple factors that work in combination. Factors like whether symptomatic or asymptomatic, exposure level, viral load, the weather and ventilation all influence the risk of transmitting the virus from one person to another.
In practice, the vaccine rollout reflects some policy tension between these two goals. If the primary goal is to stop people becoming very sick and dying, the priority is to vaccinate those most at risk – older people and people with underlying health conditions.
But if the primary goal is to stop transmission, the priority should be on vaccinating those who are out and about the most and those most likely to infect someone else – children, teens, young people and those in the workforce.
Not surprisingly, the Australian rollout gave priority to vaccinating those most of risk, even at the expense of those most likely to spread the infection. Instead, lockdowns were used to control spread while those most at risk were vaccinated.
So, while we are achieving 70% and 80% coverage, the question now is whether enough potential spreaders have been vaccinated to control case numbers.
Professor MaryLouise McLaws is one of Australia’s leading experts and she is clear that not enough people under the age of 40 are fully vaccinated. Her assessment is that, in order to stop the spread, at least 80% of people under 40 need to be vaccinated. That makes good sense.
There is no doubt that we will achieve well above 80% vaccination rates in people under 40. But we aren’t there yet.
At present, less than 50% of people under 40 are double vaccinated. You can see the rates by age group in the table and graphic below.
It won’t take too long before we are at more than 80% of young people – but we are not patient enough to wait till then. We are moving out of lockdown, ready or not. Fingers crossed!
(Increase size of screen to see a more legible version).
Herd immunity – a refresher
I have previously written about herd immunity but, with our vaccination rates getting to very high levels, it is timely to revisit some key ideas.
‘Herd immunity’ works with infections like measles. Measles is highly infectious (about 3-4 times more infectious than COVID) and yet we have almost eliminated its transmission in Australia.
The measles vaccine stops you getting measles as well as spreading it to others. With most of us vaccinated against measles, we protect everyone else who isn’t vaccinated.
So ‘herd immunity’ is the level of population immunity required to prevent sustained community transmission and it is a function of three factors:
- how infectious the disease is (the reproduction rate referred to as the Reff or the R0)
- the efficacy of the vaccines against ALL infection (not just how well the vaccine prevents severe illness and death)
- vaccine coverage in the whole population (not just the “eligible” population of people over a certain age).
The Reff for other diseases we now manage through vaccination is:
- Smallpox: R0 of 3
- Polio: R0 of 4-6
- Mumps: R0 of 10-12
- Chickenpox: R0 of 10-12
- Pertussis: R0 of 15-17
- Measles: R0 of 16-18
Delta is similar to Polio, with a Reff of about 5.0. In other words, if Delta ran unchecked, each infected person would infect about 5 more.
While research is still in progress, the general consensus is that, with a Reff of 5, the herd immunity threshold is 80%.
That is, 80% of the whole population would need to be immune to COVID to achieve any level of effective herd immunity. 80% is also the herd immunity threshold for polio.
This is not 80% of people over 16. We need at least 80% of the whole population to be immune to COVID before those of us in the Australian ‘herd’ can protect those who can’t be vaccinated.
We are currently at just 53.2% of the population fully vaccinated with the rate varying from 63.8% in NSW to 43.0% in WA.
Irrespective, it is probably not possible to achieve immunity in 80% of the whole population with the current generation of vaccines.
While the current generation of vaccines work well to prevent severe illness and death, they only reduce (but don’t 100% prevent) asymptomatic infection. The next generation of vaccines will hopefully have a high efficacy against ALL infection (both asymptomatic and symptomatic).
In the meantime, a third booster shot will improve immunity in 2022 as will extending the vaccination age range to the whole population. The next cab off the rank will be children from 5 to 11 years. They should be approved within the next few weeks. No doubt pre-schoolers and babies will be approved in 2022 once current clinical trials are complete.
In the meantime, ‘living with COVID’ means accepting that TTIQ (tracing, testing, isolation, quarantining), QR codes, masks and social distancing will need to continue. The only alternative is to passively accept severe illness and death among the unvaccinated.
My view is that the community will now accept severe illness and death among adults who elect not to be vaccinated.
However, few people in the community will be comfortable ‘living with COVID’ if the price is a high rate of paediatric COVID.
Vaccination and TTS
There were two new cases of “Thrombosis with thrombocytopenia syndrome (TTS)” blood clots caused by AstraZeneca vaccine last week.
This brings the total number of cases of TTS to 152 (76 men and 76 women; 85 confirmed and 67 probable cases) from 12.5 million doses of AstraZeneca vaccine:
- 133 discharged
- 11 in hospital
- 8 deaths (6 women, 2 men)
The TTS case fatality rate is now eight deaths from 12.5m doses of the AZ vaccine or one death per 1.56m doses. The Australian COVID case fatality rate is 1,496 deaths from 136,125 cases or one death per 91 cases.
People with disability must not pay price for botched vaccine rollout
The Disability Royal Commission recently released its draft report into the rollout of the COVID-19 vaccine to people with disabilities.
It recommended that the Commonwealth government should not allow any state or territory to ease restrictions at the 70% fully vaccinated threshold unless all people with disabilities in residential accommodation and people with intellectual disability and all active support workers have been fully vaccinated.
Read more about it here from Community Care Review.
And at The Guardian.
And The New Daily.
And here at Croakey, by El Gibbs.
As NSW opens up, it is critical that ‘living with COVID’ does not leave many in harm’s way: an excellent article by Dr Kalinda Griffiths along the same lines, calling for 95-100 percent of First Nations peoples to be double vaccinated before states and territories open up.
No one should be left behind, so don’t look back
It is hard to argue against the idea that no one should be left behind. So governments haven’t tried to mount that argument.
But they are actually doing something that I think is worse.
They are just ignoring equity as a fundamental principle of moving forward. Commonwealth, state and territory government planning is proceeding with the implicit understanding and acceptance that some people are going to be left behind.
What does it say about us as a society when the issue of vaccine equity has received so little attention?
We are not discussing it in terms of our own vaccination strategy. And we are not discussing it in terms of Australia’s responsibilities to our international neighbours.
I can only presume that the opinion polls are telling our politicians and our media that we can’t wait any longer and that the economy now needs to be at the top of the agenda.
What price are we prepared to pay to avoid waiting just a few more weeks before we get a haircut? Time will tell.
An update on NSW kids and schools
The key ingredients in keeping children safe are:
- vaccinating all children who are old enough
- vaccinating all adults – parents, teachers, grandparents, friends – who children come into contact with
- ensuring that children learn and play in well-ventilated spaces whenever possible
- mask wearing for those children who are old enough.
Schools in NSW will be progressively opening over the next few weeks and the NSW Department of Education has clearly been scrambling to get up to speed. I commented on the Victoria 3V program last week.
NSW appears to have caught up this week by completing a state-wide review of all “windows, fans and ventilation systems in more than 150,000 spaces across our more than 2200 public schools, including preschools, to ensure our schools can operate them as intended.
This included checking:
- 650,000+ windows
- 200,000+ ceiling and wall fans
- 19,000+ extractor fans.
According to their website, the audit “confirms the majority of spaces in schools can be adequately ventilated through natural and mechanically assisted ventilation”. I think this means that it is a good idea to open the windows and turn on the fans.
You can find the individual report on every NSW school at this website.
You can also read a fascinating media report here on San Francisco, where masks are mandatory at schools for children aged two and over. It took only a couple of months for mask wearing to ‘become totally normal’. The results have been stunning: only seven cases of school transmission in the whole of San Francisco this year.
ICYMI, my recent article in the SMH: Take freedom slowly or the cycle of lockdowns will start all over again.
‘They will spread it’: The major flaw in NSW’s new reopening plan.
COVID lesson: trust the public with hard truths.
“The idea that the public is incapable of dealing effectively with the unpleasant truth stymies pandemic management. It leads authorities to communicate in self-defeating ways”.
This article makes the important point that trust goes two ways and that ‘Upholding trust is key: it is the best predictor of vaccine acceptance and an antidote to misinformation’.
Could it be that our Federal and State governments don’t trust us with the truth? Surely not.
Here is the daily vaccination rollout update.
As news of COVID-19 broke around the globe, a small group of scientists jumped into action to tackle one of the greatest medical challenges of our time – to create a vaccine against a virus no one had ever seen before, and to do so in record time, during a deadly, global pandemic. Watch this fascinating documentary on SBS.
If in NSW, listen to this and marvel at how clever and fast some people are in not taking our politicians seriously: Dominic Perrottet – Paul McCratney & Wigs.
If in NSW, ACT or Victoria, now is the time to prepare your own roadmap out of lockdown. My advice is to take it in stages:
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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