Health leaders urge governments to step up COVID control

Pressure is growing on Australian governments to revise COVID-19 management strategies, reports Croakey’s managing editor, Alison Barrett.

Alison Barrett writes:

As we begin the fourth year of the COVID-19 pandemic, public health leaders have expressed concerns about the increase in COVID-19 deaths and overall mortality, supporting calls for a re-set on COVID-19 management policy.

During an interview with ABC TV’s 7.30 report this week, Professor Brendan Crabb, an infectious diseases researcher and Director of the Burnet Institute, called for a re-set of Australia’s COVID management, recommending an “anti-transmission strategy”.

Highlighting the impact of “unfettered transmission” in the community on the elderly and immunocompromised, as well as the prevalence of Long COVID – which is estimated in a recent Nature article to be approximately 10 percent of COVID cases – Crabb said, “in the end, it’s pretty clear the only way to prevent Long COVID is to not get COVID”.

Adjunct Professor Tarun Weeramanthri, president of the Public Health Association of Australia, later told Croakey that he supports Crabb’s call for a re-set of Australia’s COVID-19 management policy, saying the increase in overall mortality “should trigger a rethink”.

Professor Anne Kavanagh, Chair of Disability and Health, in the Disability and Health Unit at The University of Melbourne, supports a COVID-19 transmission prevention strategy.

Kavanagh told Croakey that “because we don’t have mitigation strategies in place to reduce transmission – including safe indoor air, isolation of positive cases and masking indoors – people who are at risk are forced to isolate themselves from community”.

A peak Aboriginal health body, Aboriginal Medical Services Alliance Northern Territory (AMSANT), told Croakey they agreed with Crabb “that the vulnerable are not being well protected given higher death rates in older people, Aboriginal people, people with disabilities and other higher risk groups”. AMSANT also supports a COVID-19 transmission prevention strategy.

Prime Ministerial impact

Speaking to Croakey on 25 January, Crabb emphasised the need to implement a “sustainable, elevated level of action” due to the ongoing and constant impact of the pandemic.

Crabb said that a mindset shift, particularly in government messaging, would be enough to enable some reductions in community transmission.

He suggested that Prime Minister Anthony Albanese “could change the practice of millions of Australians” in subtle ways by changing the narrative and mindset of people.

Crabb said that if the Prime Minister acknowledged that COVID-19 is still a concern and increased messages about the importance of booster vaccinations and air ventilation, it would make a difference.

He said the response to Monday’s interview had been “most positively overwhelming”, with many supportive comments on social media, text or email.

Croakey reached out to numerous health leaders for comment on Australia’s current pandemic situation after Monday’s 7.30 report. While some did not specifically state support for a policy re-set or an anti-transmission strategy, all acknowledged the ongoing impact of COVID-19.

They reported workforce challenges, a need for clarity over additional vaccinations and the need to manage the pandemic with a focus on equity.

“This is an equity issue – you are more at risk of severe disease and death from COVID if you aren’t white, wealthy and educated. Partly this is due to socio-economic drivers of illness – but also due to structural determinants of health,” said Australian Health Promotion Association Victoria-Tasmania Branch Co-President, David Towl.

Global concerns

Ahead of the World Health Organization Emergency Committee on COVID-19’s meeting this Friday, Director-General Dr Tedros expressed concern about the increased number of reported COVID-19 deaths since the beginning of December.

“More than 170,000 people [globally] have died of COVID-19” in the past eight weeks, Tedros told a media briefing.

“While we are clearly in better shape than three years ago when the pandemic first hit, the global collective response is once again under strain,” he said, stating that too many people are inadequately immunised, behind on boosters and that tracking new variants has become increasingly challenging with declining surveillance.

The Emergency Committee on COVID-19 is due to discuss whether to maintain the declaration that COVID-19 is a Public Health Emergency of International Concern.

Aboriginal health sector perspectives

AMSANT said in a statement that they support a COVID-19 transmission prevention strategy.

Aboriginal health services in the NT are “dealing with severe workforce shortages and primary healthcare indicators suggest that service delivery has been impacted significantly” during the pandemic, said the statement.

It had taken a “huge effort” from the health workforce to limit COVID-19 related mortality in Aboriginal people, it said.

“The sector cannot afford another serious wave – services need time to recover.”

Due to high rates of chronic conditions in Aboriginal and Torres Strait Islander people, AMSANT is also concerned about the increased risk of severe acute COVID-19 and Long COVID.

AMSANT suggests a “whole-of-population public health strategy with particular focus on high-risk groups is what is needed”.

Their recommendations for a COVID-19 transmission prevention strategy include:

• a national traffic light approach to public health advice such as the one being used in Queensland and New Zealand
• targeted public education campaigns about long-term risks of COVID-19, booster vaccines and antivirals
• evaluation of communication campaigns to determine effectiveness and how to improve
• encouragement of mask wearing in indoor public spaces
• mask mandates in high-risk areas, such as public transport, airports, essential services, to protect higher risk groups
• government financial support for people to take time off work when COVID-19 positive
• provision of subsidised or low cost N95 masks
• improved ventilation and air flow in higher risk venues where crowding occurs.

AMSANT also called for “more support for the ACCHS system to cope with the increased burden of disease including Long COVID”.

While the Aboriginal Health Council of Western Australia told Croakey they preferred “not to comment on Australia’s COVID-19 management plan for 2023 at this stage”, Chair Vicki O’Donnell emphasised the tireless work the ACCHS sector has provided to deliver vaccinations to Aboriginal people throughout WA.

O’Donnell said they would “continue to work toward achieving high rates of COVID-19 vaccination in all Western Australian regions to protect against severe consequences of COVID-19.”

In addition, they would continue to provide “clinically appropriate treatment and the facilitation of access to COVID-19 testing, including through Point of Care Testing in remote communities. Our sector also continues to provide comprehensive primary healthcare to all patients, including providing preventive health care, chronic disease management and social and emotional wellbeing services,” she said.

Time to update

Public Health Association of Australia President, Adjunct Professor Tarun Weeramanthri provided the following statement in full to Croakey:

“All pandemic plans need updating as new evidence emerges. The National COVID-19 Management Plan for 2023 acknowledges that we are not yet at a ‘steady state’ where it can be managed within ‘normal systems’, and commits the Australian Government to ‘continuous improvement and review of COVID-19 measures’.

Since the plan was released, Australian Bureau of Statistics has released data on excess mortality in 2022, showing a large increase in overall mortality, and the first decline in life expectancy in Australia in living memory. This alone should trigger a rethink and potentially a reset of the COVID-19 Management Plan.

Recent discussion in the media suggests that there are broadly two COVID-19 public health camps. The first ‘It’s not exceptional and it’s over (largely)’ camp is broadly supportive of current government ‘Living with COVID’ policies, and the second ‘It is exceptional and it’s not over’ camp is calling for a re-set of policy. PHAA has members in both camps.

But the truth is, there is a large overlap between the two camps. I would venture that nearly every public health professional believes in principle in a ‘Vaccines Plus’ approach, where the ‘Plus’ includes elements of better ventilation, masking, testing, public awareness etc.

The difference between the two camps is simply on how much to emphasise various elements, and whether to mandate or simply encourage uptake or compliance. (No one is advocating a return to lockdowns.)

As we begin 2023, I believe Brendan Crabb is correct in calling for a re-set of COVID-19 policy. This could be done firstly through a more detailed analysis of the causes of the excess deaths in 2022, so as to sharpen the focus on high needs and more vulnerable populations.

How many of the deaths were directly caused by acute COVID-19 infection, how many occurred in the 30 days post-infection, how many can be attributed to delayed diagnosis (e.g. missed cancer screening) and how many to delays in accessing care because of hospital pressures? All calculations will be estimates, but it’s important to make the data available, even if imperfect, for further analysis.

The second element of a COVID-19 re-set is a risk assessment of the likely significance of new variants.

Taken together, such a re-set early in 2023 would build trust and allow for an informed national conversation to find the right balance and societal trade-offs between health, the economy and other public goods. We should not wait for winter (COVID-19 is not yet a seasonal virus) or the advent of a new Australian Centre for Disease Control (not expected to start till early 2024).”

Leadership matters

Professor Anne Kavanagh told Croakey that relying on vaccination alone to prevent serious disease from COVID-19 is not sufficient to “provide strong protection against infection and transmission”.

“There is a cohort of people – older people, some people with disability and/or chronic health conditions – who are at severe risk of poor outcomes if they become infected with COVID.”

Kavanagh said a greater focus on safe indoor air and masking could help prevent infections and minimise the impact of COVID, but that it was important for politicians and public figures to model what they are promoting.

For example, “it is no good promoting mask wearing if people in positions of power, who are implementing policies, don’t model what they are promoting”, Kavanagh said.

Kavanagh also suggested the need for a better understanding in the general public of the longer-term consequences of COVID and risks to many people in society. “They need to understand the scale of deaths from COVID is many times the magnitude of other infectious diseases.”

While reducing transmission is in the interests of businesses, Kavanagh said the business sector has power and are likely one barrier for the government implementing an anti-transmission strategy.

She said it was “time to have a fresh look at how we are managing COVID in Australia”.

“We need more independent advice. No one is suggesting the restrictions we saw in 2020 and early 2021 but we do need to reduce transmission, increase the proportion of people who have had boosters, and increase access to anti-virals.”

Pressures on emergency services

“Emergency clinicians are currently reporting experiencing some of the busiest shifts of their careers”, according to Australasian College for Emergency Medicine President Dr Clare Skinner.

COVID-19 has exacerbated “systemic issues and pressures which have been building and compounding over decades”, Skinner said.

ACEM supports a “transparent, evidence-based and clearly-defined COVID-19 strategy, which carefully balances a range of considerations, including limiting transmission as well as the impacts of measures on other aspects of health and wellbeing.”

Skinner told Croakey that “balancing management of COVID-19, amid numerous other complex issues and pressures being experienced within the healthcare sector and within communities, will need to remain a core consideration as all involved with healthcare systems seek to navigate and address the significant challenges of today, and the future.”

Prevention and equity are core

Australian Health Promotion Association President, Dr Gemma Crawford told Croakey that “prevention and effective health promotion should be a public health cornerstone for COVID-19”.

“We recognise that like other public health issues, there is now a level of inertia and fatigue related to COVID-19 transmission and prevention, BUT, people are dying. Reports suggest it is currently the third leading cause of death in Australia, surely this is not something to be proud of?”

Crawford said that a “comprehensive approach which puts people and public health first” is needed to address impacts on health, social and workforce. She called for additional support for the public health workforce and “real inroads into the development of the CDC”.

Towl told Croakey that access to testing and treatment was largely driven by health, digital and language literacy, highlighting significant structural barriers.

“You need to be able to physically and financially access a test, have sufficient income for the mobile or Internet data to be able to register your test result (in English and online), and get a GP appointment (from home),” Towl said.

Towl noted a level of COVID fatigue and “little public motivation to change”.

Aged care matters

Aged and Community Care Providers Association CEO, Tom Symondson provided the following statement to Croakey, highlighting the sector was in a better position this year than previous summer holiday period, but they were still experiencing challenges:

“ACCPA supports an anti-transmission strategy which includes people being up to date with COVID-19 vaccinations, the wearing of masks, people getting tested and treatment, and well-ventilated buildings. Aged care providers continue to implement these and other COVID-19 infection prevention measures every day.

ACCPA also supports research to understand the impact of long COVID-19 and other health consequences from COVID-19 and the development of better vaccines.

The latest COVID-19 wave over the Christmas-New Year period did not have anywhere near the severe impact of the previous summer holiday period. This time, the sector was far better prepared with a reliable supply of antivirals, masks, PPE, RATs and access to PCR testing and vaccinations for residents, clients and staff.

The Federal Government late last year committed to continuing financial support for the aged care sector in managing COVID-19 for the foreseeable future.

Staff are more experienced in handling outbreaks and following infection protocols.  Vaccination rates have also remained high.

The industry-designed Visitor Access Code, in place since 2021, provides guidance on visitation in aged care homes where there is an active outbreak, allowing for a nominated Essential Visitor in an aged care home.

The removal of mandates in all jurisdictions has meant the onus is on providers to enforce rules like mask wearing, and RATs before a visit to an aged care home. This has left providers in a position of having to appeal to the good nature of visitors to comply with the rules to protect older, vulnerable residents.

Another negative has been the slow processing of COVID-19 grant payments which has left many providers waiting up to six months to be reimbursed for expenditure on COVID protection.

Finally, the aged care sector is looking to the government for certainty in relation to the timing and availability of a fifth/additional COVID-19 vaccination ahead of the winter season. Ideally, this could be a combined influenza/COVID-19 vaccination.”

See Croakey’s archive of articles on prevention