Experts gathered in Canberra recently to discuss the importance of interventions to promote clean air, for preventing COVID and other health problems.
Alison Barrett writes:
COVID-19 and other airborne threats were the stimulus behind a Clean Air Forum held at Parliament House last week, according to participants.
The Clean Air Forum hosted speakers from a range of sectors including public health, infectious diseases, engineering, architecture, economics and the law to discuss the issue of clean indoor air with parliamentarians, “suggest solutions and generate debate”, according to Dr Bronwyn King, who spearheaded the event.
King, radiation oncologist and CEO of Tobacco Free Portfolios, told Croakey by email the Forum was advocating for increased awareness about the benefits of clean indoor air, for health, academic performance and business productivity.
“We would like to see clean indoor air become a priority issue,” she said.
Meanwhile, the latest analysis by Actuaries Institute’s COVID-19 Mortality Working Group has confirmed that “20,200 more deaths than expected” were recorded in 2022, similar to predictions reported last month.
The group found that excess mortality was 12 percent higher than pre-pandemic expectations, and over half the excess deaths were from COVID-19.
COVID-19 was the third leading cause of death in Australia in 2022.
Based on advice by the Pharmaceutical Benefits Advisory Committee, Health Minister Mark Butler announced expanded eligibility for COVID anti-virals last week.
Effective 1 April, PBS-subsidised COVID anti-viral Paxlovid is now available to people aged 60 to 69 years with only one risk factor; previously two risk factors were required.
Butler said about the update, “if you’re newly-eligible for the oral antiviral Paxlovid, I encourage you to talk to your doctor or nurse practitioner and develop a plan for if you test positive.”
No other changes were made to eligibility for people aged 70 years and over, Aboriginal and Torres Strait Islander people, immunocompromised people and people in their 50s with two risk factors.
(Read to end of this article for further commentary on the issues surrounding wider anti-virals use, by Professor Linda Slack-Smith, an epidemiologist at the University of Western Australia).
The Clean Air Forum was supported by the Parliamentary Friends of Preventive and Public Health Co-Chairs Dr Helen Haines and Dr Mike Freelander, as well as Assistant Minister Ged Kearney and Dr Michelle Ananda-Rajah.
It aimed to have experts from around the country inform MPs and Senators about the importance of clean indoor air, and to “identify opportunities, challenges and explore next steps”, said Freelander – an experienced paediatrician, MP and Chair of the Standing Committee on Health, Aged Care and Sport.
He told Croakey via email that while the event was separate to the Long COVID Inquiry of which he is Chair, the inquiry had received submissions “from experts concerned with indoor air quality and the impact it has had on the transmission of COVID”.
“Clean air is important not just for aerosol-spread viruses such as COVID, but for other respiratory illnesses such as asthma,” he said.
Professor Guy Marks, a respiratory and public health physician, stressed that clean air is a safety issue including and beyond COVID.
“The stimulus was COVID, but there was a strong push including from me and many others that this was beyond COVID,” he told Croakey.
Laureate Professor Nick Talley said the health issues associated with indoor air included COVID and other respiratory pathogens, as well as chemical pollutants and fire smoke.
“I think COVID just brought it to the fore. COVID just made it clear that we’ve been missing this,” Talley told Croakey after the event.
If we did more about indoor air, “we would likely reduce significantly the burden” of associated illnesses and deaths, he said.
A study by the World Health Organization found that approximately 3.2 million deaths in 2020 were caused by household air pollution.
Sociologist Professor Deborah Lupton echoed the concerns raised by Marks and Talley, describing the Australian cities “that were blanketed [with smoke] during the Black Summer bushfires [in 2019-20]”.
Solutions already exist
Speakers at the Forum said many of the solutions to addressing indoor air quality already exist.
Lupton told Croakey that in relation to many other public health problems, this is “not as wicked as some of the others”.
“The words ‘low-hanging fruit’ were used quite a lot across the day,” she said. “There are fairly easy and inexpensive ways and creative ways to solve this problem.”
Talley said some measures discussed in the sessions and conversations included HEPA filters and making sure buildings aren’t “ventilating with pollution from outside”.
Public education is also an important part of the solution, Talley and Lupton said.
Public health response
At the Forum, Marks spoke on the public health aspect of improving air quality, describing three levels to control airborne threats to health: at the source, the air and the receiver.
The best strategy for controlling threats from airborne contaminants is at the source; for example, by isolating infectious people, or by preventing bushfires from occurring, said Marks.
The next best strategy after controlling airborne threats at the source – and the topic most relevant to the Forum – is managing indoor air in settings including homes, workplaces, aged care facilities, hospitals, and transport, Marks said.
The third strategy is protecting the receiver with measures such as personal protective equipment or building up resilience in a person through good nutrition or vaccinations etc.
Epidemiology comes in to identify the problem and the cause, “but the solutions [to manage indoor air quality] are in the hands, outside of the health system, of engineers, architects, and building and urban planners and regular legislators”, he said.
“We need to change our perspective on what’s possible to do,” Marks said.
Conducted by the City of Melbourne, this tested three scenarios of ventilation over three months – “opening windows, installing building integrated ceiling fans, and bringing air down to floor level instead of from above”.
The study found that all three scenarios “reduced the potential transmission of airborne viruses when compared to standard ceiling-based air conditioning”.
Displacement ventilation – bringing air down to floor level – was the most effective and energy efficient system tested. It was also the most expensive to install.
Hes told Croakey these findings “will hold true” for other airborne threats to health, including smoke and pollen.
“If we retrofit buildings to reduce energy consumption and improve air quality to meet climate change and emissions targets by 2040, then we have the capacity for the creation in Melbourne of 12,000 jobs and add $2.7 billion to the economy,” Hes said, referring to the Zero Carbon Building discussion paper.
Several participants told Croakey they felt hopeful about the opportunities for improving indoor air quality.
Marks said he appreciates the Parliament’s approach to public health – “it is clear that there are now in Parliament tremendous advocates for this issue…in a way that there has not been before, which is great”.
King said speakers at the Forum had agreed to ongoing collaborations, “to help map out steps towards making Australia a leader in clean indoor air”.
COVID anti-viral treatment: an expert view
Professor Linda Slack-Smith, social epidemiologist at University of Western Australia, provided the following response to Croakey in relation to the updated anti-viral eligibility as well as an overview of some of the barriers and equity issues.
Slack-Smith noted that prior to the expanded eligibility, some eminent people in the area disagreed on access to anti-virals, and that when she searched for “antivirals Australia” online, the Department of Health’s website has not been updated with the new anti-viral conditions. ABC has published updated information here.
Pros and cons of expanding eligibility
“Advantages are that more people may be able to benefit from the anti-virals. Where they are effective this may reduce morbidity, burden on health system and potentially long covid and other outcomes known to be exacerbated after covid infection.
Some of the decisions are around supply and priority populations rather than reducing risk in the broader population. Given issues with supply and the use of costings, it would be good to be clear on what costings are based and how decisions are made about priority access.
For example, do these costings account for long COVID and the uncertainty of long-term outcomes for COVID? We are only recently understanding viral influence on multiple sclerosis for example after many years of intensive research.
Disadvantages include how this is framed. It may be seen that anti-virals and vaccination are adequate in dealing with COVID-19 – then there is a risk this then takes the focus off other upstream prevention such as clean air and using masks indoors and although of limited effectiveness, handwashing.
Many people in aged care will not access antivirals as they are asymptomatic, arranging COVID testing ad hoc and often only RAT tests – yet we are not moving on options such as cleaner air.”
Inequity and barriers
“It appears from statements made that access is limited in part due to supply issues.
I am always concerned about treatment options available through wealth and privilege and it is likely this is happening with antivirals – which means some people are missing out.
Barriers to accessing anti-virals include inadequate communication about availability and details of anti-virals (different types with different strains) and suitability, current evidence.
One of the problems is people need to know they have the disease – given use of RATS is now more common, there is likely to be a longer delay in testing positive (when compared to PCR) and RATS are not always effective, also varies between strains of SARS-CoV-2 and types of RATS.
There appears to be a socio-economic gradient; for example, private scripts are likely more available to higher SES groups as they have access to money and knowledge of how to access.”
“Anti-virals are downstream prevention – so the person already has the disease and if using RATS may have had for longer before detection than if using PCR.
So the person is still exposed to virus and the long term risks, needs a medical certificate to access anti-virals – impacting on health services strain and increasing risks of exposure (including vulnerable at health service) and access to script will likely be affected by SES
Developing and testing antivirals takes time and there is still the need for more options in anti-virals and more effective anti-virals.
While medical innovation such as anti-virals are fantastic and save countless lives, when we think about the type of world we want to live in, some may argue that a civil society is focused on prevention not cure.
It is important to have such tools but as a society dangerous to rely on a pill to fix everything.
We have unknown long-term impact (including long and middle covid), burden on healthcare system (referrals needed urgently) and burden on our planet – treatment could be argued to impact climate change more than prevention.”
See Croakey’s archive of articles on COVID-19