Introduction by Croakey: The ongoing Sydney Delta outbreak has sent shockwaves across Australia — and, indeed, the Tasman — forcing a volte-face on elimination ambitions in favour of a so-called “living with COVID” strategy.
The New South Wales Government’s vaccine-driven plans to start easing restrictions, even as it continues to report more than 1,000 new cases a day and ICU capacity comes under strain, has stoked tensions at National Cabinet, where the leaders of several states with no local transmission have urged caution.
The NSW Government this week released modelling by the Burnet Institute on the likely trajectory and burden on the health system of the ongoing Sydney third wave, estimating that – with restrictions and vaccination trends remaining at present levels – the state’s COVID hospitalisations will peak in late October at around 3,500, with occupancy of 950 ICU beds.
At this peak, the modelling warns there will be “overwhelming impact” on the usual daily operations of ICU, requiring higher patient-to-staff ratios, and surging of critically ill patients to non-ICU spaces such as operating theatres as well as to private hospitals. According to the model, hospitals in several areas of Sydney are already reaching maximal ICU operational capacity.
Groups including the AMA and Australasian College for Emergency Medicine have urged the federal government to consider the wide-ranging impacts of paring back restrictions across an already-stretched health system, with surge planning and extra resourcing needed across the whole spectrum of care from general practice to the acute setting.
Said AMA President, Omar Khorshid:
Our hospitals are not starting from a position of strength. Far from it. As well as ambulance ramping, we have the lowest bed-to-patient ratio in decades, our emergency and elective performance continues to decline, and our doctors and nurses continue to barely cope with their workloads and the constraints of the system..
Too often we hear tragic stories of late-stage cancer diagnosis, emergency treatment delayed and sadly, avoidable deaths all resulting from an overworked system. This is only going to get worse with COVID and we cannot afford to wait any longer.”
John Bonning, President of ACEM, said “whole of system planning, including support for primary, community, ambulance and emergency department care, is needed”.
As vaccination rates increase and communities look to open up, it is crucial that all healthcare systems across our two countries are properly prepared for the likely increase in COVID-19 cases, while also supported to continue providing ‘business as usual’ care to acute patients, who we know will continue to need treatment in emergency departments.
While much of the public discussion has focussed on ICU capacity, staffing and ventilators to treat critically ill COVID-19 patients, there is a need to make sure that the whole healthcare system is supported, to ensure patient care is not delayed, and that an already strained and stretched workforce is kept as safe as possible.
ICU requirements are the tip of a very large iceberg in terms of the parts of our healthcare systems that will continue to feel the significant impacts of treating more COVID-19 positive patients, while also seeking to provide timely and appropriate care to all other patients.”
Workforce planning, including guidance around exposures, furloughing, PPE and rapid testing, and modelling which considered the very real impact on throughput and patient flow of stringent infection controls in COVID hospitals, were all essential, Bonning and Khorshid said.
Bonning also underscored the “importance of all governments focusing on equity of vaccine access and uptake, particularly in areas and regions where vaccination rates may be lagging. This must include vulnerable community members and all Indigenous communities across both countries.”
As this piece in The Conversation details, many health care workers are already under strain due to the pandemic and, as evidenced in experiences overseas, are at significant risk of burnout in coming months.
With these issues in mind, an independent, multidisciplinary group of experts convened recently to consider what more could be done to allow Australia to ease restrictions while minimising harm.
Calling itself OzSAGE, after the UK’s Independent Scientific Advisory Group for Emergencies (Independent SAGE), the group plans to collate and offer up-to-date, evidence-based advice on the key elements of Australia’s post-elimination transition, looking beyond health system impacts to consider whole-of-society actions.
In this piece for Croakey, advisory group members Dr Benjamin Veness and Professor Nancy Baxter outline the OzSAGE vision for life beyond lockdown.
Benjamin Veness and Nancy Baxter write:
Last week, the Australian Scientific Advisory Group of Experts (OzSAGE) officially released its first advice paper and high-level recommendations for the safe opening of Australia, to complement the National Plan to transition Australia’s National COVID-19 Response.
OzSAGE is a diverse, multi-disciplinary network of Australian experts. We seek to be a trusted resource for federal and state governments and parliaments, businesses, health, education, community and non-government agencies in Australia.
We will formulate independent advice on public health, health systems and other policy matters relevant to COVID-19 control, underpinned by the best scientific evidence, modelling and by our values and principles.
Inspired by the UK’s Independent Scientific Advisory Group for Emergencies (Independent SAGE), all OzSAGE members are volunteering their time and expertise with a view to improving the effectiveness of Australia’s pandemic exit plan.
We are guided by the values of respect, diversity and inclusion, justice, equity, transparency, authenticity, compassion and solidarity.
We use the precautionary principle, ethics, use of real-world examples and understand that recommendations may change over time as evidence or needs change.
The case for ventilation
Our paper notes that control of COVID-19 results in better health and economic outcomes.
Recognising and accepting that SARS-CoV-2 is spread predominantly through the air we breathe, providing advice on ventilation and filtration of indoor air has been prioritised.
Improving ventilation is critical, both because vaccines are not 100 percent effective in preventing transmission of SARS-CoV-2, but also because clean air offers health and cognitive benefits beyond COVID-19 prevention.
For children currently not eligible for vaccination to return safely to early learning centres and schools, it is imperative that governments mandate indoor air quality assessments and improvements.
The Premier of Victoria made a preliminary announcement last Friday to this effect, which we applaud and encourage other governments to adopt.
Of note, the ventilation in NSW Parliament has been assessed and improved to ensure eight air changes per hour. Similar work needs to happen throughout other indoor spaces to protect us now, and building codes must be changed to future-proof our society for the next pandemic.
Priority populations
Indoor air quality is also relevant in considering how the COVID-19 pandemic has once again demonstrated the importance of social determinants of health.
Just as crowded living conditions have been linked to transmission of other diseases, we are now seeing an alarming outbreak of COVID-19 in Wilcannia, NSW, with at least 13 percent of the total population already infected. With the Delta variant as infectious as it is (estimated R0 of 6.4), crowded indoor living conditions are ripe for producing a high secondary attack rate, especially because as more and more household members fall ill, it becomes increasingly difficult for them to isolate from uninfected persons.
Similarly, tragic outbreaks in inpatient psychiatry units in Sydney, such as the Nepean cluster, serve as a reminder of the increased vulnerability of people with mental illness especially in group residential settings.
Even prior to the pandemic we knew that “individuals across the entire spectrum of mental disorders have substantially reduced life expectancy compared with the general population”.
Data from the US published at the start of this year indicated that people with schizophrenia were almost three times more likely to die from COVID-19 than controls, even after adjusting for demographic and medical risk factors. In the end, a diagnosis of schizophrenia was second only to age as a risk factor for death from COVID-19.
Mental illness need not necessarily confer increased risk, but addressing this problem requires increased attention to the social and economic factors affecting this known high-risk group.
OzSAGE will help to identify other high-risk groups in need of additional intervention, and make commensurate recommendations necessary to ensure they are not left further behind in the race to open up.
Vaccine-plus
Vaccination targets, for example, need to consider relevant subgroups and not just total populations at national, state or local government area levels.
Contrary to the National Plan, we have called for at least 80 percent of the population 12 years and over to be vaccinated prior to lifting restrictions. There are signs that some territory and state leaders (and chief health officers) already share this view.
If expressed as a proportion of the total Australian population (a more helpful figure for many reasons including that it better facilitates comparison to peer nations) this target equates to 68 percent of all Australians being vaccinated. This would be significantly safer than the current national target of 80 percent of the population 16 years and over, which is only 64 percent of all Australians.
The current target ignores the fact that 12-15 year olds now have a safe and approved COVID-19 vaccine available to them, and risks creating the perfect conditions for more transmission events within, and seeded from, high schools.
With the currently-available vaccines and Australia’s limited two-dose schedule, even at 68 percent vaccine coverage of the total population, we will not achieve herd immunity.
OzSAGE therefore recommends ‘Vaccine-Plus’, which means vaccination plus other non-pharmacological interventions beyond the aforementioned ventilation and filtration.
Key amongst these is well-fitted face masks, which all persons aged two years and above should wear, as recommended by the American Academy of Pediatrics.
Boosters and PPE
For vaccinations, we also note emerging evidence from countries like Israel, who have seen waning immunity approximately six months post second dose.
Given the critical importance of maintaining health system capacity while trying to catch up on vaccinations in the broader community, OzSAGE urges that third dose ‘boosters’ for health care workers be considered as a priority.
This month, health care workers vaccinated in Phase 1A of the initial rollout will start reaching six months post second dose, placing them at increased risk of infection and transmission (to colleagues, patients, their own families and the community) just as the latest surge of cases hits hospitals hardest.
In the meantime, it is more important than ever that health care workers be provided with adequate personal protective equipment (PPE), which includes respiratory protection at least to P2/N95 respirator standard.
Forward-thinking health managers at sensitive settings like The Royal Children’s Hospital Melbourne have already recommended staff wear fit-tested P2/N95 respirators for all patient interaction, which OzSAGE strongly supports.
Similar change should have already occurred in NSW Health facilities; any supply concerns could be addressed through use of reusable elastomeric or powered air purifying respirators, which are — in any case — likely to confer even better protection than P2/N95 respirators.
Our initial report expands on all of these points and includes a range of additional recommendations.
In offering our expertise freely to the Australian community, it is our goal that a lack of knowledge and expertise is no barrier to an improved pandemic response.
We have sufficient evidence-informed tools at our disposal to minimise morbidity and mortality from COVID-19 while simultaneously avoiding protracted and severe lockdowns.
Decision-makers, at all levels of all sectors, have a choice. They can listen and act, or continue to watch and wait.
Dr Benjamin Veness is a child and adolescent psychiatry registrar in Melbourne and holds a Master of Public Health from the University of Sydney.
Professor Nancy Baxter is a colorectal surgeon and epidemiologist, and head of the Melbourne School of Population and Global Health at The University of Melbourne.
Both Dr Veness and Prof Baxter are executive members of the Australian Scientific Advisory Group of Experts (OzSAGE).
See Croakey’s archive of stories about COVID-19.
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