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VACCINATION alone is not enough to achieve control of the COVID-19 pandemic, experts warn, proposing a raft of measures to avoid a crippling resurgence of disease once restrictions are lifted.
Professor Raina MacIntyre, head of the biosecurity research program at the University of NSW’s Kirby Institute, is one of 48 members of a new independent pandemic advisory group, OzSAGE, which includes experts from fields ranging from medicine and public health to engineering and software design.
“One area that has not been well addressed to date is ventilation and mitigation of airborne transmission, which is the dominant mode of transmission of SARS-Cov-2,” Professor MacIntyre told InSight+.
OzSAGE is calling for a “Ventilation and Vaccine-Plus” strategy for safely lifting COVID-19 restrictions, including urgent ventilation upgrades for schools and businesses, vaccination of children, continued mask wearing and third-dose booster vaccines for front-line health workers.
Other recommendations include mask mandates in schools for K–12 and the approval of rapid antigen home test kits.
OzSAGE also wants a higher target for full vaccination before restrictions ease: 80% or more of the population aged 12 years and over, rather than adults only at 70–80% as currently contained in the National Plan, which the group says corresponds to just 56–64% of the whole population. It has called for specified minimum geographic and population subgroup vaccination thresholds for reopening.
“Without ventilation, vaccine-plus and higher vaccine uptake, reopening at [the proposed] levels will turbocharge COVID-19, as seen in countries that lifted restrictions at about 60% whole population vaccination rates,” the group wrote in a report supplied to federal and NSW government stakeholders.
Pointing to OzSAGE’s “no-one left behind” principle, Professor MacIntyre highlighted inequalities in the vaccine rollout to date, particularly among Indigenous Australians.
“When COVID-19 spread from Sydney to western NSW, the vaccination rate was 7% in Wilcannia, and vaccines had actually been diverted from this part of NSW to Sydney,” Professor MacIntyre said.
“People in residential disability care were actually in phase 1a, so should have been vaccinated early, but were not,” she said.
“Prisoners are another group that concern us, as they are at high risk for outbreaks, but undervaccinated.
“Children are another group who are disadvantaged because those under 12 years will not be eligible for vaccination until at least 2022, when clinical trial results are expected in this age group.”
OzSAGE noted in its report that vaccines are highly protective against severe disease, but also warned that increasing evidence suggests efficacy wanes after about 6 months.
“Our health workforce was vaccinated in March 2021, and its immunity may be waning just as the COVID-19 epidemic in NSW surges,” the OzSAGE report says, emphasising the need to protect the health system.
Scientia Professor Guy Marks, a respiratory physician and OzSAGE member, said that in the short to medium term vaccination alone would not bring an end to the increase in cases.
“Vaccine coverage is not an all or nothing thing,” he told InSight+. “The vaccines will become more effective, we will get more coverage and we will have boosters, but that’s going to take some time.
“In the meantime, we need to do lots of different things – mask wearing, improving ventilation in indoor spaces, retaining some restrictions on mixing,” he said.
Professor Marks said for frontline health workers in south-west and western Sydney, the likelihood that things will get worse before they get better was causing great concern.
“Without the workforce, we won’t be able to deliver the care,” he said. “We need to do whatever we can to prevent a worsening of this epidemic over the short to medium term.
“Anything we do that does not achieve that is going to have serious consequences.”
The NSW Department of Education has announced a staged return to face-to-face learning, starting with kindergarten and year 1 students on 25 October.
OzSAGE’s Dr Greg Kelly, an intensive care specialist and paediatrician, said COVID-19 was most often a minor viral illness in children and less common in children than adults, as evidenced in a new report from the Australian National Centre for Immunisation Research and Surveillance, and others (here, here and here).
“The problem is that, as we’ve seen around the world, if you get a very large number of children infected, you can have kids with severe illness, critical illness and some will die,” he said.
“So what we’re seeing in the US, with extraordinarily high community rates of COVID-19, is they have substantial numbers of really sick kids.”
OzSAGE’s report notes that in Texas, where 52% of the population is vaccinated against SARS-CoV-2, paediatric intensive care units (ICUs) are full and children cannot get ICU beds.
“To avoid these risks, we need layers of mitigation that we can use which we can add or take away depending on how much virus is in the community,” Dr Kelly said.
“We know what works: things such as masking of children and teachers, vaccinating teachers and parents, improving ventilation or buying air filters where that’s not possible, a mix of face-to-face and online learning and rapid antigen testing.”
Dr Kelly said he was optimistic Australia could get the settings right, noting Victorian Premier Daniel Andrews this month flagged that school reopenings would hinge on ventilation assessments and use of carbon dioxide monitors and particle filters.
“We’ve got a tough few months ahead of us, but there are things we know work and we’ve really got to get started on those things,” he said.
“We would hate to see a situation in 6 months where we’ve fallen behind on these things in the way we fell behind on vaccination.”
A NSW Department of Education spokesperson said that in preparation for all students and staff returning to school, the department has begun a systematic review of the suitability of all learning spaces.
“The Department of Education is working closely with NSW Health and following its advice to ensure that schools comply with restrictions, protective measures and ventilation requirements,” the spokesperson said.
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The current emphasis on vaccination is great but in the longer term shouldn’t we be urgently building remote quarantine stations in each state? Hotel quarantine has always been a makeshift solution and has been the source of all of our outbreaks. Home quarantine can’t be standardised or supervised like remote quarantine and will leak eventually. If we make purpose-built remote quarantine the first line of defence against imported viruses and continue with a vaccine-plus strategy to quickly contain the few local outbreaks that might occur, we will be able to return to almost-normal life. We need to learn from the mistakes of the last two years rather than continuing to repeat them.
Ventilation has been put in the too-hard basket because so many modern buildings do not have windows that open and the emphasis is on minimizing air transfer to reduce heating/cooling costs. But we might need to get back to jumpers and fans, and let the breeze blow through. We have a nice climate most of the time in most parts of Australia and could be doing more things outside. So many of our shops, offices, service-providers premises are basically like upside down fish tanks with little doors that open briefly to let people in and out. Crowded pubs and restaurants have air like exhalation fog clouds – germ traps! And don’t get me started on public transport – eww. Bring back the old W-class trams with their open windows and the red rattler trains! Just kidding but we seem to have forgotten about the need for fresh air. How did we do that?
The residential strata sector has tried over 18 months to get NSW Health and Fair Trading to engage on more communication and covid safe plans for apartment buildings. It has all fallen on deaf ears, and measures applied to many public and commercial facilities are not applied to private strata despite the enormous size of these complexes. it is really common now to have high rise with residents dependent on lifts, narrow hallways, indoors gyms, spas, saunas and pools. It is not a simple case of ‘closing the facilities’ or pass by-laws – often when hard working unpaid Strata Committee try to do the right thing they are subjected to pressure from residents who have a right to access their own property. What will happen now as we move toward 70 – 80 % vaccination and facilities open up, unless the Orders apply equally to these private setting these residential communities will be faced with having to deal with the anti-vaxxers and vaccine hesitant.
I don’t actually disagree with the substantive message or content of this, but I don’t think it’s appropriate that it be published here, glowing about this group, without disclosing that the MJA EIC is a member of the group being talked about.
Please add a COI disclosure.
Well the ventilation issues in public buildings & apartment blocks & on public transport have to be addressed? Masks inside in all public buildings as in Italy for example.
Also hospitals have to be funded more. As it is Hospitals weren’t coping before the pandemic – long waiting lists for elective surgeries in public system, ambulance ramping outside Emergency Departments, too few nursing staff per person in both public and private hospitals. And probably a lot of other problems that, as a consumer, I don’t know about. Now there’s more obvious distress in the health system.
There is something to be learned and changed about the LGAs of big cities who are the engine rooms of our country. And I’m not informed to enough to how things work in those LGAs to have an opinion other than ‘things’ have to be changed so that we never again see the police and army enforcing lockdown on suburbs full of hard working people, many from big families. This element of lockdown was/is a disgrace.
I am however very against surveillance of the public, other than QR code’s. I’m very worried about govt/police of abuse of these systems. Govts are given an inch, but then take a mile. We know that.
And we need some recognition that humans aren’t designed to live long periods of time away from fellow humans. I believe there will be social consequences, & not only immediately but impacting on the future – increased Domestic Violence and Child Abuse, terrible reality of not having enough money to pay rent, put food on table, pay other bills. We need to start at a base level of universal basic income of liveable amount so families are healthier, less stressed before lockdowns. And then to create living standards that see only very limited need for lockdown. A last resort. Not a first resort.
This isn’t just about virologists, epidemiologists and medical practitioners having input. This is wider ranging – a whole examination of how we live in this society should also include sociologists, town planners, architects, historians, educators and plenty more that I haven’t considered here (and that others would see the need for) as well as citizens from all backgrounds. Pandemics don’t work in high rise big cities with centralised work forces. It’s not only pandemics we have to plan for, but how we mitigate but live with increasing effects of climate crisis.
No mention at all of the second greatest risk factor for poor covid-19 outcomes, other than age – obesity. There is no downside to losing weight, exercising and eating better. Heck, this might even free up some non-covid beds.
Anonymous refers to “delayed elective surgery” and “delayed cancer screening” as effects of lockdown.
They are even bigger problems without lockdown and when “living with Covid”.
As a Cardiothoracic surgeon I can probably comment. In Melbourne last winter we kept all category 1 surgery going during the lockdown and within the time limits (4 weeks).
My colleagues in Sydney are already not able to do all of the Category 1 cases, and it will get worse there before it gets better. Operating room nursing staff are being moved and rapidly retrained for the ICU.
Patients are even less likely to come for cancer screening with poorly controlled disease in the community than when a lockdown is present but seeking medical care is permitted. And if a cancer is found they will have longer delays to get surgery.
And additional point, relevant to the ‘overwhelmed’ paediatric ICUs in Texas, Louisiana, Florida etc. – and not to diminish the (v.low) risk of severe Covid in kids – but there has been a recent surge of RSV in these Southern States.
A proportion of the ICU cases are due to severe RSV alone or co-infection of RSV & Covid – which in combo with severe Covid alone are leading to an overwhelmed system.
Clearly we should aim for high vaccination rates of all 12+ years old, not just ‘adults’ (16+, as per the National Plan).
And we should figure out how to Open Schools safely – noting that the best way of preventing infection in pre-teens is for the adults around them to be vaccinated against Covid.
With respect, trials in the 5-11 yo age group are expected soon, and certainly this year (not 2022 as stated). Results for 6m-2yr and 2-5 are a bit further behind. For comparison, pre-Covid Influenza vaccination was recommended for all 6m-5yrs, but uptake rates were only ~44%. It will not be reasonable to mandate ongoing Lockdown until ‘all of population’ & age based sub-populations reach 80%. It will be a matter of balancing priorities.
In addition to prior measures, I’ve up graded my waiting and consult room with air purifiers (HEPA 13 std) & measured Air Changes/Hour – but portable CO2 is a good surrogate. I suggest others do likewise, schools as well.
The points about other diseases in Lockdown are relevant – link to the actual data is below.
Excluding deaths from Vic2020 spike, excess mortality (any Cause) was Reduced for most of 2020, due to Lockdown and Travel Restriction reduction in respiratory infection (pneumonia+ & Influenza+++) as well as reduction in AMI/stroke++ (plaque rupture & events are known to be triggered by RTIs etc.).
From mid-Nov 2020 & continuing, there has been an increase in deaths, related to the effects of Lockdown and/or deferred healthcare – the relative contributions cannot be determined from this info, but the data are clear.
https://www.abs.gov.au/statistics/health/causes-death/provisional-mortality-statistics/latest-release
Agree that can’t simply open up without some restrictions. However, the current range of restrictions cannot continue. They destroy people and the economy. The marginal restrictions that have little benefit detract from and lead to non-compliance with restrictions that really matter. Importantly how about some analysis and comment on transmission in outside areas and the cost/benefit of restrictions on outdoor activities. Some restrictions are plainly non sensical eg. can’t travel 20k to play golf with 3 others all wearing masks but can go to the local beach and mix with thousands, many with no masks as they pretend to drink or exercise.
These people seem to be focusing on the virus, with no obvious attempt to take into account the collateral damage to health from lockdowns – delayed elective surgery, delayed cancer screening, interrupted schooling, and the impact on jobs. (Unemployment leads to a measurable increased risk of suicide as well as poorer health.) Secondly I see no reference to the structural issues which are hugely important – virus spread is strongly influenced by the age of the population, health of the population, quality of public health and clinical health services, density of housing, and use of public transport. That’s why Sydney and Melbourne were never going to be like London and New York, and why all the little recognised and unrecognised outbreaks outside our major cities fizzle out regardless of government action. The current patterns in Sydney and Melbourne should be managed via a hot spot strategy with lesser restrictions everywhere else. City-wide and state-wide lockdowns are unjustifiable and unethical.
certainly better ventilation should be everywhere especially openable windows in buildings and transport,which have been neglected in recent times presumably due to cost.
Repurposed medications that have effective antiviral action and that reduce transmission of Covid-19 must be permitted in Australia for early treatment of Covid-19. These are needed to prevent severe illness and deaths from Covid-19 and to reduce preventable deaths from other illnesses due to lack of public hospital beds and staff, particularly ICU’s.
Either education matters or it doesn’t.
How many years of school is it fair to ask a child to give up in order to save her grandparents?
Their lifespan is months to a few years: hers is decades; potentially blighted forever by closed schools (already in some places comprising a big slab of nearly 2 years).
Forget your overseas travel.
The primary focus should be on getting the kids back to their education, even if that means running some risks for the rest of us.
Boosters will be important. Hopsital workers in California exhibit decreasing efficacy of vaccine. Is this a dosing interval or vaccine ? But boosters will be important form 2022
The road has been made longer by some very bad decisions, but the destination is the same. Safe resumption of a new normal based on low covid levels, a highly vaccinated population, new engineering control in buildings as well as sensible public behaviours.. Sadly the promise of so called freedoms is a politically driven misnomer.
It is time to translate the research and medical advice into how we plan and renovate hospitals. For too long hospitals have been designed to minimise the cost of construction(”you cannot exceed the construction budget so cut out the store rooms and offices”) rather than delivering clinically relevant facilities, accessible by all patients when they need them.
Retrofitting ED’s to have better ventilation, solid barriers between patients, better staff facilities,increasing ICU beds beyond the 1990 benchmark standard and numerous other changes are necessary. Clinically appropriate facilities protect our medical and nursing staff, reduce fatigue and risk and reduce patient to patient transmission. Access to safe hospitals is a national issue. We need a national solution so all clinicians are safe at work in hospitals.
Next the research and medical advice needs to be translated for private buildings, such as high rise apartment blocks, dense private housing with no back yards and planning our suburbs.
Totally agree, especially for populations that have been left behind in the rollout, for whatever reason.
We need to think about all measures that can reduce the risks for everyone.
We need a leader who knows the difference between a firehose and a photo opportunity.
With the current numbers of COVID cases in Sydney especially other states must not open their borders! Even with 80% or more vaccinated this will create a disaster as COVID will spread like a wildfire. Vaccines are a short term solution at best.