COVID-19 landscape shifts: the good and bad news

THREE months on from the release of OzSAGE’s initial advice document, the COVID-19 landscape has shifted significantly. There is both good and bad news to dissect.

OzSAGE is an independent, multidisciplinary network of Australian experts from a broad range of sectors relevant to the wellbeing of the Australian population during and after the COVID-19 pandemic. It was formed in August 2021 and we released Advice for lifting COVID-19 restrictions in Australia on 2 September. Our advice focused on “safe indoor air” (ventilation) and “vaccines plus” (vaccination plus testing, contact tracing, quarantine and isolation, well fitted face masks, and other non-pharmaceutical strategies) as the pillars of safe lifting of restrictions, which was a priority of the Australian community at the time.

The good news

The good news includes that double-vaccination rates across Australia are now tremendously improved.

The Commonwealth’s daily vaccination data report of 2 September showed 7 512 554 people were double-vaccinated; by 2 December, that had increased to 18 858 241. More than 11 million additional people (including over 800 000 12–15-year-olds) have reached double vaccination in the space of only 3 months, raising the total population double vaccination rate from 29.2% to 73.4%.

There is also now sufficient supply of mRNA vaccines such that access is no longer restricted to younger persons. The reduced use of Vaxzevria (AstraZeneca) means that we should not expect any further vaccine-linked deaths due to thrombosis with thrombocytopenia syndrome or immune thrombocytopenia, of which the Therapeutic Goods Administration (TGA) has reported nine. Myocarditis and pericarditis have been associated with the mRNA vaccines, however there have been no deaths in Australia and the TGA notes that: “Myocarditis is seen much more commonly in people who have become infected with COVID-19 than in people who are vaccinated.” Unfortunately, increased supply has come with increased wastage, with doses of Spikevax (Moderna) literally being tipped down the sinks of pharmacies rather than being redistributed or given to competent patients seeking booster doses.

Other welcome changes since OzSAGE launched include two significant decisions of the Australian Technical Advisory Group on Immunisation (ATAGI), both regarding third doses of COVID-19 vaccines.

First, ATAGI announced on 8 October a recommendation for third primary doses in individuals who are severely immunocompromised. Second, ATAGI announced on 28 October a third dose “booster” program for all adults who completed their primary COVID-19 vaccine course at least 6 months ago. At 2 December, across these two groups, 470 000 people had received a third dose (1.8% of the population). For comparison, Singapore is at 27%.

On 29 November, OzSAGE released advice on the Omicron variant, strongly recommending boosters and encouraging them to be made available earlier. The UK recently expanded access to third dose boosters to the entire adult population, and halved the minimum gap between second and third doses from 6 to 3 months, in response to Omicron. ATAGI were asked to consider the matter and on 3 December announced a slight relaxation to permit boosters after only 5 months if “logistical reasons” apply. Even if Omicron does not become the dominant variant, OzSAGE believes high third dose coverage would be to our national benefit.

Finally, there are positive signs from some state governments that the science is cutting through. States have responsibility for key COVID-19 policy, particularly in the education and health sectors. Many have now overtly accepted that SARS-CoV-2 – the virus that causes COVID-19 – is transmitted primarily by aerosols that float in the air. These signs are seen in announcements regarding schools, but unfortunately less so for other indoor settings where aerosol transmission also occurs. Nonetheless, this is a critically important shift, as without accepting that the virus lingers in the air of poorly ventilated environments, similar to cigarette smoke, we cannot focus resources and the public’s attention on the interventions with the biggest impact.

Victoria has been the leading state in this regard, starting in November 2020 with public health messaging (here and here) that promoted meeting and socialising outdoors. In 2021, the Chief Health Officer has been even clearer: by June he was making statements at press conferences that fomite transmission (ie, transmission via contaminated surfaces) in clothing stores is “very unlikely” and that “airborne transmission” is not prevented by perspex screens.

When developing its return to school plan, the Victorian Government led the country in announcing on 22 September a multilayered risk mitigation plan that included vaccination, masks, ventilation assessments, carbon dioxide monitoring (used as a proxy measure of indoor air quality) and the purchase of 51 000 air purification devices. The following month, they also announced grants to help improve ventilation in Victorian not-for-profit kindergarten services.

Other states have partially followed suit, with a plan to at least ensure classroom windows can be opened in New South Wales public schools, which is better than nothing, but falls well short of OzSAGE’s advice for schools and childcare. Key gaps include the lack of mask mandates and continuous carbon dioxide monitoring in school rooms, particularly in primary schools where children are not yet vaccinated.

News from states such as Queensland has been less promising, despite OzSAGE member and one of TIME magazine’s 100 most influential people of 2021 Professor Lidia Morawska’s local advocacy.

The bad news

While the improvement in Australia’s overall vaccination rate is commendable, the rhetoric around the vaccine rollout has been highly politicised and misleading.

Even senior clinician-scientists and veteran broadcasters speak of us having “86% of the country vaccinated” and “86% of people in Australia [double-vaccinated]”. These figures would be accurate if we were only concerned about persons over 16 years, which was the original cohort approved for vaccination. But the country has 25.7 million people, of which over 5 million are aged under 16 years.

As inconvenient as it is, people of all ages are vulnerable to COVID-19, and they are all capable of transmitting the virus. From both a moral and pragmatic standpoint, it is important that we aim to protect all Australians and that we speak accurately about the vaccine rollout. Inaccurate statements risk lulling the population into a false sense of safety and security, and not holding government leaders to account.

Whereas claims of “86%” sound impressive, Australia’s actual double vaccination rate of 73.4% gives a better indication of just how many people lack sufficient protection against severe disease or death. The 26.6% of the population who are not double vaccinated equates to almost 7 million Australians, or more than one in four of us. In this light, “strollout” impresses as an apt choice of Australia’s “word of the year” by the Macquarie Dictionary, especially given the latest variant of concern, Omicron.

While under 12s remain ineligible for COVID-19 vaccination in Australia, we should be aiming to get our vaccination rate as close as possible to its theoretical maximum of 85.1% (that is, the proportion of the Australian population over the age 12 years). The current 11.7 percentage point gap between 73.4% and 85.1% translates to 3 million people. Singapore is at 87%, so it can be done.

If we were like the US, Canada, and Europe in having approved vaccination of children aged 5–11 years, then we could be aiming for 94.0% of the population because Australia has almost 2.3 million primary schoolers about to start a long summer break. In the US, where vaccination of children aged 5–11 years was approved on 2 November, over 3.5 million primary schoolers (approximately 13%) have already received their first dose of Comirnaty (Pfizer). In San Francisco, where children aged 2 years up wear masks in indoor public buildings, it took only three weeks for 30% of 5-11 year olds to roll up their sleeves.

Another group that has been of particular concern to OzSAGE is Aboriginal and Torres Strait Islander people. One of our guiding principles is that no one be left behind. But as Australia has begun to open up, it has become apparent that there are people who are missing out. Such groups will be particularly vulnerable if states persist with their plans to scale back contact tracing, mask mandates and other important public health measures (here, here, and here).

Australian health care workers are also vulnerable, in a different way. Despite the aforementioned improvements in recognition of airborne transmission of SARS-CoV-2 by some state governments and chief health officers, the national Infection Control Expert Group (ICEG) continues to state that airborne transmission is only likely in “specific circumstances”. Accordingly, ICEG’s guidance still fails to recommend use of fit-tested N95 or P2 respirators for all patient care in any clinical setting with known community transmission of SARS-CoV-2. This currently includes the two biggest states, New South Wales and Victoria, but will soon be all of Australia once state borders reopen.

Persistent deficiencies in ICEG’s guidance are highly disappointing and frankly baffling, as it is reasonably practicable to improve ventilation or air filtration in health care settings and to provide all staff with proper personal protective equipment, such as fit-tested N95 or P2 respirators. Such measures would substantially mitigate the risk of transmission of SARS-CoV-2 for both staff and patients. In the US, many hospitals have adopted reusable elastomeric respirators; for example, the Texas Center for Infectious Disease and the Children’s Hospital New Orleans.

Also in the US, the Centers for Disease Control and Prevention (CDC) has been well ahead of Australia in stating clearly that “the risk of SARS-CoV-2 infection via the fomite transmission route is low, and generally less than 1 in 10 000, which means that each contact with a contaminated surface has less than a 1 in 10 000 chance of causing an infection”. Australia has no direct equivalent to the CDC, however similar guidance could come from the Australian Health Protection Principal Committee and would help focus attention on mitigating airborne transmission.

While details are still emerging, recently in Melbourne, an emergency department nurse and mother of three tragically died from COVID-19. The Australian Nursing and Midwifery Federation has attributed her death to a workplace-acquired infection. This was the exact situation we have feared since the start of the pandemic, which led me and Dr Michelle Ananda-Rajah to establish Health Care Workers Australia.

Australia has been lucky to date, with no previously reported deaths despite thousands of health care workers being infected at work in Victoria alone – infections which were initially misreported as being acquired elsewhere. This is in stark contrast to the global experience, where there have been an estimated 115 500 health care worker deaths in the period January 2020 and May 2021.

OzSAGE recently released its advice on this topic, and we are available to meet with any state or federal health department open to discussing what more could be done to protect their health care workforce.

Finally, Australia’s quarantine capability remains sorely lacking. The only “gold standard” quarantine facility is the Northern Territory’s Howard Springs Centre for National Resilience, which has seen more than 11 000 international arrivals complete quarantine.

Although the federal and state governments are building an additional 1000 beds in Melbourne, plus 500 beds in each of Brisbane and Perth, none of these were ready before Omicron arrived on our shores.

OzSAGE commends Minister Greg Hunt on his decision to reintroduce significant international travel and quarantine restrictions in the face of this new, relatively uncharacterised variant of concern. Such action was consistent with the precautionary principle that OzSAGE espouses.

The Australian Medical Association has likewise called for “a network of dedicated quarantine facilities and to pursue the roll out of booster shots more vigorously”. OzSAGE is strongly supportive of calls to improve global vaccine equity and for countries like Australia to help increase global vaccine supply and access through a greater contribution to COVAX.

The New Year

What Omicron will mean and what else 2022 has in store for us remains to be seen, but there is reason to be optimistic.

This time in 2020, vaccines had only just been announced. Their efficacy has been astounding, and as mentioned, a large proportion (73.4%) of the Australian population is now protected from the worst outcomes of COVID-19. Primary school-aged children are likely to be eligible for vaccination soon, and despite a slow start, the booster program has begun.

With a concerted focus on the science, particularly mitigation of airborne transmission, Australia could continue to enjoy a low burden of disease from COVID-19. Given the long term consequences of infection are unknown, a precautionary approach that employs the full range of risk mitigations would help enormously.

Safe indoor air (ventilation) and “vaccines plus” are our path out of the pandemic.

Dr Benjamin Veness is an executive member of OzSAGE and co-founder of Health Care Workers Australia. Twitter @realozsage and @venessb

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.