It is once again time to have a bit of a break and this time I am aiming for a two-week break. I find it much better to be proactive when certain little signs begin to appear in my health than to wait for something more major to occur. So a little downtime and a little more sleep are what I require at the moment. So, I’ll be back in a couple of weeks.
Prime Minister Scott Morrison and Foreign Minister Marise Payne said in a Tuesday statement the embassy building in the capital Kabul will be closed on Friday.
Diplomats will visit Afghanistan “regularly from a residential post elsewhere in the region.” The new arrangement “does not alter our commitment to Afghanistan or its people,” they said.
Morrison and Payne said it was “Australia’s expectation that this measure will be temporary and that we will resume a permanent presence in Kabul once circumstances permit”.
But it appears unlikely a Kabul embassy will resume.
No firm commitment has been given, nor any indication of a timetable for returning to an on-the-ground diplomatic presence in the country. There is also no expectation of the security situation in Afghanistan improving.
The government statement said,
The departure of the international forces and hence Australian forces from Afghanistan over the next few months brings with it an increasingly uncertain security environment where the government has been advised that security arrangements could not be provided to support our ongoing diplomatic presence.
The visiting diplomatic model was used between the opening of Australia’s relations with Afghanistan in 1969 until 2006 when Brett Hackett was named ambassador.
The statement said: “We will continue our 52-year bilateral diplomatic relationship with Afghanistan, building on our close friendship with the Afghan people which stretches back to the historic arrival of Afghans in South Australia in the 1830s.”
Payne visited Afghanistan earlier this month and had talks with President Ashraf Ghani. She said publicly at the time that “with the departure of the Australian Defence Force, the Australia-Afghanistan relationship is beginning a new chapter of our diplomatic relationship”.
But she made no mention in her statement at that time of closing the embassy.
The appointment of Paul Wojciechowski, Australia’s current ambassador to Afghanistan, was only announced in March.
The Australian troops will leave by September. The decision to pull the remaining 80 troops followed the US announcement that it was withdrawing its forces.
In the Coalition party room one MP expressed a desire to keep a diplomatic presence in Kabul.
But Morrison said the decision had been made by cabinet’s national security committee, and keeping the embassy would be “putting Australians at risk – or worse”.
Howard, a first-term prime minister, suffered a 4.6% swing, surrendering the popular vote but somehow retaining a parliamentary majority.
Labor strategists figured the next election would be that much easier for having come so close.
This was wrong.
Consistently underestimated as a reader of the middle-Australian voter, Howard served four terms leaving Beazley with the cold comfort of being regularly tagged as “the best prime minister Australia never had”.
Could this be Anthony Albanese’s trajectory also?
The Upper Hunter case study
Behind Labor’s initial grief of its federal election loss, there were hopes within the ALP that next time might be different, given Prime Minister Scott Morrison only scraped through with the barest of parliamentary majorities in 2019.
But if the pandemic incumbency factor had not since dented federal Labor’s confidence, the weekend’s state byelection in the seat of Upper Hunter must surely have done so.
Labor’s primary vote tanked.
As well as showing that blue-collar regional voters are happy with their state Coalition government — despite its sordid scandals — the result apparently vindicated the outspoken anti-green pro-coal stance taken by Labor’s federal MP Joel Fitzgibbon.
The Upper Hunter result also buoyed Morrison’s hopes of a strong Coalition victory at the next federal election, built on converting blue-collar Labor voters into hi-viz Coalition backers.
The Fitzgibbon factor
Fitzgibbon famously quit the Labor frontbench last November, while insisting the party’s climate spokesperson, the Left’s Mark Butler, be replaced for being too committed to his task.
Under Butler’s guidance, Labor had taken a target of a 45% cut to emissions by 2030 to the last election — a policy that has since come to look mild in the global context.
But Fitzgibbon and others in the Right blamed the pledge for Labor’s poor performance in regional Australia.
By January, Fitzgibbon had his wish with the NSW Right’s Chris Bowen installed in the climate portfolio in Butler’s place.
Now, in the wake of the politically disastrous result for Labor in the Upper Hunter, an emboldened Fitzgibbon has again hit the airwaves calling for federal Labor to heed the message from its heartland. He is urging Albanese to stop pandering to inner-city progressives on climate and get back to protecting regional jobs. Coal jobs.
It is a message that carries big risks for Labor, which holds more urban seats than regional ones and which is challenged by the Greens on its left flank.
Albanese’s three problems
For Albanese, there are no easy answers.
Some within Labor fear Fitzgibbon could yet run as an independent, although he scotched this idea in interviews on Monday. He has however hinted that he might not run at all, unless he sees a material change in Labor’s emphasis.
Either way, it seems Fitzgibbon and Morrison are on a unity ticket over coal jobs and regional sensibilities generally, and that is very bad news for Albanese.
In an interview with The Australian conducted before the by-election result but published on Monday, Morrison criticised Labor for treating workers as “victims” and for suggesting the answer to their woes must always be government assistance.
He said workers no longer thought like that.
So much of what we are doing in our economic plan comes together in regions like the Hunter.
This was a reference presumably to his government’s commitment to build a gas-fired generator in the Hunter. The $600 million announcement had angered progressives, and mystified energy economists, but seems to have been viewed by Upper Hunter constituents as a vote of confidence in their future.
Albanese now finds himself battling against three countervailing forces: Morrison, Fitzgibbon, and pandemic incumbency.
Like Berejiklian, Morrison’s government has delivered its share of scandals. But in both cases, voters appear largely unfazed.
Instead, they seem inclined to credit their governments with addressing more material concerns such as keeping the pandemic at bay, and protecting their livelihoods.
The 2001 case study
In mid-2001, Howard was again trailing in the lead-up to a general election and faced a crucial byelection in the federal Victorian seat of Aston.
Governments tend to do badly in byelections and the electoral test loomed as the harbinger of a wider defeat.
Instead, it marked the government’s revival, with a triumphant Howard telling the first ever ABC Insiders program that his government was “well and truly back in the game”.
If there were an unstoppable momentum for Labor to win the federal election, they’d have rolled us over in Aston.
Just months later in the general election of November 2001 — the Tampa/ September 11 election — a sense of external threat merely reinforced voters’ tendencies to hold to the status quo.
Two decades on, the danger for Labor is people’s insecurity over health and wealth will again see voters preference the safety of a known quantity.
Meanwhile, Albanese has some way to go to emulate Beazley, let alone win the election. Before that he also has to get past Simon Crean’s unhappy distinction of being Labor’s only federal leader never to face an election.
Elizabeth Shi, RMIT UniversityAustralia’s COVID vaccine rollout has reached its next phase, now people aged 50 and over are officially eligible to receive their shot from a GP, respiratory clinic or mass vaccination hub. People under 50 are also getting vaccinated in some states.
These are the first age groups to be vaccinated in Australia likely to be in paid work. Until now, most people to have received their shot will have been over 70, and probably retired. So people eligible now might wonder how to fit in a vaccine appointment around work commitments.
If you need, or want, to be vaccinated during work hours, do you take a day’s leave or a sick day? And if you’re ill with side-effects, can you take a sick day to recover?
Let’s assume you’re not a doctor or nurse, or have some other occupation with a workplace, on-site vaccination clinic. This means the vast majority of Australians will need to factor in time travelling to the clinic, administration (such as filling in consent forms), the shot itself, 15-30 minutes waiting in case there are any immediate side-effects, and travelling back to work.
Let’s assume for now you’re an employee, entitled to paid annual leave and paid personal leave (which includes sick leave). If you’re a casual or independent contractor, the situation’s different and explained below.
Can I get time off work to get my COVID vaccine?
Whether you’re a full- or part-time employee, taking time off to get the COVID vaccine is similar to taking time off for the flu vaccine. You will usually need to take paid annual leave.
Unless your employment contract says otherwise, you are not entitled to take paid sick leave to get vaccinated. Sick leave is only for when you’re ill or injured. Being vaccinated is not considered an illness or injury.
Despite this, employers can exercise their discretion to allow you to take paid sick leave to get vaccinated.
Can I take sick leave if I feel unwell afterwards?
As a full- or part-time employee, you are entitled to take paid sick leave if you feel unwell after being vaccinated and can’t work.
You may need to provide reasonable evidence you are unfit for work, such as a medical certificate.
What if I’m a casual employee or an independent contractor?
Casual employees and independent contractors are not entitled to paid annual leave or paid sick leave.
This type of special leave is not a mandatory legal entitlement. But if your organisation doesn’t provide it, you may be able to negotiate it. Independent contractors can also negotiate with the business that contracts them.
To address the hardships casuals and independent contractors face, Victoria has announced a two-year trial of its Secure Work Pilot Scheme, which is due to begin by 2022.
This will provide up to five days of paid sick leave and carer’s leave at the national minimum wage for casual or insecure workers in sectors with high rates of casual employment, such as aged care, cleaning and hospitality.
What if I work in retail or hospitality?
If you work in retail, hospitality or some other sector that puts you at higher risk of COVID due to increased customer contact, you might be wondering if there are special provisions for you.
Under workplace health and safety laws, your employer must, so far as is reasonably practicable, provide and maintain a work environment that is safe and without risks to health.
But that doesn’t mean your employer has to give you paid time off during working hours to get vaccinated. That’s different to, say, the employer of a construction worker who has to provide a hard hat or other personal protective equipment for safety reasons.
Vaccines and hard hats seem to be treated differently, even though you could argue they both protect workers from serious illness or injury.
What other options are there?
If you’ve used up all your paid annual leave, you can request unpaid leave to get your vaccine.
Then there’s the alternative of booking an appointment for one of your days off, with some clinics offering extended hours, including evenings and weekends.
The Fair Work Ombudsman has more information about your workplace rights and obligations when it comes to COVID vaccines.
Around 13% of Australians have now received at least one vaccine dose, compared to, for example, 56% in the United Kingdom. We’ve heard reports of mass vaccine hubs in Melbourne sitting largely empty — though the current COVID outbreak has brought Victorians through the doors in record numbers.
There are a range of reasons Australia’s vaccine rollout is broadly lagging. At the core is the issue of vaccine hesitancy, in a large part due to the very rare blood clots associated with the AstraZeneca vaccine.
While addressing vaccine hesitancy will be key, as the Victorian outbreak shows, we should be looking at all possible strategies to boost our vaccine rollout. It’s pleasing to see Victorian hubs will now offer the Pfizer vaccine to people aged 40-49.
Another way to speed things up would be to drop the phased approach to the vaccine rollout, and allow all Australians over 16 to come forward.
The rollout so far
At the outset, Australia’s vaccine rollout was broken up into phases to ensure those most vulnerable to being exposed to the virus and becoming very sick with COVID-19 would be prioritised.
We’re now up to phase 2a which includes all adults over 50. Unfortunately, many people eligible under phase 1a and 1b are still waiting. It’s particularly worrying to see residents in aged and disability care who haven’t yet received one dose.
So when we consider the idea of opening up vaccine access more broadly, it is important this doesn’t compromise vaccinating priority groups. Another challenge will be working within vaccine supply constraints.
But there are good reasons to invite younger adults to be vaccinated sooner rather than later.
Targeting younger people
But it gets more complicated when you factor in behaviours and the fact an absence of symptoms means there’s no signal to practise precautions or to test and isolate.
Asymptomatic transmission is estimated to contribute to at least 50% of all infections.
If we also consider the generally greater level of mixing among younger adults in social and essential work settings, all of this together increases the contribution they make to the spread of the virus.
In Victoria’s second wave, adults in their 20s represented the highest number of cases.
So vaccinating younger adults is crucial for population-level protection, especially if the virus is circulating in the community.
Pfizer for under 50s
Bringing forward vaccination of those under 50 not eligible under phases 1a and 1b would place more demand on Pfizer supplies.
But Pfizer vaccines are a finite resource and the capacity for different states to do this is dependent on supply.
Recent changes to the shipping and storage requirements — the Therapeutic Goods Administration has ruled the Pfizer vaccine can be stored for up to one month in a normal fridge — will make distributing this vaccine a bit easier. Nonetheless, logistical problems remain.
We could convert some underutilised hubs to dedicated Pfizer hubs targeting younger adults. But we would need to manage demand within supply constraints, ensuring people aren’t turning up only to be told there are no vaccines available.
Victoria’s decision to bring forward phase 2b, but only for those 40-49, is one way to keep this manageable.
What about AstraZeneca?
Some experts are calling for under 50s to be allowed to choose to have AstraZeneca.
Under 50s are not currently prohibited from having AstraZeneca, but Pfizer is preferred. This guidance is based on the very small risk of adverse reactions to the vaccine balanced against the benefits of protection against serious illness or death from COVID-19.
The benefits outweigh the risks for over 50s. But as you get into the younger age groups the gap between the benefits and risks narrows with their lower susceptibility to severe COVID-19.
This latest outbreak in Victoria shifts the equation somewhat. But I don’t think we’ve reached a point yet where we should throw away existing guidance and recommend the AstraZeneca vaccine for younger people.
If a younger person turns up to a vaccination centre and says they’d like to receive the AstraZeneca vaccine, that’s a personal choice. But if we’re going to expand the AstraZeneca rollout to under 50s, we would need to ensure we have the information, consent and accessibility completely worked out so it’s an informed choice.
Getting it done
The phased approach was the right idea at the start. But now, with complexities such as vaccine hesitancy and distribution challenges, this approach is holding us back. While not taking our attention off the urgent need for aged care and disability care residents to be vaccinated, I argue it’s time for a rethink.
Though information about vaccine supply is not entirely clear, there probably aren’t enough Pfizer doses to offer 16-49-year-olds across the country. Victoria’s decision to prioritise 40-49-year-olds is a good compromise, recognising this group stands to benefit the most of those under 50.
We likely do have enough AstraZeneca to offer it to people under 50 who want it, as long as we ensure the right checks and balances are in place.
We also might benefit from exploring other ways to improve vaccine coverage, such as shortening the interval between doses, or trying to cover more people with just one dose, or even mixing and matching different vaccines.
Once supply moves ahead of demand, we must have processes in place that make efficient use of our vaccine resources and facilities, minimise vaccine wastage, and ensure our population vaccine coverage builds quickly.
We want all Australians to have the chance to be vaccinated, and we should continue to prioritise those who have the most to gain. But we shouldn’t let vaccine hesitancy set the pace for our entire campaign and allow vaccine hubs to sit idle.
Fiona Russell, The University of Melbourne; John Hart, Murdoch Children’s Research Institute, and Katherine Gibney, The Peter Doherty Institute for Infection and ImmunityVictoria’s seven day lockdown, which begins tonight, is an attempt to stop transmission of the quick-spreading COVID-19 B.1.617.1 variant.
Victoria’s chief health officer Brett Sutton said the reproduction number of the strain was yet to be determined, but could be five or more, meaning one person would infect five others.
B.1.617.1 is one of three so-called “Indian” SARS-CoV-2 variant sub-types. Little is known about it but it’s likely to have similar characteristics to the sub-type dominating in India and emerging in the United Kingdom at the moment, B.1.617.2.
Remind me, what’s a variant of concern?
To be classified as a variant of concern, it must pose a risk to public health over and above the original Wuhan virus. This could be due to changes in transmissibility (how easily it spreads), disease severity, its ability to evade detection by viral diagnostic tests, reduced effectiveness of treatments, or an ability to evade natural or vaccine-induced immunity.
The World Health Organization is tracking four variants of concern, which are often referred to by the country in which they emerged:
- the UK (B.1.1.7)
- South Africa (B.1.351)
- Brazil (P.1)
- Indian variant (B.1.617).
The B.1.617 variant, which was classified as a variant of concern on May 6 2021, has three subtypes – B.1.617.1, B.1.617.2 and B.1.617.3 – each with small differences in their genetic make-up.
What do we know about the ‘Indian’ variants?
Information about B.1.617 is emerging, but early reports indicate it spreads more easily than the original strain. Although there is limited data specifically on B.1.617.1, it is likely to behave similarly to B.1.617.2 as it is genetically similar.
Early data from the UK’s NHS Test and Trace records showed B.1.617 spreads at least as easily as the UK strain (B.1.1.7). In fact, B.1.617.2 may be twice as likely to infect another person than the UK strain, which was already more infectious than the original Wuhan virus.
The relative disease severity of B.1.617 is still under investigation, however even if it is no more severe than the original virus, increased transmission leads to more cases, more hospital admissions and more deaths.
Laboratory tests also raise the possibility that reinfection might be more common with the B.1.617 variant, but this is yet to be confirmed by real-world data and for all sub-types.
How effective are vaccines and how long do they take to kick in?
For most variants of concern, vaccines are still effective, but are often less effective than they were against the original Wuhan virus.
So far, there are no data on how effective any of the COVID-19 vaccines are against B.1.617.1.
B.1.617.2 has one more mutation than B.1.617.1, so they are genetically similar. Therefore the vaccine effectiveness against B.1.617.1 and B.1.617.2 is likely be similar, but this is not known yet.
Data from the UK (non-peer reviewed) on vaccine effectiveness against the B.1.617.2 variant has recently been released. It found:
- both Pfizer and AstraZeneca are 33% effective against symptomatic disease (COVID-19 symptoms such as fever, dry cough and tiredness) three weeks after the first dose
- Pfizer vaccine is 88% effective against symptomatic disease two weeks after the second dose
- AstraZeneca vaccine is 60% effective against symptomatic disease two weeks after the second dose.
The difference in effectiveness between the vaccines after two doses may be due to AstraZeneca taking longer to reach peak protection as this occurs after two weeks following the second dose.
Both vaccines are expected to provide even greater protection against COVID-19 hospitalisation and death than they do for symptomatic disease. As yet there are too few cases to do this analysis but this will take place over the coming weeks.
Lower vaccine effectiveness means even if you are vaccinated, you could still get infected. However, if an infection does occur, symptoms would be milder.
It’s also possible vaccination may not protect you for as long against this sub-type compared to other variants. But this is not known yet for B.1.617.1.
Time between doses
From December 2020, the UK had been delivering the AstraZeneca and Pfizer vaccines with a 12-week interval between doses to provide some protection to as many people as possible.
A recent study supported this decision, finding that extending the vaccine interval from three to 12 weeks for the second dose boosted the immune response in people over 80 by 3.5 times.
However, due to the spread of the B.1.617.2 variant in the UK, the strategy was changed in mid-May to an eight-week gap in order to provide greater protection from this highly transmissible virus at an earlier opportunity.
Australia delivers the AstraZeneca vaccine with a 12-week interval, while opting for three weeks for Pfizer.
Decisions on the timing between doses must balance providing greater protection earlier, against providing some protection to the maximum number of people. It’s too early to make those changes right now for Victoria but this option should be considered if the outbreak worsens.
Should people get vaccinated?
Even though we don’t know how effective vaccines are against the B.1.617.1 sub-type, don’t delay getting vaccinated. This time our outbreak is due to B.1.617.1, but next time it could be another variant.
COVID-19 vaccines are equally effective against the original strain and B.1.1.7, and are also effective against the B.1.617.2 variant (albeit a bit lower).
During an outbreak, policymakers should also consider opportunistically increasing vaccine uptake, especially in the outbreak areas. Victoria has made progress in this area and from tomorrow all 40- to 49-year-old Victorians will be offered Pfizer.
But those responsible for the most COVID-19 transmission are aged 20 to 49 years. So vaccinating even younger Victorians – 20 to 39 year olds – would also prevent spread of the outbreak. Even if the vaccine was only 20% effective against transmission this may be a very important additional measure.
Even though there are many unknowns, it is still important to get vaccinated with the vaccine that is offered right now.
Fiona Russell, Senior Principal Research Fellow; paediatrician; infectious diseases epidemiologist, The University of Melbourne; John Hart, Clinical researcher, Murdoch Children’s Research Institute, and Katherine Gibney, Senior research fellow, The Peter Doherty Institute for Infection and Immunity
Its main exports are products and components that fit into broader global supply chains for weapons and weapons systems. For example, the government boasts there isn’t a single F-35 fighter jet production operation that doesn’t feature Australian-made components.
The government sees further export potential for products and components to be used in armoured vehicles, advanced radar systems, and patrol boats, as well.
While Australia hasn’t made much headway on its export ranking, it has enjoyed some impressive sales success. In the 2017-18 financial year, the estimated value of approved export permits was A$1.5 billion. By 2019-20, it had grown to nearly $5.5 billion.
Australia’s export goals are connected to a broader effort to resuscitate domestic manufacturing.
Considerable government funding is involved in this effort, including $1 billion recently allocated to the Sovereign Guided Weapons Enterprise for building missiles.
Where do Australian arms go?
Australia doesn’t provide data on which countries it exports arms to. It only maps the regions, and unhelpfully, it lumps the Middle East and Asia together.
Heavily redacted documents obtained by the Guardian under a Freedom of Information request also indicate that in 2018-19, Australia issued 45 arms export permits to the UAE and 23 to Saudi Arabia.
Another 14 permits were approved for the countries from 2019-20.
These developments are significant, not least because the UAE and Saudis have both been embroiled in the Yemeni civil war for years, at times conducting their own indiscriminate air strikes.
The UN secretary-general anticipates 16 million Yemenis will go hungry this year because of the conflict, while 50,000 Yemenis are already starving to death.
Earlier this year, the Biden administration announced a freeze on “offensive” arms sales to Saudi Arabia and the UAE, citing the toll on civilians in the Yemeni war. Italy followed suit. Germany, too, halted weapons exports to the Saudis after the murder of journalist Jamal Khashoggi in 2018.
Advocacy groups in Australia have attempted to seize on this glimmer of momentum by calling for Australia to do the same.
When weapons end up in the wrong hands
The Australian government still claims its arms export industry operates under strict regulations:
In keeping with Australia’s national interests and international obligations, Defence facilitates the responsible export of military and dual-use goods and technologies from Australia.
Such claims are hardly new. If anything, they’re part of a long-standing Western tradition.
In the 1960s, the UN Security Council debated the merits of an arms embargo on South Africa. At the time, the French and British maintained their weapons sales were for “defensive purposes” and not “internal use”. South Africa built a terrifying internal security apparatus, making a mockery of the distinction.
The historical record shows that arms exports often show up precisely where they shouldn’t, causing untold civilian suffering. At times, they are even wielded against the immediate interests of the countries in which they were produced.
Britain’s many mistakes
Here, the British experience is illustrative (although we just as easily tell this story about any purported liberal democracy in the arms export business).
When Tony Blair’s Labour government came to office in 1997, it promised an “ethical” foreign policy. As part of this, Labour would never allow the sale of arms to regimes that might use them for internal repression. Or so they said.
The previous government had approved export licenses for the sale of Hawk jets to Indonesia’s Suharto regime. While Labour could have cancelled these licences, it didn’t do so until it was too late. A series of unedifying spectacles followed.
In 1999, Britain confirmed Indonesia had flown Hawk jets over Timor-Leste to intimidate local residents before the region’s independence referendum. Hawk jets were then used in 2003 to bomb Aceh province during a particularly brutal internal military campaign. British Scorpion tanks were also used.
These were by no means isolated incidents. In 2009, Britain conceded it was possible its weapons had been used in the Sri Lankan civil war in a manner contravening their export licences.
That same year, the foreign secretary also confirmed Israel had used British-made equipment to bombard Gaza.
Like Australia, Britain is currently exporting weapons to Saudi Arabia, though a court challenge is being brought to try to stop it. From 2013-17, it was the country’s second-biggest supplier, after the US.
While Britain recently announced it will halve its aid budget to Yemen, it will not stop supplying the Saudis with arms.
Today’s friend is tomorrow’s enemy
Arming foreign governments does not just pose an immediate risk to civilians. In a phenomenon known as “blowback”, it can undermine the interests of exporters.
In 2004, for example, the European Union lifted arms sanctions on Libya. And from 2005–09, EU member states cemented arms deals with the oil giant.
Muammar Gaddafi’s regime stored its new purchases in warehouses. Then, in 2011, Libya erupted into civil war and NATO enacted a “no-fly zone”. Many of the warehouses were looted and the weapons spilled into the hands of both government and rebel forces. This effectively turbo-charged a conflict that NATO was responsible for controlling.
A 2013 UN report said looted weapons had been smuggled to as many as 12 other countries in the region. They’ve fallen into the hands of foreign governments, separatists, warlords, and Islamic extremists. This is how arms deals can come back to bite exporters.
The arms industry has an array of potential drawbacks. There are questions about the economic efficiency of investing in defence at the expense of other sectors, and arms procurement is highly susceptible to corruption.
Even if our intentions are good and we behave transparently, we still cannot predict the future. The British Parliamentary Committee on Export Controls articulated this problem over a decade ago when discussing the Sri Lankan war:
The issue of Sri Lanka illustrates the difficulties faced by the government, and by those who, like us, scrutinise the licensing decisions made by government, in assessing how exports of arms might be used by the destination country at a future date, particularly if [the] political situation in the country at the time of the exports appears stable.
That should give us pause for thought.
Karlheinz Peter, Baker Heart and Diabetes Institute and James McFadyen, Baker Heart and Diabetes InstituteWith COVID-19 community transmission on the rise once again, those aged over 50 are weighing up the benefits of being vaccinated against the virus with the very rare risk of blood clotting induced by the AstraZeneca vaccine.
Since the first reports of blood clotting after the AstraZeneca vaccine emerged in March 2021, our understanding of the clotting disorder, called vaccine-induced thrombotic thrombocytopaenia (VITT) or thrombosis with thrombocytopenia syndrome (TTS), has grown.
We now know how to diagnose and treat it, so we’re likely to see better outcomes for patients with the condition.
How common and deadly is it?
Thankfully, developing blood clots after the AstraZeneca vaccine is very rare.
So far in Australia, out of 2.1 million doses of the AstraZeneca vaccine, 24 cases of TTS have been reported. So the risk of TTS is approximately one in 88,000.
These figures are similar to those reported in the UK, Europe, the Middle East and Canada.
Although early reports from Europe indicated approximately 20% of cases of TTS were fatal, in Australia, to date, one out of 24 TTS cases has been fatal, so just over 4%.
What exactly is thrombosis with thrombocytopenia syndrome?
Although we don’t yet have the full explanation, it appears that the AstraZeneca vaccine can activate platelets, which are small cells in our blood important for forming blood clots that prevent bleeding.
In some people, activated platelets can release a protein called platelet factor 4 (PF4), which binds to the AstraZeneca vaccine. It is thought that this binding of PF4 can induce the immune system to activate more platelets, making them stick together and thereby diminishing their numbers. This leads to blood clotting (thrombosis) and a low platelet count (thrombocytopaenia).
Having blood clots with a reduced number of platelets is a key feature of TTS.
Different to other blood clots
This mechanism is quite different to the usual process by which blood clots occur.
TTS appears to result from an irregular immune response, so current evidence suggests people with a history of heart attack, stroke, deep vein thrombosis, pulmonary embolism (a clot in the lung) or on regular blood thinners aren’t at any increased risk of TTS.
However, as a precautionary measure, the Pfizer vaccine is currently recommended for people aged under 50 years, or those with a history of clots in the brain, in the abdomen or previous low platelet count after taking the blood-thinning drug heparin.
Testing and treatment has improved
A key development is diagnostic tests and guidelines to recognise and treat cases of TTS. In most cases, patients will have a low platelet count, evidence of a blood clot, and antibodies directed against PF4. Many of these tests can be done quickly.
Treatment can now begin immediately, with specific blood thinners and medications to dampen the immune system.
As of May 20 when the latest vaccine safety report was released, 21 of the 24 Australians with TTS had recovered and been discharged from hospital and two were stable and recovering in hospital.
So what side effects are normal, and what might indicate a clot?
General side effects are common after any vaccine. In the case of the AstraZeneca vaccine, these occur in the first two days after vaccination and include:
- fever (chills)
- muscle and joint aches
- pain at the site of injection, which tends to resolve with simple measures such as paracetamol.
In many cases, the blood clots in TTS occur in unusual locations such as the veins in the abdomen (splanchnic vein thrombosis) and brain (cerebral venous sinus thrombosis). They typically occur four to 30 days days after vaccination.
Therefore, symptoms that could indicate TTS after getting the AstraZeneca vaccine include:
- persistent or severe headache
- blurred or double vision
- shortness of breath
- severe abdominal, back or chest pain
- swelling, redness, pain in a leg
- unusual bleeding or bruising.
If you experience any of these symptoms four to 30 days after your vaccination, seek urgent medical attention.
Balancing the risk and benefits
While TTS is very rare, some people will have concerns and will want to discuss them with their doctor. This is essential to allow people to make an informed choice.
However, with the ongoing risk of COVID outbreaks in Australia and their potential deadly consequences, as well as the potentially severe long-term effects of COVID-19, for the vast majority of people, the benefits of vaccination against COVID-19 as soon as possible outweigh the risks.
Karlheinz Peter, Lab Head, Atherothrombosis and Vascular Biology and Deputy Director, Baker Heart and Diabetes Institute; Interventional Cardiologist, Alfred Hospital; Professor of Medicine and Immunology, Monash University, Baker Heart and Diabetes Institute and James McFadyen, Research Fellow, Baker Heart and Diabetes Institute, Haematologist, Alfred Hospital, Baker Heart and Diabetes Institute
Michelle Grattan, University of CanberraThe Senate inquiry into the Christine Holgate affair has declared Scott Morrison, shareholder ministers and the Australia Post board should apologise to the former CEO “for denying her the legal principles of procedural fairness and natural justice”.
The Labor-Greens dominated committee said in scathing findings that Morrison’s “improper threat” in parliament’s question time suggested “a lack of respect for due process”, as well as a “double standard” when contrasted with the procedural principles applied to cabinet members.
Holgate told the ABC on Wednesday night she was “absolutely delighted” by the report and would “graciously accept” a Morrison apology.
But none will be forthcoming.
A government spokesperson said it had “no intention of responding to a politicised report published by a committee controlled by the Labor and Green parties”. The inquiry was chaired by Greens senator Sarah Hanson-Young.
Morrison reacted furiously on October 22 last year, after Holgate revealed to a Senate committee Australia Post had rewarded with Cartier watches four employees who had concluded a highly lucrative 2018 deal. The watches were worth in total nearly $20,000.
Morrison told parliament Holgate had been instructed to stand aside – if she did not want to do that “she can go”.
Holgate resisted standing aside but had little choice but to do so. Soon after, she left Australia Post. She has since been appointed CEO of Global Express, which competes with it.
The government minority on the committee, in a dissenting report, said the inquiry had been a highly politicised exercise. The Coalition senators said they did “not support aspects of the analysis of evidence and many of the recommendations of the majority report”.
They said the claim Holgate was denied procedural fairness and natural justice was contested, with evidence showing different recollections snd interpretations.
The majority report lambasted Australia Post’s chair, Lucio Di Bartolomeo, saying he should resign, and accept responsibility for the organisation’s failings over Holgate. It criticised “the veracity of his evidence provided to the committee, his capacity to defend the independence of Australia Post and the lack of effective robust policies and financial oversight processes in place throughout his tenure”.
But government senators said evidence had highlighted that the chair had sought to work constructively with Holgate when events were moving fast in the media spotlight.
The majority report said evidence suggested “there is a culture operating outside the legislated framework that results in so‐called ‘independent’ government agencies being controlled by ministers and their advisers through informal directions in a completely unaccountable manner.”
Holgate’s treatment also was “indicative of a wider pattern of behaviour towards women in workplaces, including Parliament. As both an employer and legislator of workplace laws, the Australian Government must set an example.”
The Australia Post board, notably for being heavy with political appointments, also came in for strong rebukes.
The board, “apparently acting on informal instructions from the Minister for Communications [Paul Fletcher], decided that Ms Holgate should be stood aside without being accorded procedural fairness and an opportunity to defend her actions,” the report said.
“The Prime Minister and Shareholder Ministers [Fletcher and then finance minister Mathias Cormann] created a very public expectation that Ms Holgate would be stood aside, to which the board dutifully acquiesced.
“This pressure appears to have led the Board to breach its duties under the Act, standing Ms Holgate aside without any evidence that she had acted improperly.”
The process by which board members are appointed has compromised the board’s independence from government, the report said.
The Holgate matter “has focused attention on the sheer magnitude of bonuses and incentives paid to executives, senior managers and other highly paid staff across the Commonwealth.
“If the purchase of $20,000 worth of watches for senior executives fails the ‘pub test’, what does the Australian public think of the tens of millions of dollars that are given in bonuses each year to highly paid staff at Australia Post, in government departments, and at other GBEs [government businesss enterprises]?” the report said.
It said “a comparison of other events during that period puts in stark perspective the inconsistent treatment of public officials by this government when faced with a scandal.
“On one hand, the high performing CEO of Australia Post was effectively forced to resign over the purchase of $20 000 worth of watches for securing a deal worth more than $200 million in revenue to the organisation.
“On the other hand, there appears to have been no action taken against the responsible public servants involved in the purchase of the ‘Leppington Triangle’ for $30 million of public funds, ten times more than the land’s market value.”
Among its 25 recommendations, the majority report said the Australia Post board should be restructured and include nominees of the parliament, employees and unions, and licensees. Appropriate board independence should be restored.
The Solicitor-General should investigate the legality of the October 22 instruction from shareholder ministers to the board that it should stand aside Holgate during an investigation into the watches’ purchase.
The government should rule out privatising Australia Post or divesting any of its services including parcel delivery. The Senate should oppose any extension of the current temporary regulations, which were put in place for the pandemic.
Pauline Hanson, who pressed for the inquiry and was a participating member (rather than a member of the committee) said in additional comments in the report that the chair should be removed and Morrison, Fletcher and Simon Birmingham (the current finance minister) should “each offer an unqualified apology” to Holgate.
Sarah Hetrick, University of Auckland; Joanne McKenzie, Monash University; Nick Meader, University of York, and Sally Merry, University of AucklandEven before COVID-19 lockdowns, school closures and strict social distancing, depression was on the rise in children and teenagers around the globe.
A number of studies point to an increasing use of antidepressants in young people.
So, what do we now know about how well antidepressants work in children and young people?
Our new Cochrane review, published today, found that on average, antidepressants led to only small improvements in depression symptoms compared with placebo in children and adolescents (ranging in age from six to 18 years old).
Antidepressants shouldn’t be the first port of call
Our findings highlight antidepressants are no panacea for depression in young people. The small improvements might be so small as to not be very noticeable to the individual person. What’s more, we can’t say to any one young person whether antidepressants will definitely improve their symptoms.
But it’s critical to note there are multiple and complex pathways that lead to the distress and demoralisation that are key in depression.
Different people’s responses to antidepressants are therefore quite specific, and young people may experience anything from marked improvement to deterioration.
Another important finding is that antidepressants are associated with an increased risk of suicidal thinking and self-harm.
These are not necessarily new findings, but they represent the best evidence we have so far. They remain a key consideration for GPs and other health professionals who are considering medications for children and young people.
What is new is our findings on how different antidepressants compare with each other. Many current guidelines recommend fluoxetine as the only first-line medication that should be tried. This is commonly sold under the brand name Prozac.
Fluoxetine is what’s called a “selective serotonin reuptake inhibitor” (SSRI). Serotonin is a neurotransmitter in the brain linked to positive emotions. After it’s used by nerve cells, serotonin is reabsorbed, which is known as “reuptake”. These types of antidepressants work by blocking the reuptake of serotonin, therefore increasing its availability to pass messages between nerve cells.
Our review shows three other antidepressants, including sertraline, escitalopram, and duloxetine, had similar effects to fluoxetine. Though, there’s the caveat that all of these led to only small reductions in depression on average.
However, this finding may extend treatment options for young people with depression. For example, one of these antidepressants may suit one person better than another in terms of side-effects experienced, and the time it takes to work or to wash out of the system.
What other options are there?
Against a backdrop of a global pandemic, there’s a risk we may start to consider depression as the “norm”, passing it over as a given or as insignificant.
But as those with depression, and their parents, families and friends know, depression is anything but. It impacts every facet of life and is often accompanied by a fear it may never improve.
Depression varies substantially between people with multiple factors at play, so it’s important a range of support and treatments are available for people.
Antidepressants have been, and will remain, only one of many options for young people with depression. Guidelines continue to highlight that antidepressants should not be the first port of call.
When used, they should be used in combination with evidence-based talking therapy, the most common being cognitive behavioural therapy (CBT), and there must be a commitment to ensure close monitoring of their impact.
There’s a range of ways in which young people can and need to be supported. There’s good evidence for regular physical activity, good nutrition, and adequate sleep. Support from family, schools and the broader community is also important.
A decision to use antidepressants should be on the basis of shared decision-making. This refers to conversations where the risks and benefits of all treatment options are described to the young person, and their family, who are then meaningfully involved in making the decision.
If the decision is made to use an antidepressant, it’s critical to ensure health professionals conduct regular (weekly at first) checks on depression symptoms and adverse effects. This is particularly important in terms of monitoring the emergence of suicidal thinking and self-harm.
Treatment with an antidepressant should be in the context of talking therapy, and a holistic approach to well-being.
Ensuring access to support and treatment and conveying a sense of hope is crucial.
If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.
Sarah Hetrick, Associate Professor of Youth Mental Health, University of Auckland; Joanne McKenzie, Associate Professor, Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University; Nick Meader, Research Fellow, Centre for Reviews and Dissemination, University of York, and Sally Merry, Professor and Cure Kids Duke Family Chair in Child and Adolescent Mental Health, University of Auckland