Fiona Russell, University of Melbourne; Edward Kim Mulholland, Murdoch Children’s Research Institute; Kathleen Ryan, Murdoch Children’s Research Institute; Kathryn Snow, University of Melbourne; Margie Danchin, Murdoch Children’s Research Institute, and Sharon Goldfeld, Murdoch Children’s Research Institute
At the weekend, Victorian Premier Dan Andrews announced all the state’s primary school kids would return to school for Term 4. This is an update from the previously planned staggered return to primary school, which would begin only with students in the early years — prep (first year) to Year 2.
The change was informed by our analysis of Victorian health and education department data on all cases and contacts linked to outbreaks at schools and early childhood education and care services (childcare and preschool).
We included data between January 25 (the date of the first known case in Victoria) and August 31.
Our analysis found children younger than 13 seem to transmit the virus less than teenagers and adults. In instances where the first case in a school was a child under 13, a subsequent outbreak (two or more cases) was uncommon. This finding played a key role in helping make the decision for primary school children to return to school.
Here is what else we found.
Infections linked to childcare, preschools and schools peaked when community transmission was highest in July, and declined in August. In addition, they were most common in the geographical areas where community transmission was also high.
This suggests infections in childcare, preschools and schools are driven primarily by transmission in the broader community. Controlling community transmission is key to preventing school outbreaks.
There were 1,635 infections linked with childcare, preschools and schools out of a total of 19,109 cases in Victoria (between January 25 and August 31).
Of 1 million students enrolled in all Victorian schools, 337 may have acquired the virus through outbreaks at school.
Of 139 staff and 373 students who may have acquired infection through outbreaks at childcare, preschools or schools, eight (four staff and four students) were admitted to hospital, and all recovered.
The infections in childcare, preschools and schools were very rarely linked to infections in the elderly, who are the most vulnerable to COVID-19.
Of all the outbreaks in Victorian childcare centres, preschools and schools, 66% involved only a single infection in a staff member or student and did not progress to an outbreak. And 91% involved fewer than ten cases.
Testing, tracing and isolation within 48 hours of a notification is the most important strategy to prevent an outbreak.
The majority of infections in childcare, preschools and schools were well contained with existing controls and rapid closure (within two days), contact tracing and cleaning.
The investigations of cases identified in schools suggest child-to-child transmission in schools is uncommon, and not the primary cause of infection in children. Household transmission has been consistently found to be the most common source of infection for children.
Based on our findings and a review of the international literature, we recommend prioritising childcare centres, preschools and schools to reopen and stay open to guarantee equitable learning environments — and to lessen the effects of school closures.
Children do transmit the virus and outbreaks can occur. But based on the international literature, this mostly happens when there are high rates of community transmission and a lack of adherence to mitigation measures (such as social distancing) at the school or childcare centre.
Childcare centres, preschools and schools play a critical role not only in providing education, but also offering additional support for vulnerable students.
With childcare centres and schools being closed, along with the additional economic and psychological stress on families, family conflict and violence has increased. This has led to many children and young people feeling unsafe and left behind in their education and suffering mental-health conditions.
Closing all schools as part of large-scale restrictions should be a last resort. This is especially the case for childcare centres, preschools and primary schools, as children in these age groups are less likely to transmit the virus, and be associated with an outbreak.
Now that community transmission in Victoria is so low, it’s time for all kids to go back to school.
The authors would like to thank their advisory committee from the Department of Education and Training and the Department of Health and Human Services. They would also like to thank outbreak epidemiologists at the DHHS and medical students Alastair Weng, Angela Zhu, Anthea Tsatsaronis, Benjamin Watson, Julian Loo Yong Kee, Natalie Commins, Nicholas Wu, Renee Cocks, Timothy O’Hare, and research assistant Kanwal Saleem, and Belle Overmars.
Fiona Russell, Principal research fellow, University of Melbourne; Edward Kim Mulholland, Professor, Murdoch Children’s Research Institute; Kathleen Ryan, Research Fellow, Asia-Pacific Health, Infection and Immunity Theme, Murdoch Children’s Research Institute; Kathryn Snow, Epidemiologist, University of Melbourne; Margie Danchin, Associate Professor, University of Melbourne, Murdoch Children’s Research Institute, and Sharon Goldfeld, Director, Center for Community Child Health Royal Children’s Hospital; Professor, Department of Paediatrics, University of Melbourne; Theme Director Population Health, Murdoch Children’s Research Institute
Victorian Premier Daniel Andrews has announced an end to the curfew and a COVID-safe return to work for 127,000 Melburnians, as restrictions ease at 11.59pm tonight. He has also flagged a provisional early lifting of many other aspects of the lockdown on October 19.
The downward trend in new COVID-19 cases has been better than expected, with the crucial 14-day moving average of daily new cases reaching 22.1. This is good news for Victorians, prompting Andrews to move metropolitan Melbourne to the second step of the state’s roadmap to COVID-normal.
According to the roadmap, today’s announcement was contingent on the 14-day rolling average being below 30-50 cases. The 50-case mark was passed on September 17, and the lower bound of 30 cases was reached a week later, on September 24.
Rather than easing restrictions when the criterion for new cases was met, the government had also, unnecessarily, set a date for moving to the second step: September 28.
Before today’s announcement, the better-than-expected decline in case numbers, coupled with the reduction in the number of “mystery” cases with an unknown source, had led Andrews to flag the possibility of easing restrictions faster than the provisional dates in the roadmap.
This is indeed what he has announced, with the next step potentially moving forward from October 26 to October 19. The government will now rely predominantly on epidemiological thresholds rather than dates. But Andrews added it is necessary to monitor the effects of today’s announcement for a further three weeks.
Andrews and his advisors had to keep in mind the ultimate goal of reaching zero active cases. Lifting restrictions too soon would jeopardise that.
The main changes are cautious ones, and still consistent with the zero target. The key changes are shown below.
One of the most welcome changes will be the abolition of the curfew. It had no real evidence base, given the other restrictions in place, and it became a policy orphan with no one owning up to recommending it.
The other major change is to formalise the return of on-site schooling. The research evidence on schools is complex, with different countries adopting very different rules about whether children can attend. But evidence suggests transmission risk is lower for kids under ten, so primary school return is welcome.
The return of VCE and VCAL students is presumably based on the assumption older teenagers should be able to follow physical distancing guidelines.
Victoria’s health minister Jenny Mikakos has resigned, pointing the finger at Premier Daniel Andrews’ evidence that hung her out to dry in the hotel quarantine inquiry on Friday.
Mikakos said in a Saturday statement she will also quit parliament.
She said she never wanted to leave a job unfinished but in light of Andrews’ statement to the inquiry “and the fact that there are elements in it that I strongly disagree with, I believe that I cannot continue to serve in his Cabinet”.
“I am disappointed that my integrity has sought to be undermined. I know that my statement [to the inquiry] and evidence would have been uncomfortable for some.”
Andrews told the inquiry in his written statement that after an April 8 cabinet meeting, Mikakos was in charge of the hotel quarantine program, in which private security guards were used. This program went horribly wrong when COVID got out, triggering Victoria’s second wave. Andrews, Mikakos and other witnesses have all said they do not know who made the decision to use private guards.
Andrews said: “At the start of the program, I regarded Minister Mikakos and Minister Pakula as responsible for informing cabinet about, and seeking cabinet’s endorsement of, the initial overall service model and costings that had been determined for the program. They did so at the Crisis Council of Cabinet meeting on 8 April 2020.
“I then regarded Minister Mikakos as accountable for the program. The CCC was provided with regular reports by Minister Mikakos containing data relevant to Victoria’s response to the public health emergency, key insights from the data, as well as other updates, including in relation to the program.”
Mikakos, in her statement posted on Twitter, said: “For 3 months I had looked forward to learning who made the fateful decision to use security guards. Victorians deserve to know who.”
She said she had never shirked her responsibility for her department “but it is not my responsibility alone”.
“As I said to the Board of Inquiry, I take responsibility for my department, the buck stops with me. With the benefit of hindsight, there are clearly matters that my department should have briefed me on. Whether they would have changed the course of events only the Board and history can determine,”
“I look forward to the Board of Inquiry’s final report.”
Mikakos said she was “deeply sorry” for the situation Victorians found themselves in. “In good conscience, I do not believe that my actions led to them.”
On Thursday she told the inquiry she was “not at all” involved in the decision to use private security guards, and “I do not know who made that decision”. She said she didn’t know private security guards were being used until late May after a COVID outbreak at Rydges, almost two months after the program started.
“I can‘t imagine why it [the use of private security guards] would be brought to my attention, because […][the Department of Jobs, Precincts and Regions] held the contracts with the security companies,” she said.
But her evidence immediately came into question, because she had been at a press conference in late March when the use of private security was confirmed, and private security was mentioned in a briefing note for caucus on April 8. In a statement to the inquiry on Friday, Mikakos denied misleading it.
Andrews announced at a news conference on Saturday afternoon that the Mental Health Minister, Martin Foley, will replace Mikakos as health minister.
Andrews said Mikakos had taken the “appropriate course” in resigning. But he said he had not spoken to her beforehand – or since. She has texted him that she had sent a letter to the governor, of which he was already aware.
NSW Health Minister Brad Hazzard said on Twitter:
But the Health Workers Union, which had called for Mikakos’ resignation earlier this week, welcomed her departure.
Andrews said Labor would aim to have a replacement for Mikakos in the upper house before parliament next meets. Labor’s national executive will formally determine who fills the seat because the state ALP is being federally administered at present.
There will also be a replacement in cabinet, drawn from the upper house.
Foley told the Andrews news conference he had nothing but confidence in the health department and its secretary.
Andrews said the latest Victorian COVID tally was 12 new cases, and he would be making a statement on Sunday about the easing of restrictions. He said there was no dramatic variation from the road map but there were a couple of areas where more could be done.
Testing remains a vital component of Australia’s success in managing COVID-19.
We need to diagnose people infected with SARS-CoV-2, the virus that causes COVID-19, as early as possible so they can be isolated from others and their contacts quarantined. Testing also helps us understand to what degree the virus is present in the population, so we can tailor public health measures accordingly.
If you’ve had a COVID-19 test, in all likelihood you received a PCR test. That’s the one with the throat and nose swabs, and is regarded as the “gold standard” in COVID-19 testing.
But now the Therapeutic Goods Administration (TGA) has approved a new kind of COVID-19 test, which can produce results in as little as 15 minutes, as opposed to a day or more for standard tests.
So is this new rapid test set to revolutionise COVID-19 testing in Australia? Not quite yet.
Nucleic acid tests, or PCR tests, can detect ribonucleic acid (RNA) of SARS-CoV-2 from a day or two before symptoms start, and for a week or more afterwards, as symptoms resolve. Of course, some people will test positive without ever having symptoms.
PCR tests have been the backbone of SARS-CoV-2 testing worldwide. Because of the vast global experience with PCR tests and their high performance, they’re considered the most reliable COVID-19 test.
PCR tests require specialised laboratory equipment and trained scientists and technicians to test the specimens; processing and testing take several hours.
Since January, we’ve performed an astonishing 7.4 million SARS-CoV-2 PCR tests in Australia, which has needed a massive upscaling of capacity in laboratories nationally.
At times, demand for PCR testing has exceeded capacity, occasionally resulting in delays of up to several days in getting results back to patients. Meanwhile, laboratories swamped with COVID-19 tests may be limited in their capacity to perform their routine business, including diagnostic testing for other infectious diseases.
As people are required to isolate until they receive a negative test result and their symptoms resolve, these delays may come at a cost to the person waiting, their family, and the economy.
Recognising these costs may lead some people to choose not to be tested, Victoria has offered financial compensation for people without leave entitlements awaiting test results.
But delayed case confirmation also increases the time to identification and quarantine of contacts, undermining public health efforts.
Rapid antigen tests can diagnose COVID-19 in 15 minutes. They’re relatively inexpensive and require a swab from the nose.
These tests detect viral antigens, proteins on the surface of SARS-CoV-2. The immune system recognises these proteins as foreign, and responds by making antibodies to SARS-CoV-2 (“anti-gen” means antibody generator).
Antigen tests perform best early in the infection when the amount of virus in a person’s system is highest. For a person with symptomatic COVID-19, this would be in the first week of symptoms. So they only pick up current infections – unlike antibody tests, which can detect if a person was previously infected with SARS-CoV-2.
Four SARS-CoV-2 rapid antigen tests have been licensed for use in Australia in the past two months.
Unfortunately, rapid antigen tests for COVID-19 appear to be less sensitive than PCR tests, meaning they may give a negative result in someone who does actually have COVID-19. One of the recently licensed rapid antigen tests may give a false negative result in up to 18.3% of people with COVID-19 diagnosed by PCR.
While a positive rapid antigen test result is more reliable, widespread use of these tests in asymptomatic people will result in some false positive results — that is, a positive test result in someone who doesn’t have COVID-19.
At this stage, national COVID-19 guidelines don’t include information on antigen tests. So a person with a positive antigen test would need to undergo a PCR test to be counted in Australia’s official COVID-19 case numbers.
We’re faced with a trade-off between the potential benefits of the rapid antigen tests — the ability to test larger numbers of people, consuming fewer laboratory resources, and quicker results — and the potential to miss a few cases because of the lower test sensitivity.
Despite the lower sensitivity, increasing testing rates might result in an overall net increase in the proportion of COVID-19 cases diagnosed, and therefore a public health benefit by preventing onward transmission from these cases.
One possible strategic use of these tests may be in screening people without symptoms to detect asymptomatic and pre-symptomatic infection that might otherwise go undetected. This could include people in workplaces where ongoing exposure to colleagues and the public is unavoidable, including sectors of the food supply chain or other essential services.
Because of the lower test sensitivity for the rapid antigen test, a PCR test remains most appropriate for people with symptoms, those at greater risk of poor outcomes from COVID-19, and people working in high-risk settings like aged care and health care.
While rapid antigen tests show promise, we’ll need to evaluate their efficacy in Australia before we can determine their role in our fight against COVID-19.
Katherine Gibney, NHMRC early career fellow, The Peter Doherty Institute for Infection and Immunity; Deborah Williamson, Professor of Microbiology, The Peter Doherty Institute for Infection and Immunity, and Jodie McVernon, Professor and Director of Doherty Epidemiology, University of Melbourne
Smokers are worried. A respiratory disease is running rampant across the globe and people with unhealthy lifestyle habits appear to be especially vulnerable.
We know smokers hospitalised with COVID-19 are more likely to become severely unwell and die than non-smokers with the disease.
At any point in time, most smokers want to quit. But COVID-19 provides the impetus to do it sooner rather than later.
In our new study, we surveyed 1,204 adult smokers across Australia and the United Kingdom. We found the proportion intending to quit within the next two weeks almost tripled from around 10% of smokers before COVID-19 to 29% in April.
Many more were thinking about quitting some time soon, and most wanted help to do so.
Our research shows many people who smoke understand they can reduce their COVID-19 related risk by addressing their smoking. Given this, and the broader health gains associated with stopping smoking, we must ensure people who want to quit in the face of COVID-19 are supported.
When asked whether they’d like to receive information about the risks of COVID-19 for smokers, almost half (45%) of our respondents said they would. This was especially the case among those wanting to quit very soon.
As for where they wanted to get this information, participants most commonly chose government representatives (59%) and doctors (47%) as their preferred sources.
Television news was the most favoured information delivery channel (61%), followed by online news (36%), social media (31%) and email (31%).
As well as being receptive to information, our participants were keen for support to help them quit.
Evidence-based forms of smoking cessation assistance include nicotine replacement therapy (for example, gum, patches and inhalers) and counselling.
Almost two-thirds (61%) of our respondents expressed an interest in receiving nicotine replacement therapy to help them quit, which rose to more than three-quarters (77%) if it could be home-delivered and provided free of charge.
Half (51%) wanted access to personal advice and support, such as that provided by Quitline. A similar number (49%) were receptive to being part of a text support program for smokers.
These results show us smokers are interested in forms of quitting assistance that can be delivered remotely. Making sure smokers know these sorts of things are available in lockdown could increase uptake, and in turn reduce smoking rates.
It’s also important to note the social isolation associated with the pandemic may make people more vulnerable to the addictive effects of nicotine. So they may need extra support during this time.
Strong groundwork in the form of anti-smoking campaigns, tobacco taxes, and smoke-free environment legislation has reduced smoking levels in Australia to a record low of 11%. But even at this rate, smoking remains Australia’s number-one avoidable killer.
Smoking eventually kills up to two-thirds of regular users, and the number of people dying from smoking-related diseases still dwarfs COVID-19 deaths.
Roughly eight million people around the world die each year from tobacco-related diseases (such as cancer, stroke and heart disease), compared to the almost one million deaths attributed to COVID-19 so far.
Of course, the infectious nature of COVID-19 brings its own set of challenges. But combined, we have a potent reason to prioritise encouraging and helping smokers to quit as soon as possible.
There has been speculation about whether smoking increases the risk of contracting COVID-19, or whether nicotine might actually protect against the disease. The evidence remains unclear.
Regardless of whether smoking affects the risk of contracting COVID-19 in the first place, we know it increases the risk of dying from it. Providing intensive quit support during the pandemic could facilitate a substantial boost to cessation rates and bring us closer to the day when smoking becomes history.
Smokers’ increased risk from COVID-19 and the importance of encouraging smokers to quit to reduce their risk of a range of non-communicable diseases means health agencies around the world are sending messages about the importance of quitting now.
Our results suggest these statements should ideally be accompanied by explicit offers of help to quit in the form of nicotine replacement therapy and counselling. Investment in these is cost-effective, and now is an ideal time to make them as widely available and affordable as possible.
Many smokers would also likely benefit from the use of mass media to provide more information about their greater risk if infected with COVID-19.
This heightened interest in quitting in the face of COVID-19 — reflected not only in our research, but elsewhere — represents a unique opportunity for governments and health agencies to help smokers quit, and stay off smoking for good.
Readers around Australia can call Quitline on 13 7848 or visit www.quit.org.au to access a free multi-session quit assistance program.