Danielle Wood, Grattan Institute; Stephen Duckett, Grattan Institute, and Tom Crowley, Grattan InstituteAt Friday’s National Cabinet meeting, our nation’s leaders put some meat on the bones of their 4-stage plan to reopen Australia.
The plan includes target vaccination thresholds and some details on restrictions that might be lifted at each stage. So far so good.
But the plan raises two major concerns.
First, the reopening threshold is low. We won’t know until we see the modelling, but it looks like the National Cabinet is taking a gamble that the outcomes of re-opening will be at the more rosy end of plausible scenarios.
Second, many important details are still missing, including the timing of each stage and, crucially, the steps the government is taking to get more jabs in arms.
The vaccine coverage thresholds for re-opening look low
The key stage of the plan is stage C. In stage C, the government commits to no more mass lockdowns, and vaccinated Australians can leave the country and return without quarantine.
The government says we need 80% of Australians over 16 vaccinated before we get to stage C.
The over-16 qualifier matters a lot. The virus doesn’t care who is eligible. Children can still transmit the virus and so transmissibility depends on vaccine rates across the population.
Getting to 80% of Australians over 16 I equates to just under 65% of all Australians – far lower than the 80% threshold Grattan Institute recommends for starting to re-open international borders.
The Doherty Institute modelling that informed the plan has not been released. The institute likely presented a range of scenarios. The Australian public have a right to understand the health outcomes in each and the way in which National Cabinet weighed the uncertainty in the modelling.
Committing to a vaccine coverage threshold that is too low risks a rapid surge in COVID cases that could overwhelm our hospitals and impose a high death toll. State governments would almost certainly impose lockdowns to contain this type of spread, pushing “real” reopening further back.
Coverage too low to loosen restrictions for the vaccinated
The steps discussed in stage B also contribute to a greater risk of a disorderly re-opening. Stage B envisages loosening some quarantine requirements and public health restrictions for vaccinated residents.
The main concern is that stage B kicks in at 70% of the eligible population (56% of the total population).
Under almost any scenario, the reproduction number for the Delta strain of the virus is still well above 1 at this point. That means each infected person on average infects more than one other person.
Relaxing international arrival and quarantine restrictions for vaccinated adults – who can still transmit the virus (albeit less so than the unvaccinated) – means more Delta will get in. And allowing exemptions from public health measures for vaccinated residents means the measures to contain the spread of the virus will be less effective.
With only 56% of the population vaccinated, any uncontrolled spread will translate into high rates of serious illness and hospitalisation.
Our governments will be walking a very fine line indeed.
No details on ramping up the vaccine program
The other major concern is the lack of detail about how the National Cabinet plans to ramp up the vaccine program, and timeframes for doing so.
The most concerning line of the prime minister’s Friday evening press conference was “it is all up to us” – suggesting success is largely out of the government’s hands.
Getting enough jabs into arms as quickly as humanly possible is a job for government. We need a step change in the planning and professionalism of the rollout if we are going to have any hope of making these targets in a reasonable timeframe.
Grattan’s Race to 80 report, released last week, set out the necessary steps.
On logistics, it means delivering vaccines not just through GPs but via state-run mass vaccination hubs, pharmacists, schools, workplaces, and through pop-up clinics at community halls, public transport stations, and sporting events.
On messaging, it means high-quality national campaigns but also more targeted messaging for hesitant and harder-to-reach groups, including women, young people, and those from culturally and linguistically diverse communities.
It looks like National Cabinet has not yet considered the crucial question of whether we need vaccine passports in high-risk settings such as restaurants and major events, to encourage people to get the vaccine and to reduce the risks of superspreading events.
And there is no plan to vaccinate children, even though Australia’s regulator, the Therapeutic Goods Administration (TGA), has already approved Pfizer for 12-to-16 year olds.
More to do
Australia can’t afford much more delay. The key planks of the logistics, messaging, and incentive campaigns need to be in place very soon if we are going to substantially increase the pace of the rollout as more Pfizer doses arrive in coming months.
At the same time, governments should release the Doherty modelling to help Australians understand the expected health outcomes under each of the four stages.
Vaccinations are the route back to normal life. This means all Australians have a stake in making sure our governments get this plan right.
Nial Wheate, University of Sydney; Elise Schubert, University of Sydney, and Ingrid Gelissen, University of SydneyWe now know enough about how COVID works for health authorities to have issued clear guidance on which drugs doctors should use on hospitalised patients. The recommended drugs are dexamethasone, remdesivir, and tocilizumab.
Remdesivir, also known as Veklury, is not manufactured in Australia and the Therapeutic Goods Administration (TGA) has recently issued an alert warning of a shortage of tocilizumab in Australia. And the large dexamethasone manufacturers are based overseas. The website Pharmaoffer, which shows suppliers of active pharmaceutical ingredients, lists the countries that produce the active ingredient in dexamethasone; Australia is not one of them.
More broadly, Australia lacks medicines manufacturing capability and this puts us at significant risk should supplies from overseas continue to be interrupted.
One report released last year described the Australian market for pharmaceuticals as “possibly one of the most vulnerable in the OECD”.
It’s time for Australia to re-invest in domestic medicine manufacturing.
Drugs used to treat COVID-19
Many people diagnosed with COVID-19 experience only mild, or no symptoms at all, and can be managed and monitored at home. Rest is the main treatment, and medicines such as paracetamol and/or ibuprofen can provide symptomatic relief of any mild fevers.
People with moderate to severe COVID-19 are treated in hospital. The medicines doctors will prescribe in hospital depend on a patient’s clinical circumstances, such as whether or not they are receiving oxygen therapy.
The pharmaceutical treatment options include:
- dexamethasone, a corticosteriod
- remdesivir, an antiviral and
- tocilizumab, a monoclonal antibody and immunosuppressive agent (monoclonal antibodies are lab-made proteins that mimic the immune system’s virus-fighting abilities).
Dexamethasone is already used for a wide range of conditions, such as certain forms of cancer and arthritis, and various other disorders. Now, it is used in treatment of COVID-19 to suppress inflammation and immune responses.
Remdesivir works by stopping the replication of viral RNA.
And tocilizumab is sometimes used when COVID-19 patients have signs of systemic inflammation.
Where are they made?
Australia is heavily reliant on supply agreements for medicines that come from overseas (and a manufacturing network might include a lot of countries). It’s been reported some of the large dexamethasone manufacturers are in Brazil and India.
To meet growing demand for remdesivir, its company (Gilead) has approved new deals for manufacturing in Egypt, India, and Pakistan. But while the remdesivir manufacturing network now includes more than 40 companies in North America, Europe, and Asia, the medicine is not manufactured in Australia.
Tocilizumab was developed in Japan and is now also licensed for manufacturing by the California-based company Genentech.
Need for Australian manufacturing base
There is an urgent need for Australia to increase local manufacturing of many types of medicines, not just COVID treatments, to secure current and future needs.
The Australian government has acknowledged the importance of boosting local production of medicines but it’s unclear what progress has been made.
In March this year, an interim report by the Productivity Commission on vulnerable supply chains again indicated medicines as an area of concern, noting that
the pharmaceutical industry is highly regulated, making entering the market or modifying existing facilities to respond to a crisis a slow and costly process.
The final report from this committee is currently with the government.
Manufacturing of medicines in Australia is regulated by the TGA. According to its website, it can take up to 12 months for an Australian manufacturer to get approval to bring a new manufacturing site online. This means it would take us a long time to act if a supply shortage pops up.
Significant backing from the federal government for local medicine manufacturing would reduce the risk of key medicine shortages in Australia, while also creating many highly skilled jobs.
Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of Sydney; Elise Schubert, Pharmacist and PhD Candidate, University of Sydney, and Ingrid Gelissen, Associate Professor in Pharmaceutical Sciences, School of Pharmacy, University of Sydney
Vicki Sentas, UNSW; Leanne Weber, University of Canberra, and Louise Boon-Kuo, University of SydneyWith rolling lockdowns now part of how Australians live in the pandemic age, important questions arise about corresponding changes in policing. Constantly changing public health orders bring not only confusion but expansive police authority to enforce many new criminal offences.
On one view, using the police to protect public health by stopping the spread of the virus appears a logical step. But, in practice, do public health objectives always take precedence over existing enforcement approaches?
The recent deployment of 100 additional officers and mounted police to south-west Sydney call to mind the same concerns expressed by the Victorian Ombudsman that the policing and lockdown of public housing tower blocks in 2020 were partly informed by “incorrect and potentially stereotypical assumptions” about residents.
Reports of unfair police actions revise age-old questions about the role and function of the police in enforcing social inequalities and its punitive effects.
How is COVID being policed?
Select data we obtained from New South Wales Police indicate that from March 15 to June 15 2020, the most common police action was to search those stopped. Although the public health relevance of conducting a search is unclear, police searched 45% of all people stopped for a COVID-related incident.
We also know COVID policing has affected some communities more than others. In Victoria, a parliamentary inquiry found people in lower socioeconomic areas were twice as likely to be fined as those in higher socioeconomic areas.
Our research in NSW found Aboriginal or Torres Strait Islander peoples comprised 9% of the stop incidents in which Indigenous or non-Indigenous status was recorded. Aboriginal and Torres Strait Islander people were even more disproportionately subject to coercive police powers following a stop, making up 15% of arrests and 10% of people searched.
Whatever the precise level of over-representation, these findings are consistent with the broader, long-standing experience of the over-policing of Aboriginal and Torres Strait Islander peoples.
Considering Aboriginal and Torres Strait Islander peoples comprise around 3% of the population, these data alone show disproportionate use of search and arrest powers. They also support concerns that the pandemic has intensified the policing of Aboriginal and Torres Strait Islander peoples.
COVID policing appears to rely on longstanding criminalisation strategies at odds with public health. An old-school public order approach of stop and search, and fines, undermines public health because of the social harms of criminal justice contact.
Most obviously, increased police contact through personal searches could increase the risk of transmission. And, as we explain elsewhere, questions remain about their lawful basis.
How could COVID be policed?
The social and economic costs of the pandemic have greater impacts on precarious and low-wage workers and marginalised people. It is even more critical that policing does not amplify those inequalities by prioritising punishment over keeping people safe.
The Australian approach isn’t the only possibility. Heavy reliance on enforcement contrasts, for example, with the United Kingdom, where the policing of COVID-19 measures early in the pandemic was independently assessed by policing experts as “taking place at the margins”. These experts pointed out that people are more likely to comply with rules where they regard them as morally right and reflecting social norms, rather than because they fear fines and other sanctions.
Instead of prosecuting individuals for non-compliance with frequently changing laws, a better approach would be to provide financial assistance and accessible information, particularly for disadvantaged groups.
A community-focused, public health approach would move away from coercive policing and emphasise co-developed community resources on COVID restrictions and their purpose.
A small group of NSW Police officers recently joined forces with a community organisation to hand out free masks and hand sanitiser to residents in hard-hit areas of western Sydney. But this has not been a system-wide approach, and is unlikely to erase the memory of mounted police patrols enforcing the lockdown in the same area.
It is too early to say what the lasting changes in policing may be. Will additional powers granted to police persist beyond the emergency in some other form? Will states continue to revert to border control to protect against future, non-biological risks? Will technology-driven population surveillance become more prominent?
This all remains to be seen. But it is certain that mass vaccination would shrink the need for state policing of COVID altogether.
Danielle Marie Muscat, University of Sydney; Julie Ayre, University of Sydney; Kirsten McCaffery, University of Sydney, and Olivia Mac, University of SydneyAs Sydney’s COVID-19 outbreak continues to grow, the message has shifted to urgently “get the jab”. And people’s motivation to get vaccinated is increasing.
But with ever-changing advice, many people are confused about which vaccine they’re eligible for and where to get an appointment.
Our recent review, which has been accepted for publication in the Medical Journal of Australia, shows information for the public about COVID vaccines is too complex to read, understand and act upon. It’s even more complex than other COVID public health advice, such as for physical distancing or masks.
Then there’s the results of our recent survey, which has yet to be peer reviewed, of where people from culturally and linguistically diverse (CALD) communities get their COVID information from. This finds a huge diversity of sources, beyond official government websites. So we need to tailor communications to these communities via channels people actually use.
Taken together, our research shows we are still missing clear and consistent communication about COVID vaccines all Australians can understand and act on.
No wonder people are confused
We looked at publically available COVID-19 information from government websites from Australia (federal and three states), the United Kingdom, New Zealand, and three international public health agencies (including the World Health Organization).
Most public information was above the recommended reading level for the general population (8th grade).
In Australia, information was commonly written at postgraduate level. This means it is too difficult for people with average reading ability to understand. It’s likely even harder for the 9 million Australians who have lower health literacy.
Vaccination information from the federal government website was the only Australian material to adequately outline the action or steps readers needed to take to get vaccinated. Websites from all three states (New South Wales, Queensland, Victoria) we reviewed did not.
This means there has been little progress nationally or internationally in terms of improving the readability of written COVID-19 information since April 2020.
Culturally and linguistically diverse Australians
Our review does not begin to capture the additional limitations of COVID-19 communications for CALD communities.
People from CALD backgrounds form a significant and growing share of Australia’s population. For instance, 43% of the population of southwest Sydney (one of the focuses of the current COVID-19 outbreak) was born overseas; up to 71% in certain local government areas speak a language other than English at home.
Yet, translated information and communications about COVID-19 have been sparse, intermittent and not all has been appropriate. The original source materials in English are too complex, official translators are not used, and/or translations are not reviewed to make sure the information makes sense.
There has been some progress
We’ve had some progress this week. Press briefings, crucially important for keeping up-to-date about new rules and regulations, have only in the past few days been made available in any other language than English.
Similarly, the online vaccination eligibility checker has only just been translated into 15 other languages. However, the online vaccine clinic finder, which you reach at end of the vaccine eligibility checker, remains only in English.
More positively, a COVID-19 vaccination glossary (with clear descriptions of complex vaccine terms) is now available in 29 languages.
But more work is needed
However, more work is needed to ensure COVID information is “distributed widely” to CALD communities via the most appropriate channels, as recommended in the Australian government’s own plan.
Our recent survey of over 700 CALD community members in Greater Western Sydney showed just over half (about 54%) of participants used official government sources to find out about COVID-19. However, this varied greatly between language groups, reaching as low as 29% for some.
Social media (52%), family and friends (33%), and community sources (26%) were also common pathways for seeking out information about COVID. Many sought in-language communication from overseas. For some of these groups, official sources appear less accessible or useful.
So work is clearly needed to distribute tailored communications via channels people actually use.
What actually works?
We know how to communicate public health messages clearly for diverse communities. We can:
- use everyday words for all public health communication
- test readability levels of written documents
- check the “actionability” of instructions (whether there are clear instructions of what to do next)
- use pictures, icons or animations.
We know it is possible to successfully implement these strategies. Our review identified 12 “easy-to-read” materials written at a lower reading grade that were easier to understand.
However, these were rare, difficult to find on official websites and often poorly signposted. For instance, some were on pages labelled for “people with disability”.
We need concerted action to ensure materials such as these become the “rule” rather than the exception. Plain language and in-language information simply cannot be an afterthought or “optional extra” if we are to achieve the 80% or higher vaccination rates needed to end lockdowns and return to some semblance of normal.
Danielle Marie Muscat, Post-Doctoral Research Fellow, University of Sydney; Julie Ayre, Post Doctoral Research Fellow, University of Sydney; Kirsten McCaffery, NHMRC Principal Research Fellow, University of Sydney, and Olivia Mac, Research fellow, University of Sydney
Deborah Williamson, The Peter Doherty Institute for Infection and Immunity and Sharon Lewin, The Peter Doherty Institute for Infection and ImmunitySince the start of the pandemic, COVID-19 testing in Australia has been performed using highly sensitive PCR (polymerase chain reaction) tests.
But this conventional model of testing, which involves swabbing by a health-care professional and transporting samples to a laboratory for analysis, has important bottlenecks. Recent reports indicate people have been waiting several hours just to have a swab taken.
With the current COVID outbreaks in Australia, there’s been a renewed focus on alternative testing methods to PCR — in particular rapid antigen testing.
New South Wales this week announced it would begin using rapid antigen tests in schools to allow year 12 students to return to the classroom safely, as well as in essential workplaces.
So what are rapid antigen tests, are they effective, and what role should they play in Australia’s response to COVID-19?
What are antigen tests?
Antigen tests detect protein on the surface of SARS-CoV-2 (the virus that causes COVID-19) directly from a sample taken with a swab inserted into the nose.
Because antigen tests do not amplify parts of the virus’ genetic code, they are less sensitive than PCR tests.
The main advantages of antigen tests over PCR tests include their lower cost and their speed. Most antigen tests are designed to be used at the point of care, with results available in about 15 minutes. They cost roughly A$5 to A$20 per test.
How effective are they?
In countries such as the United Kingdom and United States, antigen tests have been used widely to complement PCR testing during the pandemic.
So far, the strongest published evidence to support the use of antigen tests is in symptomatic people within the first few days of their symptoms starting, when the amount of virus in nasal secretions is highest.
In other words, antigen tests are most accurate when the viral load is highest and when a person is likely to be most infectious. If an antigen test is taken either too early or too late in the course of infection, it may not detect the virus.
There are conflicting data on the performance of antigen tests in people without symptoms. A Cochrane review looking at results across several studies found the sensitivity of antigen tests (the likelihood of a positive result if someone is infected with the virus) was between 40% and 74% in people without symptoms. So a fair proportion of people tested may receive a negative test when they really have the virus.
With this in mind, compared to a “one-off” antigen test, repeated antigen testing (for example, daily) may improve the detection of virus, particularly in people who don’t have symptoms, or when there’s a low level of disease in the community.
Importantly, “real-world” overseas studies looking at antigen testing have varied widely in the types of tests it was compared with, the populations tested, and how much disease was circulating in the community at the time of the study.
This means it’s very hard to extrapolate information from overseas directly to Australia.
We need to trial rapid antigen testing in Australia to get reliable local information
The Therapeutics Goods Administration has so far approved 20 rapid antigen tests for use in Australia.
But antigen tests can only be supplied to accredited laboratories, medical practitioners, health-care professionals working in residential and aged-care facilities, or health departments. The commercial supply of COVID-19 antigen kits for self-testing at home is prohibited.
One way we could properly evaluate the use of antigen tests in Australia is through a series of clinical trials.
These could include trials of returning travellers undertaking daily self-testing in home quarantine, or repeated testing of groups of workers in potentially high-risk workplaces (for example, food distribution centres, construction sites or aged care).
Lessons from HIV
A precedent for community-based self-testing for an infectious disease in Australia is HIV. There were initially concerns the antibody test used for home HIV testing was not sensitive enough, and not as good as the gold standard laboratory test. There were also concerns people wouldn’t know how to deal with a positive test.
But the implementation of HIV self-testing over the past couple of years has been broadly successful. Education campaigns help people understand the limitations of the test, while there are effective processes in place to support people who return a positive result.
Although COVID-19 and HIV are very different diseases, the HIV experience offers useful lessons on how to implement home testing for a high-impact disease in a low-prevalence setting, while ensuring testing is accessible and convenient for all, including marginalised groups.
It’s not perfect, but it could be useful
One fundamental proviso for the use of widespread antigen testing is that we have to be prepared to accept a degree of risk. We know these tests are less sensitive than the current diagnostic “gold standard”, meaning it’s almost certain they will miss some cases of COVID-19.
PCR testing undoubtedly underpins our high-quality laboratory response to COVID-19 in Australia. But our capacity to sustain PCR testing at the level we will eventually need for communities to function normally and for international borders to reopen is uncertain.
We urgently need pragmatic real-world trials of new testing strategies to help us understand how best to return to a “COVID-normal” life.
Deborah Williamson, Professor of Microbiology, The Peter Doherty Institute for Infection and Immunity and Sharon Lewin, Director, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital and Consultant Physician, Department of Infectious Diseases, Alfred Hospital and Monash University, The Peter Doherty Institute for Infection and Immunity
Denis Muller, The University of MelbourneElements within News Corporation are now fighting among themselves over how its platforms should position themselves in response to the worsening COVID crisis in New South Wales.
This has become clear with the decision by the editor of News Corp’s Daily Telegraph, Ben English, to ditch Alan Jones as a columnist.
Over the past few weeks, as the coronavirus outbreak got inexorably worse, the Telegraph ran a series of characteristically shrill columns by Jones attacking mask-wearing, lockdowns and NSW Premier Gladys Berejiklian.
Yet Jones also promotes these opinions on News Corp’s Sky News, where his Sky-at-Night slot is undisturbed. Indeed, Jones makes a virtue of this, telling The Sydney Morning Herald:
Have a look at Sky News YouTube, Sky News Facebook and Alan Jones Facebook and you can see. The same column that I write for the Tele goes up on my Facebook page.
On July 29, the Telegraph also took the opportunity provided by an outburst against Jones by the NSW health minister, Brad Hazzard, to distance itself from its former columnist, referring to him as a “Sky News host”.
At The Australian on July 30, Jones’s opinions were confined to rugby union.
Trying to read the entrails of what goes on in News Corp is akin to Kremlinology, but this is the second piece of evidence in the past couple of weeks that the Telegraph is executing a delicate pivot.
A decision to switch to an overt anti-Coalition position would be well above the editor’s pay grade. However, a couple of weeks ago, the Telegraph’s editor-at-large, Matthew Benns, wrote a curious critique of Scott Morrison’s handling of vaccination and quarantine, written as if by the Morrison family dog. It contained quite a lot of nipping at Morrison’s heels.
It has continued to report the growing COVID crisis straight, publishing pictures of a strained-looking Berejiklian but refraining from attacking her in commentary.
Putting all this together, the Telegraph seems to be positioning itself as champion of an heroic people, contingently tolerant of Berejiklian, intolerant of attacks on her policies, restless with Morrison, yet anxious not to damage the Liberal Party politically.
The degree of difficulty involved in staying upright while executing this manoeuvre is considerable.
Meanwhile at Sky, Jones goes on as before, and Peta Credlin resorts to some very dodgy logic in an attempt to show that the performance of the Labor government in Victoria is still clearly inferior to the performance of the Coalition government in New South Wales.
Her proposition is that the 172 cases of the Delta strain reported on July 28 was nothing like as bad as the 700 cases a day at the height of the Victorian crisis last year, even though, she said, Delta was three times more infectious than last year’s strain.
This, she said, should cause people in NSW to “take heart”.
So a snapshot one-point reading of a curve that is still rising steeply – the case numbers on July 29 were 239 – is compared with the peak of a separate outbreak of a strain that Credlin says was three times less infectious.
If the people of New South Wales take heart from that, they are really grasping at straws.
Credlin does not attack Berejiklian, masks or lockdowns as Jones does, and she carries a torch for the Coalition while also trying to boost morale in Sydney.
Andrew Bolt threads his way through this maze by attacking politicians who he says have “smeared” the people who took part in the anti-lockdown marches on July 25. At the same time he remains uncharacteristically agnostic on whether lockdowns are right.
Last year Bolt was calling lockdowns an over-reaction. It evidently makes a difference when it is your side of politics doing the locking down.
As Australia enters a pre-election phase, it matters what the Murdoch media do. Its newspapers represent about two-thirds of the nation’s metropolitan daily circulation, with monopolies in Brisbane, Adelaide and Hobart. In August, Sky News will re-enter free-to-air television via several Southern Cross Austereo regional channels, which it claims will give it an audience of seven million.
What the Telegraph does is particularly important because it is Murdoch’s main populist political attack dog in Australia. It circulates widely in western Sydney, where there are several marginal seats.
Reading the entrails is an inexact science, to put it mildly, but there is a public-interest reason for trying.