Could Britain be sued for reopening and putting the world at risk from new COVID variants?


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Kris Gledhill, Auckland University of TechnologyWith most COVID-19 restrictions now lifted in England, the world is watching to see what this so-called “freedom day” will bring.

Some scepticism is warranted, given Britain’s approach throughout the pandemic has hardly been a success. By July 19, there had been 128,985 deaths from COVID-19, and the death rate per million of population was just under 1,900.

True, there are countries with worse rates, including Hungary, Italy and the Czech Republic in Europe. But countries that have taken a different approach have vastly better figures: for example, 35.8 deaths per million of population in Australia, and 5.39 in New Zealand.

No doubt Boris Johnson’s government took its emphatic 2019 election victory and relatively successful vaccination program as a mandate for opening up.

But the current situation doesn’t support such optimism. Infection rates are now the worst in Europe and the death rate is climbing. By contrast, Australia has much lower death and infection rates but state authorities have responded with lockdowns.

Furthermore, many scientists have condemned the opening-up policy. The authors of the John Snow Memorandum stress the risks to the 17 million people in the UK who have not been vaccinated, and state:

[This approach] provides fertile ground for the emergence of vaccine-resistant variants. This would place all at risk, including those already vaccinated, within the UK and globally.

Taking the UK to court

Is it enough to hope Boris de Pfeffel Johnson will not just dismiss these concerns as piffle? Perhaps there is an alternative — taking the UK to court. Specifically, to the international courts that deal with matters of human rights.

For countries in the Council of Europe, this would be the European Court of Human Rights. Globally, there is the option of the Human Rights Committee of the United Nations.

How would this work? A court claim requires what lawyers call a “cause of action” — in this case, a breach of human rights, including the right to life and the right not to be subject to inhuman and degrading treatment.




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In the main international human rights treaty, the International Covenant on Civil and Political Rights (ICCPR), article 6 requires that the right to life, which belongs to everyone, must be protected. Article 2 of the European Convention on Human Rights (ECHR) says the same.

In 2019, the UN Human Rights Committee noted this right to life amounts to an “entitlement […] to be free from acts and omissions that are intended or may be expected to cause their unnatural or premature death”.

It also noted the obligation on states to take steps to counter life-threatening diseases.

A duty to protect

European Court of Human Rights case law establishes that the duty to protect life includes a requirement on states to take reasonable steps if they know (or ought to know) there is a real and immediate risk to life.

This has usually involved the criminal actions of dangerous people, but there is no reason it should not cover government policy that rests on an acceptance that people will die.

After all, the entire human rights framework was put in place to limit states from breaching rights.




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This duty to protect applies not just to deaths. Both the ICCPR and the ECHR have absolute prohibitions on inhuman and degrading treatment. For many people, the severity of COVID-19, including the consequences of long COVID, meet this standard.

If government policy can mitigate such consequences, human rights standards mandate that it should.

In short, this is not just a matter of the right to health. Because the UK will likely allow the virus to spread from its shores, the rest of the world is at risk and therefore has an interest here. So can other countries take action?

A political calculation

Human rights conventions are treaties — promises by states to each other as to how they will act. Article 33 of the ECHR is very clear: states can ask the European Court of Human Rights to adjudicate whether another state is breaching rights. There are many instances of this happening.

Importantly, the court can issue “interim measures” under its procedural rules to preserve the status quo while it hears a case.




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The UN Human Rights Committee may also consider state-to-state complaints under article 41 of the ICCPR if a state has agreed to this — and the UK has made the relevant declaration.

Of course, any decision by a state to take another to court is political. But this pandemic is not just a health issue, it is also a matter of life and death. Protecting life should be a political priority precisely because it is such a fundamental right.

Politicians willing to stand up for human rights should use the tools that exist to achieve that aim.The Conversation

Kris Gledhill, Professor of Law, Auckland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Calling out China for cyberattacks is risky — but a lawless digital world is even riskier


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Alexander Gillespie, University of WaikatoToday’s multi-country condemnation of cyber-attacks by Chinese state-sponsored agencies was a sign of increasing frustration at recent behaviour. But it also masks the real problem — international law isn’t strong or coherent enough to deal with this growing threat.

The coordinated announcement by several countries, including the US, UK, Australia and New Zealand, echoes the most recent threat assessment from the US intelligence community: cyber threats from nation states and their surrogates will remain acute for the foreseeable future.

Joining the chorus against China may be diplomatically risky for New Zealand and others, and China has already described the claims as “groundless and irresponsible”. But there is no doubt the problem is real.

The latest report from New Zealand’s Government Communications Security Bureau (GCSB) recorded 353 cyber security incidents in the 12 months to the middle of 2020, compared with 339 incidents in the previous year.

Given the focus is on potentially high-impact events targeting organisations of national significance, this is likely only a small proportion of the total. But the GCSB estimated state-sponsored attacks accounted for up to 30% of incidents recorded in 2019-20.

Since that report, more serious incidents have occurred, including attacks on the stock-exchange and Waikato hospital. The attacks are becoming more sophisticated and inflicting greater damage.

Globally, there are warnings that a major cyberattack could be as deadly as a weapon of mass destruction. The need to de-escalate is urgent.

Global solutions missing

New Zealand would be relatively well-prepared to cope with domestic incidents using criminal, privacy and even harmful digital communications laws. But most cybercrime originates overseas, and global solutions don’t really exist.

In theory, the attacks can be divided into two types — those by criminals and those by foreign governments. In reality, the line between the two is blurred.

Dealing with foreign criminals is slightly easier than combating attacks by other governments, and Prime Minister Jacinda Ardern has recognised the need for a global effort to fight this kind of cybercrime.




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To that end, the government recently announced New Zealand was joining the Council of Europe’s Convention on Cybercrime, a global regime signed by 66 countries based on shared basic legal standards, mutual assistance and extradition rules.

Unfortunately, some of the countries most often suspected of allowing international cybercrime to be committed from within their borders have not signed, meaning they are not bound by its obligations.

That includes Russia, China and North Korea. Along with several other countries not known for their tolerance of an open, free and secure internet, they are trying to create an alternative international cybercrime regime, now entering a drafting process through the United Nations.

Cyberattacks as acts of war

Dealing with attacks by other governments (as opposed to criminals) is even harder.

Only broad principles exist, including that countries refrain from the threat or use of force against the territorial integrity or political independence of any state, and that they should behave in a friendly way towards one another. If one is attacked, it has an inherent right of self-defence.




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Malicious state-sponsored cyber activity involving espionage, ransoms or breaches of privacy might qualify as unfriendly and in bad faith, but they are not acts of war.

However, cyberattacks directed by other governments could amount to acts of war if they cause death, serious injury or significant damage to the targeted state. Cyberattacks that meddle in foreign elections may, depending on their impact, dangerously undermine peace.

And yet, despite these extreme risks, there is no international convention governing state-based cyberattacks in the ways the Geneva Conventions cover the rules of warfare or arms control conventions limit weapons of mass destruction.

Vladimir Putin shaking hands with Joe Biden
Drawing a red line on cybercrime: US President Joe Biden meets Russian President Vladimir Putin in Geneva in June.
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Risks of retaliation

The latest condemnation of Chinese-linked cyberattacks notwithstanding, the problem is not going away.

At their recent meeting in Geneva, US President Joe Biden told his Russian counterpart, Vladimir Putin, the US would retaliate against any attacks on its critical infrastructure. A new US agency aimed at countering ransomware attacks would respond in “unseen and seen ways”, according to the administration.

Such responses would be legal under international law if there were no alternative means of resolution or reparation, and could be argued to be necessary and proportionate.

Also, the response can be unilateral or collective, meaning the US might call on its friends and allies to help. New Zealand has said it is open to the proposition that victim states can, in limited circumstances, request assistance from other states to apply proportionate countermeasures against someone acting in breach of international law.




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A drift towards lawlessness

But only a month after Biden drew his red line with Putin, another massive ransomware attack crippled hundreds of service providers across 17 countries, including New Zealand schools and kindergartens.

The Russian-affiliated ransomware group REvil that was probably behind the attacks mysteriously disappeared from the internet a few weeks later.




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Things are moving fast and none of it is very reassuring. In an interconnected world facing a growing threat from cyberattacks, we appear to be drifting away from order, stability and safety and towards the darkness of increasing lawlessness.

The coordinated condemnation of China by New Zealand and others has considerably upped the ante. All parties should now be seeking a rules-based international solution or the risk will only grow.The Conversation

Alexander Gillespie, Professor of Law, University of Waikato

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The benefits of a COVID vaccine far outweigh the small risk of treatable heart inflammation


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Jonathan Noonan, Baker Heart and Diabetes Institute and Karlheinz Peter, Baker Heart and Diabetes InstituteRepeated COVID-19 outbreaks in Australia have once again highlighted the need for rapid and widespread vaccination. We are extremely fortunate the global scientific community has been able to develop a handful of highly effective vaccines in such a short time.

As with any vaccine or medicine, the COVID vaccines do carry small risks. The rare blood clotting disorder caused by the AstraZeneca vaccine — thrombosis with thrombocytopenia syndrome, or TTS — has largely dominated the headlines.

But we’re also seeing reports of a potentially increased risk of myocarditis and pericarditis (heart inflammation) following the mRNA COVID-19 vaccines, developed by Pfizer/BioNTech and Moderna.

Here’s why this shouldn’t be cause for concern.

First, what are myocarditis and pericarditis?

There are three main types of heart inflammation: endocarditis, myocarditis, and pericarditis. These involve inflammation of the inner lining of the heart, the heart muscle, and the outer lining of the heart respectively.

Viruses, including the SARS-CoV-2 virus that causes COVID-19, are the most common cause of myocarditis and pericarditis. Essentially, the inflammation the immune system generates to combat infections can inadvertently lead to inflammation of the heart.

In the very rare cases of myocarditis and pericarditis observed after vaccination with a COVID mRNA shot, it’s possible a similar thing might be happening. That is, the vaccine causes the immune system to generate some level of inflammation so it’s prepared to mount a response against SARS-CoV-2, and this inflammation is partially misdirected to the heart.

But the risk is very small, and the conditions are treatable.

A heart diagram with an inflamed pericardium (pericarditis) next to a heart with inflammation showing myocarditis.

Shutterstock

What’s the risk?

The exact incidence of myocarditis and pericarditis following vaccination is still being defined, and it remains to be proven that mRNA vaccines are truly the cause of these conditions — although it seems likely.

In Australia, of roughly 3.7 million doses of the Pfizer vaccine administered up to July 11, the Therapeutic Goods Administration (TGA) reports there have been 50 cases of suspected myocarditis or pericarditis. This suggests a risk of one per 74,000 vaccines. The TGA notes most people who developed these conditions have recovered or are recovering.

However, given the relatively small number of vaccinations administered in Australia, it’s important to consider more complete data from countries with higher vaccination rates.




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The United States’ Centres for Disease Control and Prevention (CDC) had received 1,226 reports of myocarditis following 296 million doses of mRNA vaccines administered up to June 11. This equates to a risk of roughly one in 240,000 doses. These cases were mostly in young men and predominantly occurred after the second dose.

Independently from vaccines, myocarditis occurs in roughly 23 per 100,000 people worldwide per year (we don’t have reliable figures for pericarditis). This shows us there’s a much lower risk from vaccination than exists in the population generally.

Symptoms to look out for

Normal side effects of COVID-19 vaccines include headache, fever, chills, muscle or joint pain, fatigue and nausea.

In contrast, chest pain, irregular heartbeat, heart palpitations, shortness of breath and light-headedness could indicate myocarditis or pericarditis. Symptoms of these conditions have generally occurred within seven days of vaccination. Anyone who experiences these symptoms should seek medical attention.

In most cases, myocarditis and pericarditis can be successfully treated with anti-inflammatory drugs, such as aspirin and corticosteroids.

In Israel, 95% of cases recently investigated were classified as mild. Similarly, the CDC has reported most patients in the US have recovered quickly.

While this very small risk of heart inflammation following vaccination may be alarming, it’s crucial to understand the risk of heart damage following severe COVID-19 is far greater.




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COVID-19 and heart damage

Damage of the heart muscle is a common consequence of coronavirus. Research shows it occurs in up to 28% of patients hospitalised with COVID-19.

Importantly, the risk of death is markedly higher in COVID-19 patients who sustain heart muscle damage. While we need further research to understand precisely how COVID-19 damages the heart, myocarditis and pericarditis are major causes of the heart damage found in COVID-19 patients.

The benefit outweighs the risk

The recent limits applied to the use of the AstraZeneca vaccine in younger age groups suggests the relatively low risk of COVID-19 in Australia justifies being highly selective over vaccine use.

But while Australia has done incredibly well at containing COVID-19, the risk of transmission here remains high given the global COVID-19 situation. We’re seeing this daily as we contend with outbreaks and lockdowns around the country.

Myocarditis and pericarditis are potentially associated with the mRNA vaccines, but these complications are extremely rare, most often mild, and seem to be treatable.

As has been the consistent message from the medical and scientific communities throughout this pandemic, the benefit of COVID-19 vaccines significantly outweighs the risk of rare side effects. This is particularly true for the highly effective mRNA-based vaccines as COVID-19 continues to spread around the world.




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The Conversation


Jonathan Noonan, Research Officer, Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute and Karlheinz Peter, Interventional Cardiologist, Alfred Hospital; Professor of Medicine and Immunology, Monash University; Professor and Head, Department of Cardiometabolic Health, University of Melbourne; Lab Head, Atherothrombosis and Vascular Biology and Deputy Director, Baker Heart and Diabetes Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Concerned about the latest AstraZeneca news? These 3 graphics help you make sense of the risk


Hassan Vally, La Trobe UniversityYesterday’s announcement the AstraZeneca COVID vaccine would now only be recommended for the over 60s has highlighted the many ways we think about risk.

The decision reflects a greater understanding of the real, but extremely low, risk of the clotting disorder called thrombosis with thrombocytopenia (TTS) for people aged 50-59, who are now recommended to have the Pfizer vaccine.

But errors in the way we perceive these extremely small risks, called cognitive biases, reflect the fact that when our brains evolved we did not have to grapple with risks this small. So we struggle to make sense of them and perceive these events as being much more likely than they actually are.

This can lead us to make decisions, such as not having a vaccine that could potentially save our life. And the misperception of the likelihood of TTS is one of the main reasons many are hesitant about receiving the AstraZeneca vaccine.

So let’s start with what we know about the risk of dying from TTS associated with the AstraZeneca vaccine, expressed the traditional way, with words and numbers. Then we’ll present the same numbers graphically.




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What’s the risk of dying from TTS?

Initially, we thought about 25% of people with TTS associated with the vaccine would die. But as we learnt more about how to recognise and treat these rare blood clots, the risk of dying from it has changed. In Australia, mortality is now down to around 4%.

This is a low risk of dying from a syndrome with a small likelihood of occurring. So we can express TTS risk in another way.

Two people in Australia have died from TTS after 3.8 million doses of the AstraZeneca vaccine delivered. This makes the likelihood of dying from this syndrome about 0.5 in a million, or if you prefer whole numbers, about 1 in 2 million.




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And now, with graphics

Here’s one way of representing 1 in 2 million visually. This figure shows just how small this risk is. Are you ready for some scrolling?


The Conversation, CC BY-ND

As you can see, the risk of TTS is so small it is almost too small to communicate effectively in this format.

Perhaps even more visually powerful is to compare the risk of dying from TTS to other risks we face in our lives, using a risk scale. This allows you to compare a range of risks and put them into perspective.

As the risk of TTS is a one-off risk normally associated with the first dose of the AstraZeneca vaccine, one interesting comparison is with other one-off risks, such as adventure sports.



As you can see, the risk of dying from TTS is far lower than many activities some of us get up to at the weekend.

But not all of us spend our weekends scuba diving or rock climbing. So let’s look at the more common risks we take in our everyday lives but do not pay much attention to.

This is not a perfect comparison, as the risks are averaged across the whole population, across the entire year. But it’s useful nevertheless.



So the risk of dying from TTS after the first dose of the AstraZeneca vaccine is similar to the risk of being killed by lightning in a year in Australia. And this pales in comparison when compared to other risks, such as the risk of dying in a car accident.

So what happens next?

One of the challenges for public health has always been putting the risks and benefits of our health choices into perspective. This task is even harder when the risks involved are so small.

Using visualisations like these is one way to effectively communicate just how small the risk of TTS is and also put this risk into perspective by comparing it to other risks we incur in our lives.

When you fully appreciate how small the risk of TTS is, the decision to have the AstraZeneca vaccine to protect yourself and others becomes a much easier one to make.The Conversation

Hassan Vally, Associate Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Home quarantine for vaccinated returned travellers is extremely low risk, and won’t damage their mental health


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Gregory Dore, UNSWMany thousands of people need to return to Australia, and many at home wish to reunite with partners and family abroad.

A move away from a one-size-fits-all approach to quarantine is a way to make this happen — including home quarantine for vaccinated returnees.

The federal government implemented home quarantine over a short period in March 2020, before switching to mandatory hotel quarantine for returned residents and other incoming passengers.

But the considerably changed circumstances — most importantly, access to effective vaccines — calls for its reintroduction despite caution among politicians and the community.

The low rate of positive cases, and proven effectiveness of further safeguards to limit breaches, make home quarantine a persuasive strategy.

It’s worth remembering people who contract COVID, and their contacts, have successfully self-isolated at home since the pandemic began.

How will we make sure it’s safe?

There are several protective layers which would ensure extremely limited risk of home quarantine for fully vaccinated returned overseas travellers.

The first is requiring a negative COVID test within three days of departure, which is currently a requirement for all returnees.

The second is COVID vaccination. Recent studies indicate full vaccination provides 60-90% infection risk reduction. In cases where fully vaccinated people do get infected, these “breakthrough cases” are less infectious.

It’s also important to test returnees in home quarantine. A positive case would trigger testing of any contacts and may extend self-isolation.

Also, high levels of testing in the broader community can ensure early detection of outbreaks, enabling a rapid public health response to limit spread, if it did leak out of home quarantine.




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The risk would be extremely low

Data from hotel quarantine in New South Wales, which takes around half of returned travellers in Australia, suggests home quarantine for fully vaccinated returnees would likely present an extremely low risk.

In 2021, NSW has screened around 4,700 returnees a week, with the proportion of positive cases detected during quarantine averaging around 0.6%.

From March 1, since vaccination has become more accessible, only eight of 406 positive cases were fully vaccinated.

Unfortunately we don’t have the overall data on how many returnees were fully vaccinated, but even if only 10-20%, this would equate to a positive rate of around 6-12 per 10,000 among the vaccinated. This is considerably lower than the overall rate of 66 COVID cases per 10,000 since March 1.




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If home quarantine was initially restricted to fully vaccinated returnees from countries with low to moderate caseloads, the rate would be lower again, probably less than five per 10,000.

If NSW increased their quarantine intake by taking an extra 2,500 per week from this population into home quarantine, it would equate to maybe a few positive cases per month, compared to around 120 cases per month in hotel quarantine. As vaccination uptake increases, this capacity could be expanded, with reduced hotel quarantine requirements.

Will people comply?

The enormous desire for stranded Australian residents, overseas partners and family of residents in Australia to return and reunite should ensure a high level of compliance with home quarantine.

Home quarantine has been successfully implemented in other countries with elimination strategies such as Taiwan and Singapore. Taiwan’s system was deployed rapidly and has 99.7% compliance. Singapore uses a grading system to enable lower-risk returnee residents to do seven days in home quarantine, with a negative test required for release on day seven.

Two major reviews of the hotel quarantine system — the Victorian government-commissioned Coate report, and the national review of hotel quarantine — recommended implementing home quarantine with monitoring technology, such as electronic bracelets. Their recommendations were made prior to the approval of vaccines.

Recent data suggests the current hotel quarantine system has harmful effects. Research published in the Medical Journal of Australia in April found mental health issues were responsible for 19% of all emergency department presentations among people in NSW hotel quarantine. It’s highly likely home quarantine would be more beneficial for the mental health of returnees.

What are the barriers?

Issues which would need to be sorted through include:

  • methods for determining how risky different countries are
  • how returnees can prove they’ve been vaccinated
  • how we would test returnees and home-based contacts, and how frequently
  • and how long home quarantine would be for.

But none of these are insurmountable, and small-scale home quarantine already exists in the ACT.

Health authorities could ensure returnees can collect their own COVID testing samples, for example by doing nasal swabs or collecting saliva themselves. This would reduce contact with health workers.

Home quarantine is undoubtedly being considered by major Australian COVID policy committees, along with other measures to enable a larger number of returnees and to increase the safety of the quarantine system.

Australians’ excessive caution continues to have direct consequences for the well-being of many thousands of stranded Australian residents, together with non-resident partners and family members desperate to return.

It’s time to change this situation and make their human rights a public health priority.


The author would like to thank John Kaldor, Esther Rockett, and Liz Hicks for their input.The Conversation

Gregory Dore, Scientia Professor, Kirby Institute; Infectious Diseases Physician, St Vincent’s Hospital, Sydney, UNSW

This article is republished from The Conversation under a Creative Commons license. Read the original article.

COVID is surging in unvaccinated Taiwan. Australia should take heed


Maximilian de Courten, Victoria UniversityAlarm bells rang internationally last week when Taiwan announced it was moving to its second highest COVID alert level after a recent surge of cases.

The country last year recorded zero cases of community transmission for eight straight months.

The recent increase in cases has led many people to wonder: what happened to Taiwan’s COVID success story?

One part of the answer is a very slow vaccine rollout. Australia should take heed.

How serious is Taiwan’s current outbreak?

On May 9, Taiwan recorded zero new community cases of COVID-19 (there was one imported case in quarantine). But only five days later, new local cases had risen exponentially to 29, and then to a peak of 333 on May 17. And on Saturday, the country’s health department retrospectively added an extra 400 cases to the previous week which were not included in earlier reports.

Although these numbers are still very low in comparison to many other countries, the fact that these new cases were spread across many cities and counties alarmed health officials. Previously, when Taiwan had its first peak — in March 2020 with 27 new cases — almost all cases were from overseas and were successfully isolated. Now the opposite is happening, with almost all new cases spreading in the community.




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The current alert level three mandates wearing masks outside the home and limits people gatherings to five indoors and ten outdoors. This falls short of establishing a lockdown.

Taiwan is also temporarily barring any non-residents and transit travellers from entering the country. And there are restrictions on attending public venues, as well as sporting, entertainment and recreational events.

Level four, the highest level of the country’s restrictions would include the country’s first mass lockdown. This would only be triggered after 14 consecutive days of more than 100 cases, with 50% or more being of unknown origin.

Taiwan’s recent COVID surge

Data up to May 21, 2021.
Our World in Data, CC BY

What went wrong?

Until now, Taiwan was able to prevent the virus from spreading in the community, and contain it to a few imported cases, by its extensive public health infrastructure. This includes quarantine in a government facility or at home for incoming travellers, and quarantine of close contacts of positive cases. This infrastructure was established before COVID and enabled the country to respond quickly and in a coordinated manner to it.

Taiwan’s effective methods for isolation and quarantine were aided by using digital technologies for identifying potential cases, and widespread use of face masks.

This previous COVID success might have led to the government to focus on other priorities rather than investing in resources for mass COVID testing. Indeed, in Taiwan it hasn’t been seen as cost-effective to roll out mass testing without many (or any) cases.

Now, Taiwan has ramped up its testing capacity over the past week as much as possible, but still falls short in comparison to Australia, which conducts far more tests per 1,000 population.

Taiwan’s success also may have led to its people having less of an urgency to get vaccinated.

Where does Taiwan stand on COVID vaccinations?

Only about 1% of the population was vaccinated against COVID when this outbreak started.

Taiwan’s government invested early in developing a local vaccine, which has yet to come to market. This could be one explanation for why Taiwan came late to ordering vaccines from international suppliers, and is still awaiting further shipments from overseas.

Only last week did a second shipment of the AstraZeneca vaccine arrive in Taiwan through the global COVAX facility. However, this contained only 410,400 vaccine doses. Taiwan’s population is 23 million.

This is a warning sign for Australia

Whatever the reasons for the slow rollout of vaccines so far, for the time being and months to come, neither Taiwan nor Australia are even close to herd immunity against COVID.

Testing, tracing and isolation are still going to be important long into the future for both countries.

In saying that, even countries with the highest per capita vaccine rollout can suffer a new wave of the virus, for example Seychelles.




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There may be outbreaks in places where not enough people have been vaccinated to achieve herd immunity, or where variants of the coronavirus are resulting in less protection in those vaccinated against the original strain.

Nevertheless, short of attempting to eliminate the virus by strict isolation (not only of cases but of the whole population from abroad) and severe quarantine or lockdown measures, getting everyone vaccinated as soon as possible is the best approach to a lasting COVID-free world.

Taiwan’s COVID surge demonstrates this virus has the capacity to break through isolation and quarantine barriers at any time, in any country. Many countries need to be better prepared.

The current situation in Taiwan should be a warning to other countries that you can’t let your guard down anywhere yet.The Conversation

Maximilian de Courten, Professor in Global Public Health and Director of the Mitchell Institute, Victoria University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

What’s the risk if Australia opens its international borders? An epidemiologist explains


Tony Blakely, The University of MelbourneCoinciding with the Trans-Tasman travel bubble starting today, over the past week there have been murmurings Australia could soon relax its borders further, through mechanisms such as home quarantine or letting in vaccinated people.

But what are the risks?

Here I propose three things we must consider:

  • the prevalence of the virus in the country from where travellers are coming, including the strain of virus
  • measures taken for the people travelling, including home quarantine and whether travellers are vaccinated
  • the percentage of our population who are immune.

Importantly, all these factors matter. It’s not simply a case of needing to ensure all travellers are vaccinated.

The level of infection in the country of origin matters enormously

At around Christmas time, roughly 2% of the UK population was infected. That percentage is now considerably less, but it’s still likely around 1,000 times higher or more than the risk in China and other East Asian countries. The risk is near zero for New Zealand, Taiwan and many Pacific countries.

However, things will change. At the moment the United States seems to be maintaining high infection rates while also rapidly vaccinating the population. This is probably because of more transmissible variants, and society loosening up, offsetting gains from more people being immune. But at some point, perhaps around mid-year, the infection rate in the US should plummet as the percentage of people immune increases to somewhere around 60-80%. All this is to say we can expect infection rates in countries to vary a lot in the next six to 12 months.




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Let’s work through an example of the United Kingdom. Assume the UK has another surge of infections such that 0.5% of British people are infected and unaware of it, and could jump on a plane to Australia. Let’s assume we decide to let 10,000 Brits come to Australia each month. So 0.5% of 10,000 would mean roughly 50 infected people arriving per month.

Mitigating the risk of travellers

Of course, we would do more to reduce the risk. We could test people before they get on the plane and when they arrive. Let’s assume that weeds out another 50%, as the other half may be still incubating and not yet testing positive. That’s 25 COVID-positive British people arriving per month.

Next, let’s assume we require all travellers to be vaccinated. That will reduce their risk of unwittingly carrying the virus (through either symptomatic or asymptomatic infection) by between 66% for the UK variant and 81% for “normal” virus for the AstraZeneca vaccine. Data are still sketchy on any infection for Pfizer, but it’s likely 90% or more, given 95% protection against symptomatic disease in Pfizer’s clinical trial. If we assume 80%, we are now down to five infected Brits arriving here per month.

Importantly, the vaccine also reduces both the duration of the disease and its infectiousness, for vaccinated people unlucky enough to get infected. We don’t know by how much as the real-world evidence is still accruing, although animal data on peak viral load and duration of likely infective viral load supports this contention.

If we assume (conservatively in my view) that there is a 50% reduction in duration and 50% reduction in peak infectivity for hapless vaccinated people who still get infected, that is 25% of the risk of passing it on (that is, 50% of 50%).

Therefore, if an unvaccinated person, infected with the UK variant, was going to infect an average of 3.5 people in the absence of any social measures such as mask-wearing, the infected-after-vaccination person would only infect 0.875 other people – a 75% reduction in the reproductive rate. So our remaining five infected Brits are less infectious.

Intensity of quarantine measures for arrivals

Let’s consider the option of home quarantine. We don’t know how effective this will be, because of potential compliance issues.

But the risk of home quarantine breaches can be reduced by technology like ankle bracelets, GPS tracking on travellers’ phones to ensure they stay home, and only allowing home quarantine if any other members of the household are also vaccinated, to give an extra layer of protection.

Let’s assume home quarantine with these extra measures stops 80% of infected people getting out and about in Australia while infectious.

So we are now down to one infected British person who has slipped through per month. But given they are also vaccinated, they’re less likely to pass on the infection. And this risk can be reduced further still by ensuring they’re wearing a mask – although if they “breached” home quarantine rules they may not be likely to wear a mask.

It’s important to remember even “proper” quarantine isn’t foolproof. About one in 250 infected people last year in hotel quarantine caused a leakage.

Is Australia a tinderbox?

Yes. Perhaps only 5% of us are immune. Even if, via the above measures, we get just one infected person a month in Australia – the situation could blow up. Keep in mind the above example assumes we’re only allowing travellers from one country too. More countries means more travellers means more risk – although as above, the risk varies based on the infection rate in the origin country.

You can play with various scenarios in our COVID-19 Pandemic Trade-offs tool, launched two weeks ago. What you’ll find is that until most adults in Australia are vaccinated, any loosening up of how we respond to the virus incursion is unwise. If contact tracing cannot mop up the inevitable incursions, we’ll still need to use social restrictions, including lockdowns, until the vaccination rollout is complete.

But we can probably think about inching forward to some increased risk once all over-50s are vaccinated (phase 2A), with some modest relaxation of the border. Yet we can never totally escape the risk of outbreaks.

So what can we do now with borders?

First, continue with the Trans-Tasman bubble.




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A quarantine-free trans-Tasman bubble opens on April 19, but ‘flyer beware’ remains the reality of pandemic travel


Second, remove or greatly reduce quarantine for vaccinated travellers from many East Asian countries, which present a low risk to Australia. As an example, the average number of known active infectious people in China at any point in time recently is about 250. Let’s assume this equates to about 100 unknown infections at any point in time (that is, people who are not yet symptomatic or detected). For a population of 1.4 billion, that’s a 0.000007% risk of any person in China being infected.

This suggests that for 10,000 vaccinated arrivals from China per month with modified quarantine, the expected number of infected people unwittingly getting out into the Australian population per month is 0.000014. Or, put another way, our above UK example presents 70,000 times the risk of an arrival from China. Given such low risk, it’s hard to justify why university students from China cannot start in time for semester two this year if they’re vaccinated and going into some form of modified quarantine.

Third, we need a national framework to assess the risk. Focusing on one measure alone isn’t wise — you have to look at the whole system. Such a framework can be developed now, at the same time as setting our risk thresholds so policy-makers, airlines and other industries can start planning.The Conversation

Tony Blakely, Professor of Epidemiology, Population Interventions Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Doctors do not face a greater legal risk if they give AstraZeneca to younger Australians — here’s why


Simon Santi/AAP

Cameron Stewart, University of SydneyLast week, the federal government changed its recommendation for COVID-19 vaccines. The Pfizer vaccine is now the “preferred” jab for adults under 50.

Amid the political fallout and worries about what it means for Australia’s COVID recovery, doctors have expressed concern about their liability. Some said they would even stop giving the AstraZeneca jab until they were more certain of their position.




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Are they at greater legal risk if they give AstraZeneca to younger Australians? The government insists they are not. This is correct — here’s why.

Proving fault

In Australia, medical liability is, for the most part, fault-based. This means patients who are injured by medicines, medical devices and medical interventions must prove the doctors who used them were to blame for any injury they suffered before any compensation will be paid.

Australian liability laws are state-based, but generally speaking, fault can only be proven when the doctor has acted outside of the professional standard of care in a way that is not supported widely in Australia by professional peers.

What is the standard of care?

The standard of care for diagnosis and treatment is effectively set by the medical profession. In cases — such as COVID vaccines — where the treatment is new and knowledge about the treatment is emerging, the standard of care is also developing.

Importantly, doctors are judged by measuring their behaviour against the standard of care at the time the treatment was given. This means that if, in 2020 a doctor administers a COVID vaccine in a way that was supported by their peers at that time, they will not be found to have breached the standard of care if, years later, other side effects become known.

Prime Minister Scott Morrison inspecting AstraZeneca production.
Last week the Morrison government changed its advice around the AstraZeneca vaccine.
David Caird/AAP

We should also be careful not to automatically equate the government’s advice concerning the AstraZeneca vaccine with what the standard of care should be at the individual level.

The government’s advice is concerned with the big picture and with risks across a population. Doctors have the task of treating individuals. So, the government’s advice should be considered by doctors when working out which vaccines to offer to patients, but there may well be situations where the AstraZeneca is the best option for individual adult patients under 50.

Giving advice and accepting risks

Doctors also have a duty to inform individual patients about material risks of the treatments they provide. Every intervention comes with a set of risks but only the material ones need to be disclosed.

Material risks include those the profession would usually notify patients of (objective material risks), as well as risks the individual patient may have a particular concern about (subjective material risks).

The classic example of this is the 1993 case of Rogers v Whitaker where a woman who was blind in one eye was considering cosmetic surgery on that eye. She was concerned about any risk (no matter how remote) of going blind in her “good eye”. Later, she became blind from a complication of her treatment, which was known but very rare. The doctor’s failure to inform her was considered a breach of the duty to inform — even though it was not a risk normally disclosed — because the risk was subjectively material to her.

Again, the doctor will always be judged by what the profession knew at the time regarding these risks. If a patient is told about the material risks of the treatment and decides to go ahead with the treatment, the doctor has satisfied their legal duty to advise and cannot be held liable for subsequent injuries.

What now for GPs and AstraZeneca?

As long as doctors consider the government advice, keep up with professional news about best practice and communicate material risks to patients, they face no greater liability for providing COVID vaccines than they do for any other treatment.

The reality is the risks of people being injured by vaccines, and of doctors being sued for vaccine-related injury, is incredibly low.

At the weekend, the Australian Medical Association also said if a patient makes an informed decision to receive the AstraZeneca vaccine, GPs are protected under professional indemnity insurance.

Of course, the reality of low risk may not match the fear practitioners experience. So, are there things we can do to reduce the anxiety practitioners feel regarding liability?




Read more:
Bad reactions to the COVID vaccine will be rare, but Australians deserve a proper compensation scheme


One obvious measure is to move to no-fault systems of compensation. Many countries including the United States and New Zealand have no-fault compensation schemes for vaccine-related injury. Putting such a scheme in place may very well help doctors get over the fear of being sued. It might also give patients confidence knowing that in an extremely rare case of injury, they will be covered.

This could be done either with a one-off scheme or by expanding the National Injury Insurance Scheme, which covers personal injuries from motor vehicle accidents.

Without such schemes, Australian patients will only have access to compensation for vaccine-related injury if they can prove it was caused by a failure to act according to medical standards of care or a failure to properly inform the patient of material risks.The Conversation

Cameron Stewart, Professor at Sydney Law School, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The best hope for fairly distributing COVID-19 vaccines globally is at risk of failing. Here’s how to save it


Deborah Gleeson, La Trobe UniversityCOVAX, the global initiative to coordinate the distribution of COVID-19 vaccines in an equitable way, is crucial for bringing the pandemic under control.

But COVAX’s aim of delivering 2 billion doses to participating countries by the end of 2021 — including 92 low-income countries that can’t afford to buy vaccines directly from manufacturers — is threatened by chronic under-investment, vaccine nationalism and export restrictions.

COVAX is not intended only for low-income countries: Canada has so far received 316,800 doses through the scheme. As such, it represents an important “insurance policy” for Australia, potentially enabling access to a wider portfolio of vaccines than we could secure through negotiations with suppliers.

The vulnerability of our vaccine procurement strategy has become clearer over the last few weeks, with supply blockages limiting vaccine imports from Europe and now the government’s warning about the AstraZeneca vaccine and its links to a rare blood-clotting disorder.

Saving COVAX will require more than donations (of both funds and vaccines), as well as the removal of export bans. Countries must collaborate to urgently remove the legal and technical barriers preventing more widespread vaccine manufacturing in order to increase the global supply of vaccines for COVAX to distribute.




Read more:
Yes, export bans on vaccines are a problem, but why is the supply of vaccines so limited in the first place?


How does COVAX work?

COVAX is led by the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance (a public-private partnership that aims to increase vaccination in low-income countries); and the World Health Organization.

It aims to deliver doses to all of the participating countries that have requested them in the first half of 2021, and 2 billion vaccines in total by the end of 2021.

COVAX is complex, but essentially it works by investing in a portfolio of promising vaccines and then distributing them according to a formula to both “self-financing countries” and “funded countries”.

Self-financing countries are those which have contributed funds to COVAX, such as Australia. They are able to buy the vaccines at cheaper prices negotiated by COVAX and will initially receive enough to vaccinate 20% of their populations. In the longer term, these countries may receive enough doses to vaccinate up to half of their populations, depending on how much they contribute.

Funded countries include 92 low-income countries that can’t afford to buy their own vaccines. They will also receive enough to vaccinate 20% of their populations, provided COVAX is able to meet its goals. This is nowhere near enough to achieve herd immunity, but will at least allow health workers and the most vulnerable groups to be vaccinated.

Australia has committed A$123.2 million to enable it to purchase 25 million vaccines for domestic use.

It has also committed A$80 million specifically earmarked for providing vaccines for low-income countries. This money will be drawn from existing aid funding, however, and won’t go very far in terms of assistance.

How is the program going so far?

COVAX made its first delivery of vaccines to Ghana on February 24. By April 11, it had shipped approximately 38.5 million doses to 106 countries and territories.

The first shipment of COVID-19 vaccines distributed by COVAX arriving in Ghana.
Francis Kokoroko/UNICEF/AP

While these figures might look promising at first glance, this is a long way behind COVAX’s aim to deliver 100 million doses by the end of March.

And they don’t stand up well in the context of global vaccine roll-outs. So far, only 0.2% of the 700 million vaccine doses administered globally have been given in low-income countries, whereas 87% have been received by people in high-income and upper middle-income countries.

Tedros Adhanom Ghebreyesus, director-general of the WHO, pointed out last week that only one in 500 people in low-income countries have so far received a vaccine — a situation he described as a “shocking imbalance”.




Read more:
Why ‘vaccine nationalism’ could doom plan for global access to a COVID-19 vaccine


Why is COVAX struggling to deliver?

COVAX needs more funding, to the tune of US$3.2 billion even to meet its modest goals for 2021. But the supply of vaccines is an even bigger problem.

Rich countries like Australia have undermined COVAX by negotiating deals for vaccines directly with pharmaceutical companies, rather than waiting for COVAX to allocate them fairly. By last November, high-income countries making up just 14% of the world’s population had negotiated pre-market agreements covering 51% of the global supply.

Adding to COVAX’s problems, the flow of vaccine deliveries has mostly dried up in the last week.

Some 90 million doses of the AstraZeneca vaccine manufactured in India that were to be delivered to 64 countries in March and April have been delayed as a surge in COVID-19 cases prompted the Indian government to restrict exports.

Boxes of AstraZeneca COVID-19 vaccines manufactured by the Serum Institute of India and provided through the COVAX global initiative arrive at the airport in Mogadishu, Somalia.
Farah Abdi Warsameh/AP

What needs to happen?

WHO has called on rich countries to immediately share 10 million doses to prop up COVAX in the first half of 2021.

But so far, no country has committed to do this. Donations that come after countries have fully vaccinated their own populations will be too late. And where bilateral donations have been made outside of the COVAX program (mainly by China and Russia), they have largely been driven by security, strategic or political considerations, rather than donated to the countries where they are most needed.




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Removing export restrictions would help. But as long as demand exceeds supply and the countries where vaccines are manufactured face large outbreaks, we are likely to continue to see these types of barriers.

What is needed most are more sustainable approaches to dramatically boost the global supply of vaccines and ensure there’s enough to go around.

This first requires removing the intellectual property protections that allow vaccine developers to hold exclusive rights to control who can make and sell them.

India and South Africa have put forth a proposal at the World Trade Organization to waive intellectual property rights for COVID-19 medical products during the pandemic, which has been supported by more than 100 low- and middle-income countries. However, several high-income countries, including Australia, have blocked it.

Secondly, governments need to support mechanisms for sharing intellectual property, such as the WHO’s COVID-19 Technology Access Pool (C-TAP).

This was set up nearly a year ago, but no vaccine developer has contributed to it yet. Governments need to make sharing intellectual property and contributing to the pool a condition of public funding for the development of COVID-19 products.

Finally, governments need to help low- and middle-income countries to produce their own vaccines. This means investing money to build up manufacturing capacities in these countries and facilitating technology transfers from companies based in high-income countries.

For COVAX to supply enough vaccines for even 20% of the world’s population, rich countries will need to step up. And fast.The Conversation

Deborah Gleeson, Associate Professor in Public Health, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

AstraZeneca’s blood clot risk is incredibly small. Australia shouldn’t follow the UK’s lead of offering under 30s another vaccine


Nathan Bartlett, University of NewcastleAuthorities in the United Kingdom overnight recommended people under 30 be offered an alternative COVID vaccine to the AstraZeneca/Oxford shot.

The recommendation came after the European Medicines Agency (EMA) found a “possible link” between the vaccine and blood clots. The EMA also said blood clots should be listed as a “very rare” side effect of the vaccine.

It’s important to note there’s still no conclusive evidence the vaccine is causing the clots, as so few have been reported. However, evidence there is a link is increasing, which has prompted more focused monitoring.

The benefits of getting a COVID vaccine still far outweigh the risks. I would still be encouraging everyone to be vaccinated with the AstraZeneca vaccine.

Prime Minister Scott Morrison said this morning “there’s nothing to suggest at this stage that there would be any change” to Australia’s current rollout strategy. The Therapeutic Goods Administration and the Australian Technical Advisory Group on Immunisation are currently reviewing the data and latest advice from Europe and the UK.

What’s causing these clots?

Blood clotting events linked to vaccination are being called “vaccine-induced prothrombotic immune thrombocytopenia” (VIPIT).

In these rare instances, clots are forming in a patient’s blood, and not just in veins but in arteries and other rare locations like the brain and abdomen. This is also paired with low platelet counts (cells needed for the blood to clot).




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What is thrombocytopenia, the rare blood condition possibly linked to the AstraZeneca vaccine?


It appears, in these instances, the body’s response to the vaccine is triggering an “off target” immune response that is attacking platelets. Limited data that is yet to be peer reviewed suggests antibodies targeting platelets cause them to become activated and trigger clotting. This autoimmune response also targets the platelets for destruction, reducing their level in the blood. So platelets are either tied up in clots or are eliminated. Both processes contribute to “thrombocytopenia” (low blood platelet count).

Like infections, vaccines trigger an immune response, so when receiving any shot that stimulates a robust immune response there’s a small but real risk your immune system will generate “off target” effects. In these rare instances, these effects can lead to autoimmunity, which is an immune response that attacks your own cells.

All vaccines and medications come with small risks

The numbers of clots reported after the AstraZeneca are very small, so we don’t exactly know how common they are. But they appear to occur at a rate between one in 25,000 and one in 500,000.

The UK’s vaccine advisory board said there were 79 cases of blood clotting issues among more than 20 million people given the AstraZeneca vaccine. That’s a chance of about 0.0004%, or one in 250,000.

Researchers haven’t yet identified any specific risk factors so far for the development of blood clots following COVID vaccination. We need to understand as quickly as possible what these are if indeed a causal link is established.

Some have suggested there could be a link with women taking the contraceptive pill having a higher risk of blood clots after receiving the AstraZeneca vaccine. But there’s no evidence for this at all. As far as I know, information on whether women receiving the vaccine are taking the contraceptive pill isn’t captured. Perhaps it’s something to consider going forward.

Young people don’t appear to be at particularly higher risk of blood clots linked to the vaccine. The publicised cases of blood clots have occurred in mostly women under 60 years of age.

Australia shouldn’t follow the UK’s new recommendation

One reason the UK is able to advise younger people to receive other vaccines is because it has other vaccine options, including the Pfizer and Moderna shots. Offering the under 30s an alternative vaccine isn’t really going to hinder the rollout, which is going very well in the UK.

But this isn’t the case in Australia. The AstraZeneca shot is the only one we have guaranteed supply of, given CSL is producing it in Melbourne.

It’s important to remember the AstraZeneca vaccine is a very safe and effective vaccine. It’s also easier to store and distribute than the Pfizer vaccine.

The priority is vaccinating as many people as possible and quickly

It’s important to note we’re in uncharted territory. This is the first time in modern history we’ve been in a situation where we’ve needed to roll out a vaccine to deal with a pandemic.

We’re also using new vaccine technologies that we’ve had to expedite to try and get on top of this virus as soon as possible. These new technologies, including AstraZeneca’s, have never been tested at this immense scale until now.

There are a lot of unknowns, but certainly the scale in which were doing this means we’re going to see very rare adverse events linked to these vaccines.

At this stage the priority is still to vaccinate as many people as possible, as quickly as possible.

My primary concern is ongoing high levels of transmission across the world. The more cases there are, and longer we delay vaccinating people, the higher the likelihood is of new variants of the virus emerging.




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UK, South African, Brazilian: a virologist explains each COVID variant and what they mean for the pandemic


Even though we have very low COVID-19 case numbers in Australia currently, we’ve seen regular outbreaks stemming from hotel quarantine. We can’t predict what’s going to happen in the future. The longer the virus is waiting at our doorstep, the greater the risk we’ll have another outbreak and end up in lockdown and much worse — and nobody wants that.The Conversation

Nathan Bartlett, Associate Professor, School of Biomedical Sciences and Pharmacy, University of Newcastle

This article is republished from The Conversation under a Creative Commons license. Read the original article.