Victoria may have eliminated COVID-19, but eradication is a distant dream


Michael Toole, Burnet Institute

Today Victoria satisfied a common definition of elimination for COVID-19, recording its 28th consecutive day of zero new cases. While there is no international definition of elimination, two average incubation periods without community transmission is widely accepted as local elimination, especially in a geographically isolated country like Australia.

It’s a remarkable achievement following a severe second wave which peaked at daily new case rates of around 700 in early August. But elimination is not eradication, and we can expect the virus to return at some point, as has happened in several countries that previously boasted minimal or no community transmission.

So how did Victoria get here, and what can it do to keep numbers as low as possible?

Elimination is not eradication

There’s no universal definition of elimination. As applied to other infectious diseases such as polio and measles, it means a prolonged period of zero local transmission in a country or region. For measles, the World Health Organisation (WHO) is very exacting and demands no community transmission for 36 months.

With more than 500,000 new daily COVID cases being reported globally, preventing new local transmission in Victoria will depend on the state building a virus-proof defence.

Several countries have shown the virus can return after a long period of minimal local transmission. The most pertinent example is New Zealand, which experienced 102 consecutive days of zero community transmission before a cluster cropped up in Auckland on August 11. Israel, South Korea, Vietnam and Hong Kong have also experienced reemergence of the virus following significant periods of minimal community transmission. And this month, we witnessed a cluster in suburban Adelaide that originated in a quarantine hotel, after South Australia had experienced many months of no community transmission.




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Of all the places that have seen off a second coronavirus wave, only Vietnam and Hong Kong have done as well as Victorians


Indeed elimination doesn’t mean the virus is completely gone. For example, Australia eliminated local transmission of polio in 1972. But it wasn’t until 30 years later, in 2002, that the WHO declared Australia polio-free.

Almost 20 years after that declaration, we still can’t say we’ve eradicated polio because eradication refers to the global removal of a human pathogen; only smallpox has achieved that status. One strain of the polio virus continues to circulate in Afghanistan and Pakistan. In 2007, a 22-year-old student from Pakistan was diagnosed with polio at Box Hill Hospital in Melbourne’s East.

So, how did we get to zero?

Since the grim height of Victoria’s second wave in July and August, several coordinated interventions have eventually borne fruit. One of the most important was the strengthening of the test-trace-isolate-support system. While details are emerging during the parliamentary inquiry into Victoria’s hotel quarantine system, some of the features of this strengthening are known:

  • decentralisation through regional hubs and metropolitan public health units

  • increased engagement and involvement of communities, through programs aimed at public housing estates and local initiatives led by GPs and community health centres

  • adoption of “upstream” contact tracing, identifying contacts of index cases before they developed symptoms as well as after developing symptoms. In both groups, contacts of contacts were identified. This led to the rapid control of clusters such as those in Kilmore and Shepparton.

Other important initiatives included the joint federal-state Victorian Aged Care Response Centre, which eventually managed the explosive outbreaks in residential aged care facilities, and more effective infection prevention and control in health-care settings.

And there were the containment measures that kept people from intermingling. Stage 3 restrictions were reimposed on July 8, limiting the reasons people could leave home. A study published in early August found these restrictions averted between 9,000 and 37,000 cases. From July 23, masks were mandatory at all times outside the home. On August 2, stage 4 restrictions and a night curfew effectively shut down Melbourne. From then on, the number of new cases steadily declined.

Perhaps the greatest achievement of Victoria’s response was to maintain a strong health focus amid a chorus of criticism, much of it from Canberra or the Sydney-based media, pushing the “economy first” mantra. In fact, data show countries that managed to protect the health of their citizens have generally protected their economy more effectively.




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How can we stay where we are?

The first requirement is an effective quarantine system for returned travellers. With cases surging globally, the proportion of travellers who are infected will increase significantly from the 0.7% reported between March and August. This will require arrangements that employ well-trained and adequately paid workers who are regularly monitored by infection control and occupational health and safety experts. The advance contact tracing, which will identify the close contacts of staff before they might test positive for the virus, announced by Premier Daniel Andrews would be a useful adjunct as long as confidentiality is assured.

Crucially, experienced teams of contact tracers must be on standby. They need to maintain the rigorous standards developed over the past few months and engage in simulation exercises that test their capacities. They must retain a focus on community trust and avoid the vilification of individuals that marred the South Australian response.

What’s more, the state must sustain proven containment measures such as physical distancing, hand hygiene, masks indoors, and getting tested if you have symptoms.

Australia is an almost COVID-free oasis, surrounded by a tsunami of virus. Maintaining this status for the next six months or so, while at the same time opening up, will be a huge challenge. Recent responses in Victoria, NSW and SA suggest we are up to it.

And as the story of the sharp-eyed doctor in Adelaide showed us — when she tested a patient in the emergency room who’d initially felt “weak” but had very few COVID symptoms, alerting authorities to the previously silent spread of the virus — to maintain elimination we’re also going to need a little luck.




Read more:
South Australia’s 6-day lockdown shows we need to take hotel quarantine more seriously


The Conversation


Michael Toole, Professor of International Health, Burnet Institute

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

Hating on the Woodville Pizza guy won’t fix a problem that was entirely foreseeable



Shutterstock

Gemma Beale, Flinders University

Over the course of a single week South Australia was plunged into one of the world’s strictest, and briefest, lockdowns.

The drama, estimated to have cost the state’s economy A$100 million, came down to pizza – specifically, fears the state’s outbreak of COVID-19 was an especially virulent strain transmissable by pizza boxes.

In the end it actually came down to a kitchen hand lying about having a second job at a pizzeria, rather than simply being a customer as he first told contact tracers.

South Australian premier Steven Marshall has said authorities will use “all and every avenue to throw the book at this person”. Members of South Australia Police’s “Taskforce Protect” have reportedly combed through hundreds of hours of CCTV and seized phones, a laptop and a hard drive “directly related to the person of interest”.

It is understandable state authorities would want to signal the importance of truthfulness in this scenario. But the instinct to grasp punitive measures fails to account for the cause of the problem.

This debacle again illustrates the problem of insecure and low-paid work, and the moral jeopardy it forces on hundreds of thousands of people really just trying to make ends meet.

We’ve seen this before, in Victoria, with the problem of nursing home staff and meat processing workers still going to work and not self-isolating despite having COVID symptoms.

Now South Australia has illuminated the problems of workers in “essential” jobs having to moonlight in second jobs, and perhaps feeling the need to lie about it.

We need a holistic response that considers the systemic reasons that force people into such situations to preserve their livelihood.




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Holding down second jobs

At least two links in the chain of events leading to the South Australian outbreak highlight the problem of precarious and insecure work.

The first is how the pizzeria – the Woodville Pizza Bar – became a transmission vector.

That had to do with a kitchen hand at the pizzeria also working as a security guard at Peppers Hotel, one of the hotels being used to quarantine travellers returning to the state. He apparently caught the virus from a cleaner at the hotel, who caught it from a quarantined guest.

This part of the story has prompted calls for workers at quarantine hotels to be banned from from working second jobs.

To which the obvious retort should be: if we don’t want people to work two jobs, perhaps we should ensure they have enough hours and pay so they don’t need to.




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Migrants in plight

The second link – the man who lied about working at the pizzeria – speaks to the predicament faced by tens of thousands of people in Australia on visas (in this case, a temporary graduate visa). In a bizarre coincidence, he too was working in the kitchen at another quarantine hotel (The Stamford).

There are an estimated 900,000 foreign nationals in Australia on visas with work rights, almost always with restrictions. The jobs they find are often insecure low-paid casual or gig jobs, possibly cash in hand.

Many of these jobs – in hospitality, for instance – were the first to disappear with lockdowns. And because they aren’t citizens, they have been excluded from federal government financial support.




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Address the problem, not the symptoms

Sure lying is wrong – particularly if it shuts a city down.

But it should also be unsurprising in the face of fear – and fear of losing work is central to insecure work.

This is compounded for migrant workers by an additional fear: losing the right to stay in the country, through breaking rules that limit working hours. But they often have little choice, as the only way to make enough money to compensate for being exploited and often earning well below the minimum wage.

What has happened in South Australia is a symptom of the same problem that bedevilled Victoria’s outbreak. It should have been foreseeable. Researchers have been warning about the negatives for years. The pandemic has made them plain.

A punitive and knee-jerk call for punishment is at best another half measure. It won’t fix the systematic problem of precarious work.The Conversation

Gemma Beale, PhD Candidate, Flinders University

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

Blaming the ‘worried well’ for long COVID testing queues won’t help anxious South Australians. This will


Bridget Haire, UNSW and Jane Williams, University of Sydney

It’s been a big week for South Australia. First, the announcement of a six-day lockdown to limit the spread of COVID-19. Then today we heard this lockdown may have not been needed, after a man lied to contact tracers, prompting an early lifting of restrictions.

In between, South Australians have been waiting in queues for up to ten hours for COVID-19 tests. And the state’s chief public health officer Nicola Spurrier warned the “worried well” not to clog up important public health services.

Labelling people anxious about COVID-19 the “worried well” isn’t helping, especially in a climate of uncertainty, as South Australia has experienced this week. It might also discourage people with mild symptoms to come forward.

So who are the “worried well”? And what should we really be doing to encourage the right people to get tested?




Read more:
South Australia’s 6-day lockdown shows we need to take hotel quarantine more seriously


Who are the ‘worried well’?

The “worried well” is a term invented to describe apparently healthy people who think they might have a disease or medical problem, so see a doctor or have testing.

The term carries the whiff of a sneer, along with the implication such people are wasting health resources.

It shouldn’t be confused with hypochondria, which is chronic anxiety about your health to the level it may be considered a psychiatric illness.

The “worried well”, in contrast, are often responding to a situation that asks people to be paying special attention to an aspect of their health.

They might attend more regularly than required for cancer screening, for example. They are also more likely to believe it is important to take responsibility for their own health — a concept public health messaging actually reinforces.




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We can’t dismiss people’s real anxiety

Dismissing people who seek medical attention for vague ailments or unsubstantiated risks as the “worried well” ignores the very real problem of the anxiety created by attention to particular illnesses.

Anxiety can cloud health perceptions and judgements, and prompt people to seek reassurance.

In the face of a global pandemic, where an invisible pathogen is transmitted often through pre-symptomatic or asymptomatic people, many of us are a bit anxious.




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Vigilance can be useful for achieving compliance with the COVID-safe rules that have restructured our daily habits, such as physical distancing, avoiding touch and regularly washing our hands.

Anxiety is less useful if it results in people who have no known exposure and no COVID symptoms presenting for testing, particularly if there is a concern testing services may be stretched by demand.

However, applying a stigmatising label to such people is counterproductive.

Yes, it can be frustrating

In the context of an outbreak where there is urgent need to test people who have been exposed, and where testing capacity is being overwhelmed, reference to the “worried well” may be a symptom of public health officials’ understandable frustration.

It is, after all, a delicate balancing act to get everyone deemed at risk to test in a timely manner, without their ranks being swelled by those seeking reassurance who believe they were at risk but who have no clear or likely route of exposure.

But that doesn’t make the “worried well” a fair or useful label, and may work against achieving the widespread testing needed to control infection.




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We’d be better off promoting testing as doing the ‘right thing’

New South Wales and Victoria have promoted COVID testing as doing the “right thing”. Both emphasise people with COVID-like symptoms should be tested regardless of whether they have had a known exposure.

Similarly, the South Australian government is asking everyone with COVID-like symptoms to be tested, regardless of whether the symptoms are mild.

One of the risks of a phrase like the “worried well” is different people can interpret it in different ways. So if someone with mild COVID-like symptoms is
worried they might be called one of the “worried well”, they might second-guess themselves and not get tested.

We have seen the dire consequences of people underestimating a sniffle, or mild respiratory illness, in the terrible tragedy of the Newmarch House aged-care cluster in New South Wales earlier this year.

Clear, consistent, targeted public health messaging works

The best way to ensure the right people get tested is by using very clear, consistent and targeted public health messaging.

Currently, in South Australia this means people with symptoms, people who have been identified through contact tracing, and people who have visited sites listed on the contact tracing website where exposure may have occurred.

Clear and consistent repetition of these groups is needed throughout relevant media, including the broadcast media, internet and social media.

Have the ‘worried well’ really clogged up testing?

It is not possible to assess how many of the more than 617,000 COVID tests conducted in the state so far met the criteria of credible risk according to the published criteria.

But if there is serious concern there is unnecessary testing, this needs to be swiftly addressed by explaining who needs testing and why. This needs to be repeated in multiple places, including being visible where people queue to test.

Clear and accessible pathways also need to be provided for people with COVID anxiety who don’t meet testing criteria, which the state government is beginning to address.

This is so people can be reassured in ways that do not involve unnecessary testing, and if necessary learn how they can address their concerns using the appropriate designated mental health services.




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The Conversation


Bridget Haire, Postdoctoral Research Fellow, Kirby Institute, UNSW and Jane Williams, Researcher at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney

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

View from The Hill: Scott Morrison hopes ‘open Christmas’ can still be achieved despite South Australian outbreak


Michelle Grattan, University of Canberra

South Australia is battling to prevent a serious COVID outbreak turning into a second wave, as several states slam restrictions on their borders to prevent the import of cases from SA.

The outbreak is a setback the goal of having most of Australia open by Christmas – although Scott Morrison on Monday was quick to say he hoped it would not stymie that timetable.

Queensland, Tasmania, and Western Australia as well as the Northern Territory announced border clamps on travellers from SA. In WA’s case it had only just eased restrictions for them.

NSW and Victoria are leaving their borders open. Victoria will impose health checks on people flying into Melbourne from Adelaide.

SA on Monday announced 18 new cases, in people aged from one through to their 80s. Thirteen of the cases are linked to a Parafield Gardens cluster.

The outbreak started from hotel quarantine. A hotel worker and two security guards have tested positive. The worker spread the virus through a large family.

The SA outbreak and the reaction of various states once again shows the split between leaders over the issue of “living with COVID”.

Morrison and NSW Premier Gladys Berejiklian argue small numbers of cases can be managed while the economy, and borders, remain open. But several state leaders take more conservative approaches, confident they have the support of their populations.

The SA outbreak will test the effectiveness of the state’s contact tracing. The federal government last week released the report of chief scientist Alan Finkel, who found states’ systems were now generally sound while recommending some improvements.

SA premier Steven Marshall said: “Time is now the essence and we must act swiftly and decisively”.

“We will throw absolutely everything at this to get on top of the cluster.” He said the next 24 hours would be critical.

The SA government is closing gyms, recreation centres, and trampoline/play cafes for an expected two weeks. Community sports fixtures and training are also cancelled.

Among a range of caps, gatherings at private residences will be limited to 10 people.

All international flights to Adelaide are suspended for the rest of the week.

The state’s chief public health officer, Nicola Spurrier, said “What we are facing is, indeed, a second wave but we haven’t got the second wave yet. We are in very, very early days.”

AnglicareSA said two employees from its Brompton aged care home had tested positive to COVID-19 on Sunday.

The workers hadn’t been at Brompton since Friday 13 and had not worked at any other AnglicareSA residential aged care home.

On Friday national cabinet committed to having internal borders – apart from WA’s – open by Christmas.

Morrison said on Monday: “It is not a surprise that [an outbreak] can occur from a quarantined facility. What matters is how you respond in these situations”.

Acting Chief Health Officer Paul Kelly said he was confident the systems were in place to deal with this outbreak.

The Australian Health Protection Principal Committee held an emergency meeting on Monday.

Asked about the different responses between NSW and WA on borders, Morrison said the AHPPC had not recommended collectively any one response.

“What is important is these don’t get sort of locked in as part of another enduring disruption and as soon as South Australia is able to get on top of this I would be expecting that states would keep on the path that we have set towards Christmas.”

After the disastrous consequences of Victoria’s second wave for residential aged care, with residents accounting for most of the deaths, Morrison said: “We have stood up the aged care response centre in South Australia. That is important to ensure that we deal with any potential risks or issues in residential aged-care facilities. I particularly spoke to the premier about that today”.

Addressing a Committee for Economic Development of Australia dinner on Monday night, Reserve Bank Governor Philip Lowe highlighted the link between what happens on the health front and the trajectory for the economy.

“There is still considerable uncertainty about the [economic] outlook,” he said.

“If we do get further good news on the health front, we could have a rapid rebound.

“At the same time, it is still possible that we experience further outbreaks. And the hoped-for medical advances may be delayed and could face production and distribution challenges slowing their rollout. This means that there are downside scenarios too.”The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

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

South Australia’s 6-day lockdown shows we need to take hotel quarantine more seriously


Catherine Bennett, Deakin University

South Australian Premier Steven Marshall today announced a six-day “circuit breaker” lockdown to try and snuff out the state’s COVID outbreak.

From midnight Wednesday, residents will be asked to stay in their homes. Hospitality venues will shut, as will schools and universities. Construction will grind to a halt and exercise won’t be allowed outside the home.

The only permitted reasons to leave home are to shop for food or medicine, or for essential health care. Elective surgery will be paused, except for urgent operations.

There are now 22 cases linked to the cluster that emerged from hotel quarantine, and a further seven suspected cases.

Why lockdown?

While this may seem like an overly cautious approach to a cluster that isn’t yet as big as we’ve seen in other places, I think it’s a wise move.

This is how lockdowns should be used. Indeed, the World Health Organisation advocates lockdowns as a way to buy precious time while other essential public health measures are mobilised, such as contact tracing and widespread testing. The focus here is on preventing a rise in cases, unlike the lockdown in Melbourne where the cases had already taken off widely in the community and it was about turning the wave around.

We’ve seen the virus in this particular cluster spread very rapidly. In just two weeks it has spread through five generations — that is, to five “rings” beyond the initial case.

We’ve also seen cases passed on through quite casual contact, via a pizza shop in the suburb of Woodville.

The state’s chief health officer, Nicola Spurrier, said:

This particular strain has […] a very, very short incubation period. That means when somebody gets exposed, it is taking 24 hours or even less for that person to become infectious to others, and the other characteristic of the cases we have seen so far is they have had minimal symptoms and sometimes no symptoms but have been able to pass it on to others.

This short incubation period and rapid spread is why the government has opted for a six-day lockdown, giving the space to put out the spot fire while protecting the wider community, and especially high-risk settings and vulnerable populations where cases numbers can escalate rapidly with serious consequences.

Also, as Spurrier said, the cases so far have had no, or very mild, symptoms. So this six-day window allows the testing of close and casual contacts to be completed so the cases that are out there become visible to the health department.

The decision to restrict exercise altogether is strict, but warranted in my view. The rationale is similar to putting a wide range of people into isolation, as they don’t yet know where the edge is of the current cases, or the full extent of exposure. The rationale for the extension of restrictions beyond Adelaide and surrounds to the whole state is less clear at this stage.

If it protects the population from an escalation of cases, then six days without outdoor exercise will ultimately be better for physical and mental health than longer strict rules, even with some exercise allowed.

Significant restrictions will remain after the six days, but not full lockdown, according to the state’s Police Commissioner Grant Stevens.




Read more:
South Australia’s COVID outbreak: what we know so far, and what needs to happen next


The good news

The good news is there have been no mystery cases so far. All positive cases have been linked back to hotel quarantine at the Peppers Waymouth Hotel (known as a “medi-hotel” locally).

Testing rates have been very high. Some 5,300 tests were done on Monday, and more than 6,000 on Tuesday. This number of tests is comparable to three or four times that number in a larger city like Melbourne. Local residents have been very patient in queuing up to get tested, sometimes for several hours.

South Australia’s contact tracing team hasn’t really been severely tested during the pandemic. But the team has received extensive training and is reportedly robust, having been given the tick of approval from Chief Scientist Alan Finkel’s recent review into Australia’s contact tracing, published last Friday.




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More than 4,000 people have been quarantined already, including not just contacts, but contacts of contacts, and even beyond that to ensure “casual contacts” are also followed up and tested. This is a sign of a rapid and strong public health response.

What needs to change?

Before this cluster, testing was not mandatory for hotel quarantine staff — although this has now changed to compulsory weekly testing.

This is a positive step, but in my view we should ideally start testing hotel quarantine staff daily.

Getting a nasal swab every day is quite intrusive, so I think we could use saliva tests instead. Yes, they don’t have quite the same level of sensitivity as the “gold standard” PCR tests based on nose and throat swabs, but they’re more tolerable for frequent testing.

Saliva samples can also be efficiently managed if pooled together, and if there’s evidence of a positive test in the broad sample, individual samples can then be checked. Testing early and often is the best approach.

We also need to get serious about resourcing our hotel workers. Spurrier confirmed some workers had worked at multiple sites. This obviously increases the risk of the virus spreading through the community — we saw this with some aged-care staff working across multiple venues in Victoria.

We need to prevent workers from needing to work across multiple sites, by paying them more. Even if they’re not working full-time, they need to be paid as such to ensure they don’t need to take on extra work and increase the risk of spreading the virus to other workplaces. This goes for all staff — security staff as well as cleaners. Cleaners have a very important job and are particularly vulnerable.

I’d like to see national guidelines crafted for hotel quarantine. Today there is national agreement on weekly testing, but I think this should be a minimum. Infection control protocols and monitoring, and pay rates with accompanying sole employment rules also need to be considered. It’s an issue that isn’t going to go away, and it’s an important gap that needs to be filled.




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The Conversation


Catherine Bennett, Chair in Epidemiology, Deakin University

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

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