The highly infectious Delta variant has spread significantly in both states, making contact tracing and containment more difficult.
This may be welcome news for those in Sydney who have been under stay-at-home orders since June, and those in Melbourne who have lived through more than 220 days of lockdown over the past 18 months. It means these states will leave strict lockdowns eventually without having to wait for case numbers to decrease to zero.
But with other jurisdictions across the country continuing to pursue COVID-zero, what does this mean for Australia?
States and territories divided
The future is likely, at least in the short term, to look similar to the current situation with different rules for different states and territories.
Those states pursuing COVID-zero may have greater freedoms, almost resembling pre-COVID life, with generally low levels of restrictions such as mandatory venue check-ins. Though strict lockdowns would be likely when cases do appear.
States like New South Wales and Victoria will require ongoing low level restrictions, such as masks and capacity limits — even with vaccination rates of 70%–80% of over 16s.
Moderate or strict lockdowns would likely still need to occur in response to rising case numbers and local outbreaks.
The importance of ongoing low-level restrictions has been shown consistently by Australian modelling and is highlighted by the current rise in case numbers in the highly vaccinated population of Israel.
How will this impact travel?
Likely the biggest impact of divided COVID-zero policies across states and territories will be interstate travel, with different rules between jurisdictions depending on their COVID-zero status.
Restrictions imposed to date would suggest travel between COVID-zero states and territories, who haven’t had any recent COVID cases reported, would be allowed.
There’s also the possibility of interstate travel occurring between jurisdictions with ongoing community transmission.
Will other states give up on COVID-zero?
As the virus continues to spread, other jurisdictions across Australia may also stop trying to reach COVID-zero.
NSW and Victoria having high levels of ongoing community transmission makes other states and territories more vulnerable to imported COVID infection.
However, tight border control and strict lockdowns when required do appear to be working in some jurisdictions, for example Western Australia.
How will vaccination impact this?
As vaccination rates increase, the need for lockdowns and strict restrictions decreases.
In terms of vaccination, New South Wales is currently leading the way with 76.4% of over 16s vaccinated with at least one dose, and 43.6% fully vaccinated.
Other states’ vaccination rates are also rising, albeit more slowly. Approximately 36% of over 16s in Western Australia and Queensland are fully vaccinated.
If the current rate of rollout continues, it’s anticipated 70% of over 16s in Australia could be vaccinated by early November, with 80% coverage reached later in the same month.
With vaccination rates increasing rapidly and restrictions easing despite high case numbers, NSW and Victoria may provide test cases for the other Australian states and territories in terms of a roadmap to living with COVID.
While modelling provides a tool to guide decision makers about what to expect, these calculations are based on a number of assumptions. Predicted outcomes differ depending on key factors such as the ability of the public health workforce to maintain optimal contact tracing.
The real world experience of decreasing restrictions with COVID transmission in the community will provide important information for those that follow.
It’s important to remember, while the country is slightly fractured in its current response, we are all in this together. As vaccination rates continue to rise in the coming months, states and territories will likely return to a more level playing field.
In good news, it does seem we will have more freedom in the coming months as vaccination rates continue to rise.
But this will be an evolving situation that requires constant monitoring and changes in response to the local spread of disease, with all states and territories likely to require low level restrictions for some time.
With the easing of restrictions, it’s important we all listen to and follow public health directions and get vaccinated as soon as we can to try to maintain manageable case numbers and workload for our public health workforce.
Australia’s plagued vaccine rollout meant such requirements lay in a distant future — until now.
Australian political leaders have begun talking about a two-track future.
Proof of vaccination is already required in contexts around the globe by governments and private companies for people seeking to travel, dine and party.
We can expect a similar scenario here. So how will Australians be able to prove they’re fully vaccinated?
How can I prove I’m vaccinated?
NSW and Victoria are experiencing high new COVID case numbers. Both states have indicated reaching vaccination targets of 70-80% will be required for widespread easing of restrictions.
They’ve also suggested some freedoms will be only available to people who are fully vaccinated.
NSW Premier Gladys Berejiklian yesterday announced freedoms for fully vaccinated people once 70% of the state’s eligible population are double dosed. These include being able to go to hospitality venues, hairdressers and gyms, and have five people to your home.
Attention is now turning to the ways in which these and other Australian governments will require proof of vaccination for entry into public and private spaces.
Currently, vaccinated Australians can access a COVID-19 digital certificate through MyGov or the Express Plus Medicare app.
For returned travellers, this technology is likely to inform the circumstances under which they quarantine. Fully vaccinated travellers may have less stringent requirements than those who are unvaccinated, so technology to demonstrate this will be necessary.
States are also preparing to require proof of vaccination for local participation in hospitality venues and events. This would very likely be different to the way you would prove your vaccination status for travelling overseas.
New South Wales is set to trial and then introduce a vaccine passport in October.
Vaccination data from the Australian Immunisation Register would be embedded in the Service NSW app, meeting hospitality industry demands for a simple process.
However, errors in the uploading and registration of data for vaccinated individuals will need resolving to avoid leaving them out in the cold.
Victorian Premier Daniel Andrews has announced the state will pursue its own version of a vaccine passport.
A “vaccinated economy” to be piloted in regional Victoria will allow only the double-dosed to access events, facilities and services. Again, the hospitality industry supports easy-to-use vaccine passports following their role in reopenings overseas.
What about people who can’t get vaccinated?
Currently, the only formal medical exemption in Australia for COVID-19 vaccines is available on a federal government form. Until now, this form has been used for the country’s “No Jab” policies.
Recently updated for COVID-19 vaccines, it lists a very narrow set of criteria for exemption and can be lodged only by specific medical practitioners.
All levels of government using vaccine passports will need to consider whether other types of exemptions are appropriate or necessary, including for people who have recently been infected with COVID and are advised not to vaccinate for up to six months.
Victoria’s human rights apparatus indicates a wider set of considerations or exemptions may be necessary for those unwilling or unable to vaccinate.
Governments will then need to work out how to manage these exemptions with the technologies they use.
One common way of managing people who are unvaccinated for any reason is to demand proof of a negative COVID-19 test.
Italy’s vaccination passport uses this alternative, and France’s Pass Sanitaire, or “health pass” has a similar option. Israel’s Green Pass system enables temporary passes for the uninfected, good for 72 hours.
Whether or how these negative tests would be integrated into Australian systems remains to be seen. Pending policies for nightclubs in England and Scotland are set to exclude the “negative test” opt out, meaning only the fully vaccinated will be able to access these venues.
Some Australian states and regions will be scrambling for technology if they want to go down the vaccine passport route.
The check-in app used in Queensland, Tasmania, the NT and the ACT lacks verification mechanisms and is not designed to hold a vaccine passport.
Western Australia is focused on vaccine requirements for interstate travellers and health-care workers, and so far has made no moves towards requiring vaccines for local activities; nor has South Australia.
Research suggests there’s public support for these kinds of measures in Australia, and there are good reasons to prefer governments introducing the terms of a vaccine mandate rather than private corporations.
However, there are issues of legality, viability and ethics to consider, with venue and individual compliance likely to remain a key issue.
We need to get two doses of vaccine into as many adults as possible — firstly because that helps reduce severity of illness and infection, but also because reaching vaccination targets is likely to bring some new freedoms.
The COVID-19 vaccines (Pfizer, Moderna and Astra Zeneca) continue to be highly effective in reducing risk of severe disease, hospitalisation and death, even against the Delta variant.
But as soon as we finish one vaccine rollout we may need to begin the next rollout of booster doses.
When will I need my booster shot?
First, we need to differentiate between a booster dose and a third dose as part of the initial round of vaccinations. They are two very different things.
Some people who are immunosupressed might need a third dose as part of their primary COVID-19 vaccination schedule. In other words, their third dose comes not long after their second dose and is given to improve their initial protection.
A booster shot is given much later after the initial two dose round of shots. A good example is the way we give tetanus and whooping cough booster vaccines.
There’s a great explainer on who might need a third dose as part of their primary vaccination schedule over here.
For the rest of us, we don’t know for sure when you will need a booster shot. You’ll read lots of different figures on this — six months, eight months, more — and that’s because the research is ongoing. We don’t yet have a definite answer to the best timing for a booster dose.
Pfizer recently announced its research had shown a booster dose resulted an increase in antibodies against the initial virus as well as against the highly infectious Delta variant. These results are awaiting publication and the safety of the booster dose needs to be known. The European regulator (known as the European Medicines Agency) has also started to evaluate an application for the use of a booster dose of the Pfizer vaccine.
In a recent letter to The New England Journal of Medicine, published online earlier this month, doctors and public health experts at University of California San Diego said their data suggested vaccine effectiveness against any symptomatic disease may wane over time since vaccination:
Vaccine effectiveness exceeded 90% from March through June but fell to 65.5% […] in July.
Over time, data will emerge on immune responses and safety after a booster dose.
It may be that booster doses are particularly needed for certain groups in our community — for example, older people or frontline workers. There is also discussion of whether severely immunosuppressed people should get a booster dose from around six months after their third primary dose.
The US booster plan is dependent on the Food and Drug Administration determining that a third dose of the two-dose vaccines is safe and effective, and following advice from the Centers for Disease Control.
Israel’s booster rollout has begun, with people there becoming eligible for a booster five months after their second dose.
The European Centre for Disease Prevention and Control recently said that there is
no urgent need for the administration of booster doses of vaccines to fully vaccinated individuals in the general population.
Can we mix and match, by getting a different brand of vaccine for the booster?
We don’t yet know for sure.
There may be benefits to getting a different vaccine to the one you first got as a booster. We also know that new vaccines designed specifically to target novel variants are in development and it may be better to receive a booster of a variant-specific vaccine.
It will be worth keeping a close eye on a key trial by the UK-based COV-BOOST group, which is aiming to find out which vaccines against COVID-19 are most effective as a booster vaccination, depending on which vaccine was used to provide the initial primary vaccine course.
This study will give us good information on whether it will be better to get a booster shot that is the same brand as your primary dose, or whether to switch to another.
For example, should a person who initially got Pfizer for their first two doses get an AstraZeneca shot for their booster? Or vice versa? Or should they get a booster of a new variant vaccine?
A trial is underway in the US looking at the safety and immune responses of using a different booster vaccine to the first two doses, but also includes a Beta (B.1.351) variant vaccine.
Hopefully, supply chain issues for the Pfizer vaccine will improve in the coming months.
This will help with the rollout of initial doses.
For now, the priority is getting the two doses into arms
Monitoring of the effectiveness of the COVID vaccines will continue, particularly against the delta variant and any new variants that emerge.
Trials are also underway of the safety and immune responses to a variety of different booster vaccines, including the next generation variant vaccines.
The World Health Organization said in August:
In the context of ongoing global vaccine supply constraints, administration of booster doses will exacerbate inequities by driving up demand and consuming scarce supply while priority populations in some countries, or subnational settings, have not yet received a primary vaccination series.
The focus for the time being remains on increasing global vaccination coverage with the primary series.
For now, Australia must focus on getting our primary adult coverage as high as possible in order to protect against severe disease, hospitalisation, and death.
A breakthrough infection is when someone tests positive for COVID after being fully vaccinated, regardless of symptoms.
The good news is most breakthrough infections usually result in mild symptoms or none at all, which shows us that vaccines are doing exactly what they’re supposed to do — protecting us from severe disease and death. Vaccines aren’t designed to protect us from getting infected at all (known as “sterilising immunity”).
However, if you’re vaccinated you’ll clear the virus more quickly, reducing the length of time you’re infectious and can pass the virus on.
Here’s why breakthrough cases are happening, and why you shouldn’t worry too much.
Two studies from the United Kingdom suggest the immunity we get from COVID vaccines wanes over time, after about four to six months.
While the more-infectious Delta variant continues to circulate, waning immunity will lead to more breakthrough infections.
But the reduction isn’t large currently. Vaccine effectiveness is very high to begin with, so incremental reductions due to waning won’t have a significant effect on protection for some time.
Israeli data shows some vaccinated people are becoming ill with COVID. But we need to keep in mind Israel’s vaccine rollout began in December 2020, and the majority of the population were vaccinated in early 2021. Most are now past six months since being fully vaccinated.
Given most people in Israel are vaccinated, many COVID cases in hospital are vaccinated. However, the majority (87%) of hospitalised cases are 60 or older. This highlights what’s known about adaptive immunity and vaccine protection — it declines with age.
Therefore we’d expect vulnerable groups like the elderly to be the first at risk of disease as immunity wanes, as will people whose immune systems are compromised. Managing this as we adjust to living with COVID will be an ongoing challenge for all countries.
What would be concerning is if we started seeing a big increase in fully vaccinated people getting really sick and dying — but that’s not happening.
Globally, the vast majority of people with severe COVID are unvaccinated.
We’ll probably need booster doses
Waning immunity means booster doses will likely be needed to top up protection, at least for the next couple of years while the virus continues to circulate at such high levels.
Our currently approved vaccines were modelled on the original strain of the virus isolated in Wuhan, not the Delta variant, which is currently dominant across most of the world. This imperfect match between vaccine and virus means the level of protection against Delta is just a little lower.
Because the level of effectiveness is so high to begin with, this small reduction is negligible in the short term. But the effects of waning over time may lead to breakthrough infections appearing sooner.
mRNA vaccines in particular, like Pfizer’s and Moderna’s, can be efficiently updated to target prevalent variants, in this case Delta. So, a third immunisation based on Delta will “tweak”, as well as boost, existing immunity to an even higher starting point for longer-lasting protection.
We could see different variants become endemic in different countries. One example might be the Mu variant, currently dominant in Colombia. We might be able to match vaccines to whichever variant is circulating in specific areas.
The dose makes the poison
Your level of exposure to the virus is likely another reason for breakthrough infections.
If you’re fully vaccinated and have merely fleeting contact with a positive case, you likely won’t breathe in much virus and therefore are unlikely to develop symptomatic infection.
But if you’re in the same room as a positive case for a long period of time, you may breathe in a huge amount of virus. This makes it harder for your immune system to fight off.
This may be one reason we’re seeing some health-care workers get breakthrough infections, because they’re being exposed to high viral loads. They could be a priority for booster doses.
Might unvaccinated kids be playing a role?
It’s unclear if children are contributing to breakthrough infections.
Vaccines aren’t approved for young children yet (aged under 12), so we’re seeing increasing cases in kids relative to older people. Early studies, before the rise of Delta, indicated children didn’t significantly contribute to transmission.
More recent studies in populations with vaccinated adults, and where Delta is the dominant virus, have suggested children might contribute to transmission. This requires further investigation, but it’s possible that if you’re living with an unvaccinated child who contracts COVID, you’re likely to be exposed for many, many hours of the day, hence you’ll breathe in a large amount of virus.
The larger the viral dose, the more likely you’ll get a breakthrough infection.
Potentially slowing the number of breakthrough infections is one reason to vaccinate 12 to 15 year olds, and younger children in the future, if ongoing trials prove they’re safe and effective in this age group. Another is to protect kids themselves, and to get closer to herd immunity (if it’s achievable).
A silver lining
Breakthrough infections likely confer extra protection for people who’ve been fully vaccinated — almost like a booster dose.
We don’t have solid real-world data on this yet, but it isn’t surprising as it’s how our immune system works. Infection will re-expose the immune system to the virus’ spike protein and boost antibodies against the spike.
However, it’s never advisable to get COVID, because you could get very sick or die. Extra protection is just a silver lining if you do get a breakthrough infection.
As COVID becomes an endemic disease, meaning it settles into the human population, we’ll need to keep a constant eye on the interaction between vaccines and the virus.
The virus may start to burn out, but it’s also possible it might continually evolve and evade vaccines, like the flu does.