Month: August 2021

On Friday 27 August National Cabinet discussed plans for the vaccination of 12-15 year olds and gave further consideration to the use of the Doherty Institute’s model of the dynamics of covid-19 infection and vaccination. The agendas for its future meetings should include the following five matters.

1 – The nation needs and deserves a detailed schedule of the numbers of various vaccines due to be delivered to Australia in the next 12 months. It is understood that there may be some unavoidable delays, even when contracts have been entered into. These could include the sort of batch quality issues currently being experienced in Japan with Moderna. 

Everyone is now aware that the ‘dark matter’ that has hung over Australia’s vaccination program from the very beginning is insufficient supply. The public and those working on the pandemic need to know what the expected schedule is. Apart from anything else, such a schedule is required in order to agree to the second of these five agenda items: a new priority order for vaccination.

2 – A new priority order for vaccinations must be drawn up for all to see and discuss. It would be a tragedy if those groups which were in 1a all those months ago were to be pushed down the ranking before they have been accorded what they were originally promised: to have all of their group fully vaccinated. 

However the overriding purpose of vaccination has shifted from the situation in which, with very little Covid in Australia, the most important criterion for ranking was vulnerability to serious illness and death. Vaccination is now a key asset in efforts to reduce the number of infections. And even though it would be a tragedy, it is now clear that some tragedies simply will not be avoided.

If year 12 students in the most affected LGAs in Sydney are to be a higher priority than people in aged care facilities, let’s have public discussion and understand the reasons why this is so.

If it is simply impossible to deliver to the Aboriginal Medical Service in Orange the 900 doses a fortnight it needs, let’s understand that now so that remedial action can be taken immediately. The alternative is to dissemble, to let the actual situation dribble out, delaying mitigating action and making the situation even worse. 

To some extent the responsible agencies have hidden behind the phrase ‘The Most Vulnerable’. No-one could argue against vaccinating ‘the most vulnerable’ first. However someone has to convert the phrase into action.

From the beginning, to this vulnerability criterion were added practical, commonsense criteria about the potential seriousness of the impact on health and other essential services of staff having to isolate and be away from work. That remains a critical criterion.

The new criteria for allocation include geographical and demographic characteristics. Where you live and what contribution you are likely to make to spread of the disease have become as important as the extent to which you are likely to be severely affected by the condition.

If vaccine is still in short supply in September and October, very difficult decisions will have to be taken. Teenagers or the 20-39 year olds? Home aged care workers or teachers? People living with disability or those in remote areas with little access to health services?

3 – The Commonwealth must take the lead in developing protocols and systems for determining which employees in which sectors will have a mandated requirement for vaccination.

Notwithstanding the legal complexities that apply, this is too important an issue to leave to individual companies or workplaces. If it is agreed, for instance, that all hospital staff, teachers, childcare workers or food distributors should have mandated vaccination, then the implications for distribution of available vaccine (2 above) can be factored in.

Individual entities such as District Health Boards for hospitals and Departments of Education for schools can be expected to deal with specific matters such as how to manage people on their staffs who have sound reasons for avoiding vaccination.

This issue will have to be considered in conjunction with plans for a ‘vaccine passport’ (by whatever name).

4 – if he hasn’t already got one, Lieutenant-General Frewen needs to appoint a supremo to ensure that resources and other encouragement are provided to the wide range of community groups that, between them, are having success in helping to ensure that particular groups who are marginalised are getting vaccinated. There are also many valuable local initiatives providing care for communities affected by the pandemic in other ways.

Absolutely no ‘centralisation’ is required but support, information, data and publicity will all help such effort. The circulation of case studies can contribute to these practical remedies and to the morale of communities everywhere. Support should be provided by both state and federal governments to ensure that the efforts of such groups are optimised. 

The new emergency brought about by Delta is what has seen such community groups mobilised. Perhaps even community spirit needed a jolt to overcome complacency. Also, at last, the various jurisdictions have injected urgency into their management of covid, including through adopting practices that have been applied in other countries months ago. This includes flying squad type programs to target particular areas or groups of people, mobile clinics, and a range of incentives for getting vaccinated. 

5 – Some appropriate, energised and capable agency needs to be commissioned to produce (for the public) data on all aspects of the pandemic and its management. One of the gravest and most surprising aspects of the pandemic to date has been the lack of good data at national, state, regional and demographic group levels. This needs to be rectified as a matter of urgency.

There is still much to be done in relation to the pandemic and the vaccination program in particular. With action on these five matters Australia can put the muddle behind it and move on to better ways and better days. Public discussion of the priorities for vaccinations (which priorities may or may not be new), informed by plentiful data, can help make sure that confidence replaces hesitancy. 

It needs to be accepted that if supply remains inadequate some very challenging choices will have to be made about which people are the top priority and which will just have to be delayed.

27 August 2021

In terms of influence over Australia’s vaccination program, nothing has been more significant than the fact that, from the beginning, there has been an overall shortage of supply. This has cast a dark shadow over all aspects of the program.

Details of the schedule for receipt of vaccine supply must determine absolutely the timing of vaccinations and which groups of people will be first. The public has been kept in the dark about this delivery schedule.

Agreement on the priorities for allocation of vaccine will be critical for as long as there is a supply shortage.

Public debate on the matter has been impossible because most of the planning and management has been done secretly. A sad and surprising feature of the response to the covid pandemic has been the failure to assemble, analyse and utilise data on all aspects of the phenomenon and to keep the public informed. There is so much the public (and, apparently, researchers) don’t know about a disease that threatens everyone.

In the lead-up in Australia to the availability of vaccines and in the first stages of their application, the most important criterion for their allocation was a judgement about which groups or classes of people were ‘the most vulnerable’.

Decision makers and commentators could, in effect, hide behind the phrase. No-one would argue against vaccinating ‘the most vulnerable’ first. However someone – in the case of vaccines, governments – had to convert the phrase into action. They have to decide whether to allocate the last vial of vaccine, as it were, to an elderly person, a nurse, an infant, a mobile 25-year old, someone with a disability, an Aboriginal or Torres Strait Islander person, or a worker in the hotel quarantine system. The decision is difficult and has ethical, practical, clinical, economic and global implications.

To this vulnerability criterion were added practical, commonsense criteria about the potential seriousness of the impact on health and other essential services of sickness and the resulting absence of members of their workforce.

Largely because the processes in train were not under any single agency’s control, management of the early days of the vaccination program was missing. There was no national leadership and an extraordinary absence of urgency. Things just drifted.

It seemed as if the standard dynamic in play was for political pressure to be applied to the Commonwealth, following which it ‘got off the hook’ by announcing some new initiative, with the actual operationalisation of the decision falling to the States and Territories or to GPs. This was the case, for instance, with the sudden weekend announcement in April 2021, just a week  before the first general practices were due to come online, that over 4,500 general practices would be providing vaccination. Very little vaccine was actually available to GPs and their phone lines ran hot with frustrated patients.

Initiatives such as pop-up and drive-through vaccination clinics, local support for local rollout to specific cultural groups, and a flying-squad type approach to communities facing special risks were slow to emerge, despite the demonstrated success of such activities in other countries.

The media and other leaders of the debate about covid must take some of the blame for the fact that, even after all these months, the priorities first agreed (those groups allocated to category 1a) have not yet been fully vaccinated. We have allowed the debate about vaccination to move on from one priority to another without any care about whether those of the highest order have first been met.

Delta has re-written the story. With the Delta variant rampant the competition for scarce vaccine has become even stronger. Given the second wave in Sydney and the rest of NSW, the balance between various criteria for prioritisation has shifted. It is no longer agreed that ‘vulnerability’ is the key criterion and that a focus on minimising death and serious illness after infection is the standout purpose.

Rather, vaccination is now a key asset in the battle to limit the number of infections. The new key criteria for allocation include geographical and demographic characteristics. Where you live and what contribution you are likely to make to spread of the disease have become as important as the extent to which your health is likely to be severely affected by the condition.

This means that some of the priority tasks originally agreed are in danger of remaining unfinished. This is likely to have serious implications for the groups affected such as the elderly, Aboriginal and Torres Strait Islanders, hospital staff and people with a disability.

The Federal Government has permitted this change, but it has not led on it. It has been the States and Territories and their health advisers who have taken the lead.

Ironically, with the narrative changing from the  suppression of cases to ‘living with covid’, the main purpose of vaccination will to some extent switch back and once again be to minimise illness and death.

The most urgent challenge is to complete the work contingent upon the original priorities, including complete coverage of patients and staff in residential healthcare, aged care and disability facilities.

From 17 September all staff of residential aged care facilities will be required to have had at least one dose. One assumes that the number of doses allocated for this purpose has been  checked off against the schedule of vaccine supply.

Such an approach illustrates the fact that the exercise is akin to a complex logistical exercise in planning and management of stocks and flows. Such challenges are familiar to the defence force, for example when it engages in war games or assistance after a natural disaster. It is therefore good to have the military involved.

The Commonwealth must provide the public with more and more detailed data. It must also lead on seeing that Australia is a strong contributor to global and regional initiatives to support vaccination programs in poorer nations.

With greater understanding of the importance of vaccination and how decisions relating to it are made, people are likely to be more invested in the vaccination campaign and thus be more willing to comply with and support it.

17 August 2021

Calling something as poorly designed as Australia’s Covid vaccination system ‘a rollout’ gives wheels a bad name. The failure to manage effectively the identification of priority groups for coronavirus vaccination, and to deliver vaccines to them, has to date been an awful failure of public administration.

The Federal Government’s approach to prioritising population groups for covid vaccines can be characterised as one that has favoured and promoted whichever group has newly-acquired media coverage while having no compunction whatsoever about whether higher priorities have been met. One of the clearest and most shameful examples of this procedure relates to staff in residential aged care facilities.

When vaccines first became available, aged care residents and staff were identified as one of the first priorities. They were in 1a. On 7 January 2021, the Prime Minister announced that 4 million Australians would be vaccinated by the end of March 2021; this would include all residents and staff of residential aged care facilities.

The importance of the allocation of a priority was that vaccines were in short supply. And because there was very little coronavirus in Australia at the time, no one demurred about the decision to look after the elderly and their institutional carers first. In the unlikely event that the virus did appear it was the elderly who would be most vulnerable to serious illness and death. And society owed a debt of gratitude to the grandparent generation.

Surprising though it may seem in a country that has generally been well-served by agencies that collect and use quantitative information, the absence of good data on this matter has been an ongoing problem. Despite the fact that the aged care workforce had been given a top priority back in January, in the first week of June the responsible Federal Ministers, Greg Hunt and Richard Colbeck, admitted that they were not able to say what number of aged care staff had received zero, 1 and 2 covid vaccinations. Greg Hunt, Minister for Health, apologised to Parliament for an incorrect report on the matter. He confirmed that 20 aged care facilities had not yet been visited as part of the national vaccination rollout.

There are over 2,600 residential aged care facilities in Australia. Around 240,000 people are employed in direct aged care, of whom about 150,000 are in that residential sector. The other 90,000 direct care workers are employed in community aged care. Over 85% of this quarter of a million are female.

The wisdom of making aged care staff one of the highest priorities for vaccines had been tragically illustrated by the second wave in Victoria. Of the 730 covid-related deaths in that State in the period from early July to late October 2020, 655 were of patients in residential aged care.

Some of the particular fragilities of the aged care system had also become clear. Because of low wage rates and the casualisation of staff, it was not uncommon for individuals to work in more than one facility, thus increasing the risk of infection spreading from place to place. And the care system could be compromised by the temporary loss of staff to illness.

Another problem was that, unlike the situation with previously required vaccinations, the status of staff with respect to covid inoculation was not linked to payroll. Furthermore, it was not until June 2021 that operators were required to report each week to a central agency (the Federal Health Department) on the covid immunisation status of their staff.

Some of these issues were compounded by confusion or overlap between federal and state jurisdictions. The Victorian government moved to ensure that staff of the facilities it managed could no longer work across multiple sites. The Federal Government, which is responsible for the regulation of the majority of aged care homes, scrapped that policy in November 2020. It was replaced with a set of principles that would see that “ideally” (sic), an aged care worker would be limited to working at a single aged care site. The federal government reinstated the regulation in June 2021.

At the end of that month, two-thirds of staff working in aged care homes across Australia were still not fully vaccinated.

Finally, something stirred. On 2 July National Cabinet agreed to adopt the “strong advice” from the Australian Health Protection Principal Committee (AHPPC) to make vaccination against covid mandatory for all staff of residential aged care facilities. The new requirement comes into operation on 17 September 2021. All staff will be required to have had at least a first dose of a COVID-19 vaccine.

This action will be underwritten by a grant program to help the centres and, through them, their individual staff members. Eligible payments will help with travel to the nearest vaccination site and cover for lost wages. The Federal Government will oversee compliance by all centres.

Lt General John Frewen is now Co-ordinator General of the National Covid Vaccine Taskforce. Given this pivoting of leadership, it should be permissible to observe that if military precision and logistics had been applied from the very beginning, the promised commitment to aged care workers could have been acquitted in the six weeks to the end of March.

The mandatory vaccination of aged care staff must be completed on time, with a high level of competence and effectiveness. In some respects, it will be harder than it would have been in February and March. There is now much greater competition between population groups to be prioritised, due in particular to the situation in NSW. Some might even dare to whisper that the elderly ought to have no higher priority than young adults – the mixers and spreaders – and Aboriginal and Torres Strait Islander people.

We want leadership. And no more unmet goals or unreached horizons. Because it is now clear and alarming that the priorities set eighteen months ago are no longer fit for purpose.

25 July, 2021

Jack¹ from Bathurst phoned into Life Matters this week. He thought to help the Covid vaccine situation by bringing forward his second AstraZeneca jab. But no one could tell him what effect that would have on the efficacy of his jabs.

Jack’s second jab is due in mid-August. So he had the capacity to fast track it by four weeks. He called the local clinic and was told that he would lose 16% of immunity for each week the second jab was brought forward. Having “fallen out” with the person he was speaking to, he called again. Another clinician said he would lose 10% of immunity per week.

Jack’s question is a good one. It needs to be answered if those in a similar situation are to help by bringing forward their second AZ jab.

One of the experts on the Life Matters radio program gave some very precise figures about the efficacy of the two vaccines available to us in Australia – but did not directly answer Jack’s question. I thought there must surely be a table of such numbers somewhere, so I went searching online. I couldn’t find a consolidated tabulation but there are of course miles of research papers on individual aspects of the question.

So I started to compile my own. I have included in it the stats from the ABC interview with Associate Professor Margie Danchin. (I will be very happy to hear from someone about where I can find a decent, professional table of this sort. Surely?)

If Jack’s question is answered in such a way as to make it clear that there will be no, or very little, loss of efficacy by bringing forward the second jab, it will make a significant contribution to the acceleration of the effective use of AstraZeneca which so many people are now hoping for.

I’ve called it A current policy and information hotspot. All we need is reliable scientific evidence that there will be little loss of efficacy and a whole cohort of people who have already demonstrated their willingness to be vaccinated with AstraZeneca can provide an immediate boost to the nation’s well-being and prospects.

¹ close to his real name.

The efficacy of AstraZeneca and Pfizer against Alpha and Delta variants

– figures from a small number of online sources,speedily compiled on
22 July 2021

	Protective efficacy against symptomatic Covid (Alpha)	Protective efficacy against symptomatic Covid (Delta)	Protective efficacy against hospitalisation due to Covid (Delta)
AstraZeneca, first dose	30% PHE	“barely any” in article in Nature. Life Matters: 30%	“barely any” in article in Nature. Life Matters: 71%
4 week gap – AstraZeneca 2nd dose	55%	? [If it was pro rata, 42%]	? [If pro rata, 78%]
8 week gap – AstraZeneca 2nd dose	?	?                                             ? [a current policy and information hot-spot
12 week gap – AstraZeneca 2nd dose	74.5% Life Matters: 81%	67% Life Matters	2 doses: 92% Life Matters. But what gap?
Pfizer, first dose	50% PHE	33%	“barely any” Nature, Delphine Planas et al, 8 July2021
Pfizer, 3 week gap (21 days rec.; best protection after 7 more days)	93.7%	80% for ‘infection’ 88% for ‘symptomatic disease’ – PHE and Canada [64% in Israeli study: less effective against symptomatic disease than against severe disease]	96% PHE
Pfizer, longer gap	?	?	?

Sources:

PHE – Public Health England, May 2021. ‘Analysis of real-world data.’ Radio interview on Life Matters, Hilary Harper with Assoc. Prof. Margie Danchin, Murdoch Children’s Research Institute. (Monday 19 July 2021). New England Journal of Medicine. ‘Nature’, article by Delphine Planas et al, 8 July 2021.

Note: this piece was published in Pearls and Irritations on 25 July 2021.

19 July 2021

If enough of us ever get vaccinated to get over the immediate emergency, it will be useful to take time to reflect on the medium-term implications of the global pandemic for the governance of Australia and the world. There is much to be done and much we can learn.

The pandemic has thrown new light on the benefits and costs of globalisation.

The economic status of Australia and the well-being of its citizens are closely tied to aspects of globalisation. Australia is a relatively small economy with limited domestic demand. The nation has prospered through having natural resources in abundance which, given a worldwide free trade regime, can be sold to countries less well endowed.

However, the pandemic has woken Australia to the risks of too great a dependence on globalisation. It is now clear that the single most serious issue for the nation was supply of vaccine. In preparing for vaccination, the Federal Government made errors in commissioning and negotiating supply from other nations. This was compounded by decisions made by some of those other nations which were in their own interests and over which Australia had no control.

The problems posed by the absence of sovereign capacity to manufacture goods and services that become essential when the world faces a widespread emergency were apparent even before vaccination started. There were shortages of items of personal protective equipment and hand washing gel (in the days before we understood that soap and water was best). These were mitigated to some extent by the flexibility of some manufacturers who re-tooled rapidly; and by home-grown household activity, such as mask-making.

Incidentally, perhaps it would be wise to include toilet paper as a bottom-line commodity in forthcoming trade agreements that Australia signs.

On the other side of the globalism ledger, the pandemic led very rapidly to the effective closure of two of Australia’s major export sectors and employers: international tourism and international education. This was caused by interruption of another key element of globalism: the free and untrammelled movement of people around the world.

Fortunately, the export of natural resources, particularly iron ore and coal, as well as agricultural produce, seems to have proceeded unabated. The astonishing increase in the international price for iron ore, not related to the pandemic, has done much to shelter Australia from the worst economic effects of Covid-19.

Building manufacturing capacity and finding ways to make existing industries more resilient will have beneficial economic effects. Just as the shift to renewable energy sources is making new industries economic, so will national re-tooling for greater emergency self-sufficiency help to build Australia’s economy and provide employment opportunities.

Moves to mitigate against inadequate supply of goods and services needed in an emergency, and in response to the decline of major industries, provide incentives for Australia to rebuild its manufacturing sector.

In the 1960s manufacturing provided one quarter of GDP. By 2010 this had fallen to 6%, providing 8.6% of employment. In 2020 it was 4.2% of GDP and 7% of employment –  or 853,000 people.

The Federal Government has indicated that it has plans for what it calls A Sovereign Manufacturing Capability Plan. It will apparently cover business opportunities both small and large, from manufacturing for niche markets right through to the production of guided weapons.

International agencies

As a middle-sized nation which benefits from both international trade and the rule of law, Australia has traditionally been a strong supporter of the bastions of globalism: multilateralism and international agencies. Once the health emergency is over it will be useful to scrutinise the performance of these agencies and to act on lessons learned about their structure, operation and value.

The agency most closely involved in the pandemic has obviously been the World Health Organisation (WHO). The majority view seems to be that the WHO had a poor start due to being slow in declaring the novel coronavirus outbreak ‘A public health emergency of international concern’, its highest level of alarm. Some commentators have attributed this to sensitivity about China’s potential reaction to such a declaration.

Since then, the WHO has been a critical and positive contributor to management of the pandemic. The challenge for the WHO was all the greater given that it was confronted by active opposition from the United States under Donald Trump. He cut funding for the WHO in May 2020.

Some of the WHO’s most important work is concerned with global vaccine equity and the gap between richer and poorer nations – the so-called ‘two-track pandemic’. The scale of this challenge is illustrated by the fact that several affluent countries are already discussing the rollout of booster shots to their populations, while the majority of people in developing countries—even front-line health workers— have still not received their first shot.

This is a matter that needs urgent international agreement and action, in which Australia, as an affluent country, should take an active part. There is much to be done in the medium term to make the world a fairer place before the next pandemic or similar crisis emerges.

The most critical immediate task in world health is to ensure that developing nations are given all necessary support for obtaining and using vaccines. Supply in sufficient quantities is the core challenge and spreading it fairly between richer and poorer nations. One way to achieve this would be to assist medium-sized countries to establish the capacity for producing vaccines. Cost is a key factor and it is to be hoped that ways can be found for the sort of generosity shown by governments and the private sector over the last 18 months to continue to be demonstrated.

Given the massive impact on world trade and damage to the budgets of all countries, including those that are affluent that have been donors of international aid, the impact of the Covid-19 emergency on the people and governments of poorer countries may yet become unmanageable. Much will depend on the role played by international aid and trade in the new order.

One particular example of successful collaborative international action is COVAX. Its aim is to accelerate the development and manufacture of Covid-19 vaccines, and to guarantee fair and equitable access for every country in the world. Among other things it is working to ensure that donations of vaccine to developing countries are synchronized with national vaccine deployment plans.

Apart from the WHO, international agencies concerned with the pandemic include the International Monetary Fund (IMF), the World Trade Organisation (WTO), the World Bank and the OECD.

The IMF is preparing a Special Drawing Rights (SDR) allocation to boost the financial reserves and liquidity of its members.

The WTO is involved because cooperation on trade is needed to ensure free cross-border flows and increasing supplies of raw materials and finished vaccines. It is working on negotiations towards a solution around intellectual property, which remains the main sticking point in relation to making medications available at low prices. The WTO is also working on freeing up supply chains for vaccines and other medicines.

The World Bank has provided a $12 million financing facility for vaccination and has vaccine projects in some 50 countries.

In anticipation of an end to the immediate Covid crisis, preparations can begin for evaluation of the way international agencies have performed since the beginning of 2020.

Note: a modified version of this piece was published as Part 1 of Preparing for an evaluation of Australia’s response to the Covid-19, 13 July 2021.