Month: September 2021

“Cabinet confidentiality ensures that members of national cabinet may exchange differing views and achieve outcomes together.” (Media statement, September 17, 2021) 

Sensitivity analyses were considered in relation to two of the Doherty model’s variables, the standard or level of test, trace, isolate and quarantine (TTIQ) practices, and of public health and social measures (PHSMs).

But as far as we know, consideration was not given to the variable which almost all experts thought ought to be changed: the 54 per cent and 65 per cent full vaccination thresholds for the whole population (70 per cent and 80 per cent of “the eligible population”). 

There may have been an unwillingness to accept that those original vaccination thresholds were too low. At any rate, national cabinet concluded that “with high vaccination and appropriate TTIQ and PHSMs to constrain outbreaks, overall cases and deaths are expected to be similar in order of magnitude to annual influenza”. (emphasis added)

So the question for each state and territory is what levels of TTIQ and PHSM are appropriate given the incidence of infection that exists in their jurisdiction at any given time.

The trouble is that the dependent variable in the model — the thing against which the level of TTIQ and PHSM is tested for a yes or no answer — is movement from phase A to phase B. And the meaning or significance of such a move is unclear. Phase B lists a number of actions that may be taken by a jurisdiction. There is nothing that a jurisdiction must do — just a list of possible actions.

In what will be a challenge to “the NSW approach”, the Doherty Institute’s revised advice to national cabinet was:

“At high caseloads, maintenance of optimal TTIQ is unlikely to be possible. In such instances, flexibility to strengthen PHSMs generally or locally will be needed (as envisaged in the national plan) to regain epidemic control. The required intensity and duration of measures should be informed by ongoing situational assessment of transmission and its related health impacts.”

Despite this warning, the cabinet’s confidentiality statement issued to the public assumes enough TTIQ and PHSMs to constrain outbreaks. This assumption is what allows it to conclude that cases and deaths would be similar in order of magnitude to influenza.

But back to the national plan. It would help if its meaning was clear. When Scott Morrison announced the plan on the evening of July 30, he read carefully from his prepared notes, presumably in recognition of the plan’s complexity and the need to get the words exactly right. (He was so keen to spell it out that he asked for the light to be turned on so he could see his notes.)

What he said was:

“At each stage, I want to be clear about what the vaccination targets mean for phase B and phase C. States and territories move into the next phase when 1) the national average for the vaccination program, as a percentage of eligible adults, is achieved nationally, and then 2) that state itself has achieved the vaccination threshold in their own state. So, it’s like a two key process. To get to that next phase, all of Australia has to get there together, on average. And, then beyond that each state and territory will pass into that second and third phase based when they reach those thresholds. 

Later in his address: “Phase B, which is achieved by the whole country reaching 70 per cent, and then each state and territory reaching 70 per cent…”

Later still: “When we reach 80 per cent, that is, first again, nationally an average of 80 per cent, and the state or territory has reached 80 per cent, we will move into Phase C.”

So here is the problem. The references to a national average suggest an average across the eight jurisdictions. Most telling are the bolded words on the plan document itself that say: “Average vaccination rates across the nation”.

So, let’s say the percentage of the eligible population with two doses in the jurisdictions is 80 per cent in two, 75 per cent in two, 65 per cent in two and 40 per cent in two, the national average, per jurisdiction, would be 65 per cent. That would be a fail. If the laggard two got up to 60 per cent, with no changes in the other six, the average would be 70 per cent — a pass.

The other interpretation, encouraged by the term “achieved nationally” and “by the whole country reaching 70 per cent ” is that the national criterion refers to whether or not a majority of the Australian population has reached the threshold. It is a long stretch, but not completely ruled out for people who are cavalier with words and meaning, to deem “average vaccination rates across the nation” to mean a majority.

 This second is the interpretation ACT Chief Minister Andrew Barr had when he gave his daily update on September 12: 

“New South Wales are not enacting the national plan if they do things at 70 per cent ahead of the rest of the nation reaching 70 per cent. They are entitled to make changes to their local restrictions, as they have been doing and that’s their purview entirely. But the national plan is very clear that the nation needs to reach the 70 per cent threshold and the nation needs to reach the 80 per cent threshold. Those same constraints apply to the ACT as well. Based on the current vaccination trajectory it will be New South Wales and the ACT that will get to those thresholds first. But our actions under the national plan are limited by where the rest of the country is at.

“Having said that I think it’s important to note that when the nation crosses 70 per cent and 80 per cent is very highly contingent on the vaccination programs in New South Wales and Victoria because together they are nearly 60 per cent of the national population … It’s important that people understand that and their reporting of the national plan reflects that — it’s in bold at the top of the national plan.”

Those bolded words are: Phases triggered in a jurisdiction when the average vaccination rates across the nation have reached the threshold and that rate is achieved in a jurisdiction expressed as a percentage of the eligible population (16+), based on the scientific modelling conducted for the COVID-19 Risk Analysis and Response Task Force.

It’s hard to see how individual jurisdictions can be free to make changes to their local restrictions while at the same time their actions are limited by the provisions of a national plan. They are certainly not going to be restrained by something as ambiguous and unfocused as the present Plan. 

But perhaps there isn’t a real national plan at all — just a Clayton’s one used for federal window-dressing. That would explain why there has been so little comment on it, save by Laura Tingle and the Grattan Institute.

If that’s the case, the prime minister should come clean and stop using the term.

And perhaps the next time there is a national emergency, a pandemic or something equally national in its implications, the first thing to do in Australia is to implement new emergency arrangements that have been developed through the experiences of the COVID-19 pandemic.

One of the most critical matters to have been agreed must be the means by which an uneven (or natural) distribution of the emergency does not allow the situation in the various jurisdictions to become so widely varied.

We need to be “in this all together” — but clearly as yet we are not.

Note: this piece was first published in John Menadue’s Pearls and Irritations on 26 September 2021.

 I have recently posted to www.aggravations.org several pieces on the pandemic in Australia – written between 26 August and 2 September but posted all together. (There was a delay as I tried unsuccessfully to get them published elsewhere.) Here’s an overview of the most recent four.

Covid – five things National Cabinet should agree (20 Aug) entreats someone (anyone!) to give the public a detailed schedule of expected receipt by Australia of Pfizer and Moderna over the next 12 months. There may well be uncertainty due to contracts yet to be agreed, negotiations unfinished, quality issues or even suppliers reneging on agreements. But the Federal Government owes it to its public to keep us informed and allow us to share the joy and pain (think ‘accountability’).

Speaking of which, it would be a tragedy if the commitment made to the groups in priority ranking 1a is not completed.

The Commonwealth must take the lead in developing protocols for determining which employees in which sectors will have a mandated requirement for vaccination. Resources need to be made available to community organisations that are helping to ensure that particular groups who are marginalised are getting vaccinated. And, fifth of all, someone (anyone!) needs to provide public data on all aspects of management of the pandemic in Australia. To date it’s been an information-free zone. Think black box.

Vaccinating Australia: insufficient urgency, too much choice? (26 Aug) begins with the assertion that the Gift of vaccination is being Stawelled and although it isn’t a race, Australia is coming last.

No-one seems to have been in a hurry, and those whose turn it is to run are confronted with so many different lanes and handicaps that some of them have been confused. This second article in the group bemoans the lack of urgency and innovation; (the U.K.’s first drive-through vaccinations were given in December 2020). The Federal Government, responsible for aged care, gave the job of vaccination of aged care patients and staff to private enterprises. It allowed a range of other parties to be involved (PHNs, GPs, State and Commonwealth hubs, hospitals) and, confronted with so many options, staff of aged care who were left to their own devices were uncertain and unmotivated. There was no understanding of the importance of individual convenience of accessing a jab.

When things have settled down it will be useful to understand why the covid vaccination campaign doesn’t seem to have benefited from the successful models for life-time (inc. children’s) public health and workplace vaccinations.

The third piece, Vaccine: Let’s not forget the first priorities (1 Sept), focuses in more detail on the failure to get residential aged care patients covered. The unimpressive history of the Government’s ‘national vaccine rollout strategy’, from early January 2021 to (the forthcoming) mandating of vaccination for aged care staff (17 Sept) is briefly rehearsed. (There are two chances that this target will be met – one of which is Buckley’s.)

In the early days the first criterion for setting the priority of a particular group of people was the extent to which they were vulnerable to serious illness and, potentially, to death. No-one objected to this criterion but unfortunately the same people (no-one) bothered to manage the work that needed to follow.

Analysis of what went wrong has to consider the shortage of vaccine supply (obviously), generalised incompetence and lack of urgency, the absence of public information, confusion or overlap between federal and state jurisdictions and, in particular, an ill-disciplined approach to setting priorities for vaccination and acting on them. This last is critical when there is a shortage of supply.

With the Delta variant rampant, vaccination became the key asset in efforts to limit the number of infections, not simply the means of protecting the vulnerable. New criteria for allocation included where a person lives and what contribution they are likely to make to spread of the disease.

The piece ends with consideration of how vaccine supply has to be cross-matched with demand. Such an exercise must be happening behind the scenes, but without it being known to the public (see above!) the Government can maintain its mal-practice of trumpeting success in obtaining extra vaccine supply without emphasis on the fine print ie that the bulk of it doesn’t arrive until month x or next year.

Between you and me, this particular piece was written in the middle of the night after I had bumped in to a television re-broadcast of the day’s Question Time. What upset my sleep were bits of the Prime Minister’s responses in which he claimed that the speed at which vaccinations were by then occurring had made up for the 4-month delay, so much so that the original target would be met by Christmas “or even sooner”. He credited this turnaround to the fact that the government had “been able to bring forward doses” and had “been able to achieve and realise additional supplies”. [It’s clear now that this referred, inter alia, to the swap with Boris.]

In that same Question Time the Prime Minister reported that double-dosed vaccination rates in aged care facilities were “upwards of 80%”. He seemed to regard this as a success, despite the too long history of the issue, and attributed it to the priority given to vaccinations in aged care “which has enabled us to visit all of these facilities to ensure that the double doses are done”. It is not clear what ‘upwards of 80%’ means, or how many of the other 20% have had their first.

The last piece posted in this batch is Vaccination: Accounting for the muddle.

A ledger is needed for Australia’s vaccination program:

‘An account represents a detailed record of changes that have occurred in a particular asset during the accounting period. All these separate accounts are kept in a loose leaf binder, and the entire group of accounts is called a ledger. The ledger is a record which provides all important information.’

The ledger must provide information to the public in an open format and in language people can understand.

Both sides of the ledger must be considered – vaccine supply and demand for vaccine. The Federal Government should inform the public even when things are uncertain and, especially, when plans become unavoidably changed.

The supply side of the ledger is affected by variations in the planned period between a first and second jab. It seems extraordinary that there is no readily available chart showing the best estimates from the research community around the world of the changes in efficacy for the various vaccines consequent upon changes to the time between first and second dose.

The undisciplined approach to priorities for vaccination has extended to a lack of action on them. It’s as if the system’s  managers have colluded with public opinion: ‘The highest priorities are still not met – so let’s focus on new ones!’

Instead of a blitz approach to vaccine in aged care facilities, a complicated system developed led by private enterprise entities. Decision makers and commentators were able, in effect, to hide behind the phrase ‘the most vulnerable’. To this vulnerability criterion was added the seriousness of the impact on health and other essential services of sickness and the resulting absence of members of the workforce. This is still important.

With the Delta variant, where a person lives and what contribution they are likely to make to spread of the disease have become as important as the extent to which someone’s health is likely to be severely affected by the condition, should they be infected.

 The magnitude of the challenge of allocating scarce vaccine is illustrated by listing those groups who have recently been suggested as being of the highest priority. They include the original highest priorities, hospital staff, Aboriginal and Torres Strait Islander communities, year 12 students, people in selected hot-spots, teachers, inter-State transport workers, children, the 16-39 year olds, childcare and disability support workers, and paramedics.

Unless and until there are ample supplies of vaccine, some extremely difficult decisions will have to be made. If they are not, people will have unrealistic expectations and there is a real risk that they would then be alienated from the program.

Lecturer: Have you done the assignment?

Student: Yes – but I haven’t had time to write the short one.

That’s the most you’ll get from me as an apology!

1 Sept 2021

In two weeks’ time, as part of their employment arrangements, all staff of residential aged care facilities will be required to have had at least one coronavirus vaccination. That’s around 150,000 people in over 2,600 facilities.

There are two chances that this target will be met – one of which is Buckley’s.

Note: this is the second of three posts that have been delayed as I tried unsuccessfully to have them published elsewhere. 

A sad, brief history

The Government’s national vaccine rollout strategy was released in early January 2021. The target population (c.20 million) was all of those 18 and over.

The highest priority (‘1a’) was allocated to quarantine and border workers, front-line health officials, aged and disability care workers, and aged and disability care residents.

On 1 February the Prime Minister said he expected to “offer all Australians the opportunity to be vaccinated by October of this year”. Later he said 4 million would be vaccinated by the end of March.

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.

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 – which does not inspire great confidence.

What went wrong

Many things can explain what has gone wrong. In particular they include the shortage of vaccine supply, generalised incompetence and lack of urgency, an ill-disciplined approach to setting priorities for vaccinations, a curious absence of public information, and the usual confusion or overlap between federal and state jurisdictions.

Supply

Nothing has been more significant than the fact that, from the beginning, there has been an overall shortage of vaccine supply. This has cast a dark shadow over all aspects of the vaccination program. The shadow remains despite the arrival of Spring.

The government failed to make sufficient contractual arrangements to meet its commitment to have Australians at the front of the queue for vaccine. This was compounded by the failure of leaders, experts and commentators to ‘make real’ the different probabilities of sickness from coronavirus as distinct from blood clots.

An ill-disciplined approach to setting priorities for vaccination

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

Setting and acting on agreed priorities should have been a matter of the most importance. But unfortunately, as a nation, Australia has had a superficial approach to the matter.

Initially this could perhaps be attributed to disinterest or complacency. With very little covid around, the main criterion for setting the priority for a particular group of people was the extent to which they were vulnerable to serious illness and, potentially, to death. No one could object to the residents of aged care facilities being a top priority and, through them, the workers who care for them. 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.

The wisdom of making aged care staff one of the highest priorities 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.

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 the potential criteria for prioritisation has shifted. It is no longer universally agreed that ‘vulnerability’ is the key criterion. 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.

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. 

A lack of public information

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 data and public information on many aspects of the pandemic has been an ongoing problem.

Despite the fact that the aged care workforce had been a top priority since 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 in early June that 20 aged care facilities had not yet been visited as part of the national vaccination rollout.

It was a problem that, unlike the situation with vaccinations they previously required, 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 the Federal Health Department on the covid immunisation status of their staff. 

Matching supply with priorities

Details of the schedule for receipt of vaccine supply must be matched against the priorities determined and thus the number of people who are eligible and who expect to be able to get vaccinated.

There is a State-by-State schedule of ‘allocation horizons’ but it is impossible for outsiders to understand. (https://www.health.gov.au/resources/publications/covid-19-vaccination-covid-vaccination-allocations-horizons)

This might be because the Federal Government itself cannot be sure of how much will be delivered from overseas or when. In Parliament this week the Prime Minister claimed that the speed at which vaccinations are now occurring has made up for the 4-month delay. He has even suggested that the rollout is going so well that the original target will be met by Christmas “or even sooner”. He credited this turnaround to the fact that the government has “been able to bring forward doses” and “has been able to achieve and realise additional supplies”.

In the same Question Time reply he said “We have more irons in the fire that will see further doses being made available”. [These are quotes taken verbatim from the PM’s QT speech. Some changes have been made to the Hansard record between ‘Proof’ and Final.]

All this is terribly imprecise. The uncertainty about how much is being received and where it is was illustrated by the on-again, off-again switching of some supply to Sydney’s worst affected suburbs. Just this week there seems to be the same uncertainty about special deliveries set aside for Aboriginal and Torres Strait Islander communities.

Hopefully what is happening is that a detailed schedule for supply of Pfizer and Moderna is cross-checked against the planned rollout, which must be subject to agreed priorities. The next population groups to be eligible are the 16-39 year olds (from this week) and 12-15 year olds from 13 September.

It will be vital that these people do not face the same frustrations and logistical difficulties that many older people have already experienced. If the supply schedule suggests that there will be inadequate doses for aged and disability care, for all hospital staff (now very clearly a top priority), special rollout to Aboriginal and Torres Strait Islander communities, year 12 students, selected hot-spots et cetera et cetera then the expectations of these other cohorts should not be raised.

The current situation

In Question Time this week the Prime Minister reported that double-dosed vaccination rates in aged care facilities is “upwards of 80%”. He seemed to regard this as a success, despite the long history of the issue, and attributed it to the priority he has given to vaccinations in aged care “which has enabled us to visit all of these facilities to ensure that the double doses are done”. It is not clear what “upwards of 80%” means, or how many of the other 20% have had their first.

The public now has a better appreciation of the uncertain nature of statements such as these. It needs to be clear, for instance, whether they refer to adults only and whether they mean the first jab or full inoculation.

The next key target for aged care staff is mandatory vaccination, to begin on 17 September. Every effort must be made to complete the task on time with a high level of competence and effectiveness.

Let’s get on board with Buckley. They’re all we have.

Note: this is the second of three posts that have been delayed as I tried unsuccessfully to have them published elsewhere.  

 26  Aug 2021

The Gift of vaccination is being Stawelled and although it isn’t a race, Australia is coming last. No one seems to be in a hurry, and those whose turn it is to run are confronted with so many different lanes that it is quite confusing.

The basic problem is the imbalance between demand and supply. ‘The market’ has proved to be imperfect again. Demand is being limited by regulation about whose turn it is – by population group, calendar dates and choice of vaccine.

My wife was accommodated by her GP. My GP seems not to have been favoured so I tried the local field hospital – recalling some of my previous trips to the place when it was a cricket pitch. But it was the wrong day or the wrong brand and all I came away with was the phone number to call.

The hold music was not too bad at first but after an hour I accepted The Voice’s offer to leave my mobile number and it would get back to me.

I don’t always carry my phone with me unless I’m photographing Nature; so a few days passed.

Having tried the leave-my-number routine a couple more times, I thought surely I could be provided with the necessary material if I attended in person. Upon arrival at the correct hospital I was the fourth person around. One of the other three was keeping guard and however hard I tried I couldn’t get more than the phone number. No appointment, no access, no worries. Very firm. (Someone who only has one job can really concentrate.)

At the hospital’s main entry I had better luck. I quickly had a small sticky label and very soon thereafter a lollipop.

One might think that a large and diverse system would be a good thing, given the number of people to be serviced. In fact I think people have been uncertain about how to get the job done and the queuing and appointments system has been slow and clunky.

In a previous piece I suggested that a one-off boost to the number of people who have had the jab could be given by offering all those who, like me, had the first AstraZeneca some time ago the option of bringing forward the second one. Granted there is uncertainty about the extent to which this would affect, week by week, the efficacy of the vaccine.

Governments have been slow to realise the value of localised, targeted, culturally appropriate options for vaccine delivery. So many commentators on media have argued that the main barrier or disincentive is the lack of convenience in getting it done.

Perhaps because the processes in train have not been under any single agency’s control, active management of the program has been missing. Things have just drifted.

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 U.K.’s first drive-through vaccinations were given in December.

The most serious result of the underperforming program has been the failure to meet the earliest targets, such as protecting through inoculation the staff and patients of residential health, aged and disability care facilities. One of the results of this failure has been the loss of capacity, especially in hospitals, when staff members have had to be isolated.

The case of aged care workers

At the outset the task looked like one that would provide many political benefits, given the generally positive view of vaccination. It was therefore no surprise when the Prime Minister said that responsibility for the vaccination program was the Commonwealth’s. There was the usual caveat that its management would be in collaboration with the States and Territories.

So arguably the uncertainty began early, with the potential for overlap and task shifting between Federal and State departments. The program grew like Topsy.

Consider, for example, the case of workers in aged care.

The Commonwealth contracted commercial entities to deliver vaccinations to the 2566 Commonwealth-subsidised residential aged care facilities for residents and, where additional vaccines were available, workers. (Giving staff doses that were left over at the end of a clinic for residents must have given a negative message?)

Staff of aged care facilities could also attend a GP’s rooms, or a State clinic (in a public hospital), or one of the specially established state vaccination hubs.

But Primary Health Networks (PHNs) were nominated as the primary point of contact for residential aged care facilities on vaccination for residents and workers, and were allocated Pfizer doses for this purpose. The PHNs liaised with the contracted providers, which could provide in reach, mobile and hub models for residential aged care workers and residents.

Workers from residential aged care facilities located in the same PHN as disability vaccination hubs could access a Pfizer vaccine at these hubs.

A forward schedule of dedicated Covid-19 vaccination clinics was available to aged care provider peaks and unions to provide local information on upcoming clinics to residential aged care workers.

From August selected pharmacies have been providing Pfizer vaccines.

Convenience has been a major issue. For many people, getting the vaccination involves the loss of a shift, loss of wages, logistical issues with access, or finding information in an appropriate language.

The menu was extensive but many who consulted it found its fair and its language to be quite alien.

 Alternative means

Some people believe the Commonwealth should not manage new, large-scale programs because of a poor track record in such things. The alternative view is that no agency is in a better position than the Commonwealth to oversee a program which requires uniform eligibility checks and national data and tracking.

The experience to date from covid-19 suggests that what is required is national leadership and record-keeping, with the actual rollout being undertaken by a limited number of agency types. State and Territory arrangements should allow for local providers to work in settings and with population groups who require the deliverers to have special skills. For example, delivery to those who do not have English as a first language should involve people with whom they are familiar and language they know well.

This principle should be applied whenever possible to meet the special requirements of people who are disadvantaged in economic, social and cultural terms.

In setting up the program  for covid consideration was presumably given to scaling up the National Immigration Program (NIP) which has a good reputation as a provider of a range of vaccinations over a person’s lifetime. It would be valuable to understand why such a model was not developed.

Workplace vaccination against flu has also been successful in many instances and must also have provided lessons for covid.

For as long as vaccine remains in short supply relative to demand, setting priorities for its use will remain critical. The priority order for allocation of a scarce resource that saves lives is something that should be openly discussed and understood. To date little evidence on the matter has been publically available.

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 campaign and thus more willing to comply with and support it.

Note: this is the first of three posts that have been delayed as I tried unsuccessfully to have them published elsewhere.