A New-Normal CityState is emerging in the Great Southern Land from the rubble of COVID-19.

Citizens of the Great Southern Land are bracing themselves for the re-opening of their Nation following the devastation visited upon it by the Covid-19 pandemic. The reopening takes place as substantial reconstruction continues.

Domestic architects, builders and planners have expressed disappointment that, as happened the first time round 120 years ago, development is progressing unevenly across the Nation. Eight different construction companies have been engaged, with the only thing they have in common being the requirement that staff are fully masked.

Surprisingly, the rebuilding in train is subject to no Nationwide planning controls. The result will be an entity comprised of eight villages of diverse architectural styles, with less coherence than would have been possible with some centralised leadership.

It is, admittedly, difficult to fashion a Nation in a coherent style from a number of separate villages if their starting points are quite different. This is the case in the Great Southern Land, where the extent of the devastation caused by the pandemic varies widely between villages.

Coherence is also harder to achieve when each of the elected Village Heads has ambitions for their own jurisdiction. This leads naturally to competition between the eight.

At its most extreme, this competition can result in some Heads actively working for diversity rather than for Nationwide uniformity or at least coherence. This means that many of the toughest future challenges of governance will again be focused on the relationship between the parts of the Nation rather than on the opportunities provided to a coherent whole.

Initially it was assumed that a Nationwide approach would be brought to the rebuild by National Cabinet. The authority of this secret new body appeared for some time to furnish significant Nationwide power to the Great Southern Land’s Chief Planning Officer (CPO). In July and August 2021, when it was clear that a New-normal would have to be built, some Nationwide building standards were mooted by the CPO. He issued guidelines which would have seen each village rebuilding in parallel timelines. There were to be two criteria to be met by each construction company, one a Nationwide standard, the other relating to each separate village. In what was described as a two-key process, both criteria were to be measured against the Magic Numbers 70 and 80.

However from the beginning of the rebuild there was differential take-up of the guidelines by the  various construction companies. There was also uncertainty about the means by which measurement against the Magic Numbers was to be effected. As a result, for all practical purposes those guidelines became nothing more than historical artefacts of governance.

It became clear that neither the CPO nor his Deputies had sufficient competence or interest in the matter to exercise the leverage that was available to them. There will need to be significant climate change for this situation to be improved.

In the largest village the footings of the new edifice were completed some time ago, and the second storey is already taking shape. Some of the Village’s swamps remain undrained but good use has been made of the higher ground which it is assumed will be free from flooding.

Unfortunately the reconstruction of this Village is now subject to some uncertainty due to a sudden change in its senior management. Under the previous regime there had been an unsustainable pace of construction resulting in occasional design changes being made on the run. This meant planners, builders and suppliers experienced some frustration. Despite this its rebuild continued to out-pace that of other villages.

Completion of the re-build and decisions about the re-opening of this major Village will fall to the new management. Other Village Heads will have the advantage of learning from its experiences, including with respect to outdoor swimming and picnics.

Less enthusiasm for a rapid early opening has been demonstrated to its South and North.

For some time it seemed likely that the village in the South would be Victorious in the competition for the gold standard. But very recently the ground suddenly moved, which delta blow to the Village’s prospects for donuts, resulting in more devastation than had been anticipated.

The ground is shifting

Given this newly-demonstrated instability, the building standards there are more restrictive than in the largest Village. This has been unacceptable to a very small number of people who have memorably demonstrated their dissatisfaction. Fortunately the vast majority of the Villagers recognise the need for caution to protect the benefits from the resilience they have shown.

The lack of Nationwide leadership has been exhibited by the CPO’s Deputies as well as  by himself. One example concerns Rapid Antigen Testing (RAT), which has been used by people in the UK for over a year, with self-administered test results being provided to a centralised online database for analysis and record-keeping. After a long time, presumably due to  an abundance of caution, the Regulator of Such Things has approved the use of RATs in the Great Southern Land. Rather than having himself lead energised Nationwide work to roll out RATs, the CPO’s Health Deputy has asked each village to consider their greater use. This is yet another missed national leadership opportunity.

The CPO has enlisted the support of the Defence Force in the Covid-19 work. Generally speaking its role has been to repeat encouragement about the need for people to get vaccinated and promises of a coming abundance of vaccine supply.

Nationwide leadership and energy in the rebuild have to date been very disappointing. But there are many important tasks going forward in the post-Covid rebuild which will benefit from Nationwide leadership. They  include the following.

One – further and ongoing analysis of the Magic Numbers 70 and 80. Planners and engineers need to carry out stress tests and make sure that, despite the variety of building styles, all construction results in  villages that are safe and draughty.

Two –  confirm that there is no national building standard, that villages are free to build to their own standards and in their own timeframe. Initiate spot-checks to ensure the designs adopted are safe for all citizens and suit the circumstances of each village. Windows must be able to be opened.

Three – manage  travel bubbles from the Nation to and from other parts of the world.

Four – lead work to repatriate citizens stuck overseas.

Five – work to ensure the availability of leak-proof quarantine facilities.

Six – work to facilitate global vaccine equity.

Seven – fund scientific endeavours to produce new vaccines and develop improved ways to manage viruses and viral infections.

Eight – fund and oversee systems for providing financial support to those people and firms adversely affected by the devastation.

Simply pressuring Village Heads to open their borders is not leadership. The Village to the NorthEast is being unfairly pressurised merely because it has the misfortune to be contiguous to the largest Village. Many of those who wish to cross the border into the NorthEast should not be leaving their homes under their own Village’s regulations anyway.

Decisions about opening the rebuilt Nation must still hinge on the balance between safety for the villagers and economic activity. The CPO should move to re-assert their nationwide authority and work for a high degree of National coherence despite the existence of different architectural styles, varying amounts of devastation and speeds of rebuilding.

Leadership out of the turmoil is particularly important at a time when many interest groups are favouring economic activity simply because of the passing of time, rather than because the weights in the balance between wealth and health have changed.

The Clayton’s but secret Covid national plan

Those hoping for clarification on the national COVID-19 plan from last week’s national cabinet meeting will be disappointed. The main outcome from the meeting was a statement about the importance of its discussions and documents remaining “cabinet in confidence”. 

“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.

COVID vaccination: “The highest priorities are still not met – so let’s focus on new ones!”

 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!

Vaccination: Accounting for the muddle

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

               ‘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.’

 A ledger is needed for Australia’s vaccination program. To date it has been a muddle, but there’s plenty more to do and therefore plenty of opportunity to improve it.

The ledger must provide information to the public. This means that it must be both open and constructed and written in a language people can understand.

The asset is the vaccine, still in short supply. The business is Australia. The Board is the government. The CEO is Scott Morrison. (There is soon to be a shareholders’ meeting and the Board will be looking to the CEO to protect their reputation and their remuneration.)

Both sides of the ledger need to be considered.

Vaccine supply

Of all factors in the vaccination muddle, nothing has been more significant than the shortage of vaccine supply.

The Morrison government must show more trust in the public and take them into their confidence where vaccine supply is concerned. The public needs and deserves to see the details of expected supply of vaccine over the next 12 months and more.

What is the anticipated delivery schedule for Pfizer and Moderna? Will there possibly be others? What progress on a vaccine for under 12 year olds? Greg Hunt has said that a million doses of Moderna will arrive in Australia in late September and 10 million Moderna shots are scheduled to be delivered to Australia this year.

AstraZeneca: in economic terms, an inferior good??

Just this week 1 million doses of Pfizer have been received in a swap deal with Singapore. Are more such arrangements possible?

The Federal Government may not be certain how much will be delivered from overseas or when. But the public should kept informed. The Government should inform them even when things are uncertain and, especially, when plans become unavoidably changed – when targets can’t be met. Given such information the public will feel more involved and more supportive of whatever timeline is necessary.

The supply side of the ledger is also being affected on an almost daily basis 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.

Individuals are making decisions every day without information about changes in efficacy and the gap between the first and second. GPs have been trusted with providing decisive advice to their patients without clear knowledge of projected changes in efficacy.

Vaccine demand

One of the most egregious problems is that there has been a very undisciplined approach to the setting of priorities for vaccination and, more importantly, of action to meet them.

In January 2021 a priority ranking per population group for vaccination was agreed. 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 (emphasis added).

This order might have been forgotten but it has never been changed. How is it possible, then, that during Question Time on Monday 30 August the Prime Minister – with no sense of contrition or regret, said:

“And what we have been able to achieve this year, prior to these most recent waves hitting New South Wales, Victoria and the ACT, is that we have double-dose vaccination rates in our aged-care facilities upwards of 80 per cent. And what that has meant is that our most vulnerable in our community this year, because of the vaccines, compared to last year, and in particular the priority we placed on vaccinating those in residential aged-care facilities and ensuring that we were able to visit all of those facilities to ensure that those double-dose vaccinations were provided – that has saved hundreds (sic) and hundreds (sic sic) and hundreds of lives.”

An earlier piece on this blog has discussed the forthcoming vaccination requirements for aged care workers. Not including aged care in the home, this will apply to some 154,000 people in more than 2,700 facilities.

An analysis by the Guardian Australia, published on 25 Aug, revealed that 582 centres had vaccinated less than 50% of their workforce with a single dose, while 60 centres hade vaccinated less than 20%. (Only one in five aged care homes close to vaccinating all staff against Covid as deadline looms, Sarah Martin and Nick Evershed, Guardian, 25 Aug 2021.)

The priority order has not been discussed or changed but what has happened is that a number of other priorities have emerged and jostled with those original population groups for a place in the sun.

The process can be characterised as “The highest priorities are still not met – so let’s focus on new ones!”

With an appropriate amount of urgency, energy and innovation, it would have been possible to provide vaccinations to every patient and staff member in residential aged care in three weeks, never mind three months. What was required was an almost exclusive focus on the top priorities for a short time. Every facility could have been visited by a vaccination team, flying-squad style.

It’s the kind of logistical exercise the military are good at, as evidenced by its work after a national disaster. It would have required open, effective liaison with the facilities themselves, collaboration between State and Territory agencies, and with local government, local volunteers, the SES and local health staff. But it could have been done. It must now be done.

Instead of this blitz approach, a complicated system was devised led by private enterprise entities to deliver the vaccines. There was the occasional mention of the lack of progress, but the stronger interest shifted to other priorities, as if leaders, experts, the media and their public were bored with the old priorities and were more interested in ‘discovering’ and promoting new ones.

Decision makers and commentators have, in effect, hidden behind the phrase ‘the most vulnerable’. It has been easy to defer to this term without actually converting it into action. Now that the Delta strain has written a new script, someone has to decide on a daily basis 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, a year 12 student, an interstate truck driver, or a paramedic.

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. This is still an important consideration.

With the Delta variant, the 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.  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.

Both sides of the vaccine ledger need to be openly discussed. Matching projected receipt of vaccine with agreed priorities will be very difficult. Some horrible options will have to be chosen.

But with an open book and full information provided to the public, there will be greater certainty about the path towards ‘full vaccination’ and unrealistic expectations can be avoided.

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

The situation is serious. The following groups have already started to fill positions in the queue for vaccine or are scheduled to do so:

  •  all aged care staff (by 17 Sept.)
  • more aged care residents (“As of August 20, 86 per cent of aged care residents and 67 per cent of NDIS participants in residential accommodation have had at least one dose of vaccine.” ABC News, Tracking Australia’s COVID vaccine rollout numbers, Digital Story Innovation Team, 2 Sep 2021.)
  • in NSW: “New public health order requires staff to have their first vaccine dose by September 30. To continue working, staff must either be fully vaccinated by November 30 or have their second appointment booked.” (“The nation’s leaders should mandate COVID-19 vaccination for doctors, nurses and hospital cleaners, according to Australia’s peak medical body, with the federal government declaring the issue is ‘very high on the agenda’ of all state and territory chief health officers.” ABC News, Doctors back mandatory COVID-19 vaccination for health worker, Stephanie Dalzell, 31 Aug 2021.)
  • Aboriginal and Torres Strait Islander people. (Is there a priority order? By place? Age group?)
  • Teachers? “last week many teachers felt betrayed after the announcement that New South Wales teachers will need to be vaccinated as part of the ‘road map’ to getting students back in school, – “ “There was little detail to the announcement apart from it being implemented from November 9.”
  • inter-State truck drivers?
  • “On August 20, NSW mandated that childcare and disability support workers who live or work in a council ‘of concern’ must have received their first vaccination dose by August 30.”
  • In NSW: “Authorised workers who live in an LGA of concern and need to leave it for work are only permitted to do so if their employer has implemented rapid antigen testing, or they have had their first vaccination dose by August 30.” NSW Government website, COVID-19 vaccination for workers, 1 September 2021.
  • paramedics?

And let’s not forget that it has been agreed that the next cohorts will be 16-39-year-olds (from early Sept) and 12-15-year-olds from 13 September.

While ever there is a shortage it will be essential to set priorities and stick to them.

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

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

Vaccine: Let’s not forget the first priorities

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.  

Vaccinating Australia: insufficient urgency, too much choice?

 26  Aug 2021
Jacob Despard of Tas. wins the Stawell Gift on April 2, 2018.
(Photo by Darrian Traynor/Getty Images)

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.

Turning their back on Pfizer?

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.

STAWELL, AUSTRALIA – APRIL 17: A general view of the Strickland Family Women’s Gift during the 2017 Stawell Gift. (Photo by Scott Barbour/Getty Images)

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.  

Covid – five things National Cabinet should agree

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.

Covid: there has been an ill-disciplined approach to vaccination priorities

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.

Vaccinating aged care staff: mismanagement by Scott Morrison’s government.

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.

The right answer to Jack’s question can help use all that AstraZeneca

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 dose30% PHE“barely any” in article in Nature. Life Matters: 30%“barely any” in article in Nature. Life Matters: 71%
4 week gap – AstraZeneca 2nd dose55%? [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 dose74.5% Life Matters: 81%67% Life Matters2 doses: 92% Life Matters.
But what gap?
Pfizer, first dose50% PHE33%“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.