12
Aug
2020

Health worker testing for COVID-19

Australia’s COVID-19 journey takes a turn for the worse

by Stephen Duckett and Anika Stobart


Update published on the Cambridge Core Blog, 12 August 2020

Since June, Australia’s COVID-19 journey has taken a turn for the worse.

After early successes in flattening the curve at about 7,000 total cases and 100 deaths by the end of April, a localised second wave began two months later, more than doubling Australia’s total count within a month to more than 20,000 cases and 200 deaths. Unlike the first wave, where two-thirds of cases were from overseas sources, the second wave has all been from community transmission.

Most of Australia has had very few cases since April. But the second-most populous state, Victoria, was not so lucky. Its second wave began to emerge in late June, when a resurgence of cases was linked to failures in hotel quarantine of overseas arrivals. At this time, most Australian states had partially eased restrictions. Clusters emerged in lower socio-economic areas of Victoria’s capital, Melbourne. The state government put high-risk postcodes back into partial lockdown. Sadly, this also included a strict lockdown of thousands of residents living in nine public housing high-rises. When daily new cases breached 100, the state government extended the lockdown to the whole city, later also mandating the wearing of masks.

But the partial lockdown was not enough to get COVID-19 under control. The daily case numbers continued to slowly increase, moving from about 100-200 cases per day in early July up to 700 by the end of the month. Many cases were spread through workplaces, particularly those with lower-paid and insecure jobs, where people were often not entitled to paid sick leave. This was particularly the case in aged care, where some carers work across multiple nursing homes. By the start of August, there were about 800 COVID-19 cases in nursing homes, accounting for more than 60 per cent of Australia’s COVID-19 deaths.

In August, the Victorian government introduced Australia’s harshest lockdown yet. The government mandated a six-week full lockdown of Melbourne, and partial lockdown of the rest of the state. This practically brought Victoria’s economy to a halt, putting strict limits on construction and manufacturing and closing retail, schools and childcare. Essential shops such as supermarkets and pharmacies remained open, but only one person per household per day is allowed to shop. Otherwise, people are required to stay in their homes, with only one hour of exercise permitted per day, and a night-time curfew between 8pm and 5am. These restrictions are being coupled with radically enhanced enforcement by police and the army, including door knocks and hefty on-the-spot fines.

The rest of Australia looked on at the unfolding crisis in Victoria. COVID-19 is largely contained to Victoria due to the continuing strict border closures between states. The neighbouring state of New South Wales closed its border to Victoria at the start of July, but inevitably, some cases slipped through. Clusters have emerged in the capital city, Sydney, with the state recording between 10 and 20 new cases per day by late July. The state has slowly ramped up some restrictions, but appears reluctant to introduce more sweeping measures.

Reflections

Despite Australia’s early successes, there have been key government failings.

Firstly, the Victorian government failed to properly oversee hotel quarantine. Genomic testing has shown that second-wave cases could be traced back to breaches in infection protocols by security guards at hotel quarantine. Victoria’s reliance on private security guards rather than police or the defence force – used in other states – has been heavily criticised. A government-appointed inquiry is now looking into the case.

Secondly, both the national and Victorian governments have fallen short in preparedness, particularly of high-risk settings such as public housing and aged care. Although the health system is not overwhelmed, the Victorian government has struggled to keep up with the escalating crisis. The COVIDSafe app has proved largely unhelpful. The aged care response has particularly been a shambles. Despite the anticipated infections in nursing homes, the national government – responsible for aged care – did not ensure sufficient personal protective equipment (PPE) or infection protocols, did not adequately support and train staff, and did not communicate well with families.

Thirdly, there has been a naivety in the governments’ social response. Australian governments overlooked some inequities of the crisis, and did not proactively support people in insecure jobs who would find it difficult to self-isolate. It was too late by the time Victoria introduced a $1,500 worker support payment and $300 test isolation payment. Only in late July did the national government similarly announce paid pandemic leave. Meanwhile, the national government has committed to roll-back the enhanced unemployment benefits and the wage subsidy scheme, despite Victoria entering the worst stage of the crisis yet.

Debate has continued to rage about Australia’s shifting national strategy, which is now confusingly to suppress the virus with ‘the goal of no community transmission’.

Second post, published on the Cambridge Core Blog, 11 May 2020

Australia’s response among the most successful in the world

Over April, Australia recorded an average of 70 new cases a day, bringing its cumulative total to about 6,800, including almost 100 deaths. By early May, average daily new cases were down to 20, with some Australian states recording no new cases for successive days. About 63 per cent of Australia’s total cases have originated overseas.

Testing and contact tracing

After a shortage of testing supplies in March, new kits arrived which enabled health officials to ramp up testing. The testing criteria were expanded, and by the end of April more than half a million COVID-19 tests had been conducted across the country. Some Australian governments conducted ‘testing blitzes’; testing anyone showing even mild symptoms such as a cough. Australia’s positive testing rate now sits at about 1 per cent.

To assist with contact tracing, the Australian Government on April 26 released a ‘COVIDSafe’ app. If a person with the app is diagnosed with COVID-19, health officials can trace the infected person’s contact with other people with the app. But downloading the app is voluntary, and some people are concerned that it invades their privacy or that the stored data could be misused. As of 5 May, almost 5 million Australians had downloaded the app, well short of the Government’s target of 10 million.

Health system preparedness

A low case count means Australia’s health system has not been overwhelmed (at least for now). In early May, about 200 Australians were in hospital with COVID-19, including about 30 people in intensive care units (ICUs). Before the pandemic, Australia had about 2,400 ICU beds, and concerted efforts in the past few months have resulted in a ramp-up availability of up to 7,000 beds.

Australia’s health authorities continued to prepare for potential outbreaks or a second wave of infections. State governments have purchased additional personal protective equipment (PPE) and promoted local manufacturing of supplies. This has enabled a resumption of non-urgent elective surgery.

Economic and social impacts

The Prime Minister, Scott Morrison, has started to shift his rhetoric from concern about the health risks to concern about the economic fall-out from the crisis. The Government estimates the lockdown is costing Australia’s economy around USD $2.5 billion each week. Unemployment is expected to top 10 per cent in the June quarter.

To help cushion people from the effects of the lockdown, the national government has increased income support for the unemployed and introduced a substantial wage subsidy package. Australian governments have also strengthened Australia’s domestic violence support systems and increased funding for mental health support services.

Unwinding lockdown restrictions 

With case numbers subsiding, the focus has now turned to finding an ‘exit’ strategy. Throughout April, debate raged over whether to keep the restrictions until the virus was eliminated – an option which now seemed possible – or whether to ease restrictions while seeking to keep case numbers low.

On 8 May, Australia’s ‘National Cabinet’ agreed to a three-step plan and a national framework to bring Australia out of lockdown over the next few months. Step 1 allows outdoor gatherings of up to 10 people, small cafes and restaurants to open, and some recreational activities. This will eventually be scaled up to outdoor gatherings of 20 people in Step 2, and 100 people in Step 3. International border restrictions will remain for the ‘foreseeable future’.

Within the national framework, state governments are ultimately responsible for deciding on lockdown restrictions. Each state government will determine the exact timing and content of the plan for their local jurisdiction. Some states have already taken Step 1, but other states with higher case numbers will move more slowly.

Reflections 

Australia’s response to coronavirus to date has been among the most successful in the world. This can be attributed to Australia’s strong border restrictions and public compliance with spatial distancing rules.

The Government has also successfully reduced risks to healthcare workers and people needing care, by expanding telehealth services.

But some problems remain. COVID-19 ‘clusters’ continue to emerge. And two inquiries have been launched into the handling of the Ruby Princess cruise ship. The inquiries are determining how and why authorities approved 2,700 passengers to freely disembark the ship in Sydney on 19 March, despite some passengers showing symptoms of COVID-19. Now 10 per cent of Australia’s total cases and about 22 percent of deaths have been linked to the ship.

There is also mounting criticism that the Government’s income support payments are too narrowly targeted. Many people in industries hardest hit, such as casual workers in the arts and entertainment industry or in hospitality, do not qualify for the wage subsidy scheme.

And fractures in the national governance approach have started to emerge, exposed by fierce debate about whether to keep schools closed. Much to the Prime Minister’s frustration, public schools – the responsibility of state governments – remain closed in some states.

 

First post, published in the Cambridge Core Blog, 7 April 2020

The good, the bad, and the Ruby Princess

Australia’s response to COVID-19 has been led by a ‘National Cabinet’ comprising the Prime Minister and the leaders of each state and territory government (the states and territories have primary responsibility for health). This is an innovation to help overcome Australia’s fractious federal-state relations.  As of 6 April, the number of new COVID-19 cases in Australia has been falling for more than a week.

International borders and containment

Australia’s first coronavirus cases were linked to travellers returning from Wuhan, China. On 1 February, when Australia had 10 known cases, the Government banned foreign nationals entering the country from mainland China. It also required Australians travelling from mainland China to self-isolate for 14 days. At the same time, the Government evacuated hundreds of Australians from Wuhan to designated quarantine facilities in Australia.

As the virus began to spread outside of China, the national government tightened its international border restrictions. Bans on foreign nationals entering Australia were extended to Iranians on 1 March and South Koreans on 5 March. Australian travellers from these countries were required to self-isolate for 14 days on arrival. By 15 March when Australia had 300 confirmed cases, mostly from overseas arrivals, self-isolation was made mandatory for all international arrivals. Health officials implemented contact tracing strategies to reduce the risk of community transmission. From 20 February, anyone who had contact with a confirmed case has been required to self-isolate for 14 days.

Through early March, Australia’s COVID-19 cases continued to grow exponentially; most coming from overseas. This culminated in a decision on 20 March – when Australia had nearly reached 1,000 confirmed cases – to effectively shut Australia’s international borders. Only Australian citizens, residents, and immediate family members are now allowed to travel to Australia. Upon arrival, Australians are mandatorily quarantined in designated facilities for two weeks. Since 24 March, Australians have also been restricted from travelling overseas unless they qualify for an exemption.

Spatial distancing

Australia progressively implemented spatial distancing measures from mid-March, when there were about 300 confirmed cases in the country. Initially the Government focused on social gatherings; limiting their size to a maximum of 500, then 100, then 10, then two. Australians are required to keep a 1.5 metre distance from others.

The Australian Government ramped up its spatial distancing measures when the country had about 2,000 total cases and there were hundreds of new cases each day. The Government explained that some Australians had not been adhering to the requirements, and further restrictions were necessary to slow the spread of the virus. Australians were told to expect to be living with the restrictions for at least six months. This begun on 23 March, when restaurants, pubs and cafes were closed (except for take-away services), as well as entertainment venues such as cinemas, and indoor exercise venues. Three days later, this list of businesses was extended to galleries, libraries, markets (except food markets), auction houses, etc. On 29 March, the Government restricted indoor and outdoor gatherings to two people. Australians must now stay at home unless shopping for essentials, travelling to work or education, exercising, or attending medical appointments. Weddings are limited to five or fewer people, and funerals are limited to no more than 10 people.

Although the Australian Government has not called for a nationwide closure of schools or childcare centres, most state governments have closed their public schools and are teaching online. Australian universities have moved teaching online.

Testing

Australia has a high testing rate compared to other countries. As of 5 April, Australia had tested almost 300,000 people. Due to the limited number of testing kits, Australia’s testing regime has been targeted rather than widespread. The focus has been on people who show symptoms and have returned from overseas or been in contact with a confirmed case in the last two weeks. The testing criteria has begun to be expanded.

Capacity of the health system

Australian hospitals are rapidly preparing for the increased demand. Governments have injected more funding into public hospitals. Some state governments are increasing their intensive care unit (ICU) capacity, with one state, Victoria, aiming to increase the number of beds from 500 to 4,000. All non-urgent elective surgeries have been suspended. The health workforce is being increased (for example, by fast-tracking recruitment and upskilling), and more people are doing contact tracing. Some governments are planning to set up temporary hospitals.

The Government has also expanded its telehealth service, which allows doctors to conduct a health consultation with patients over the phone or by video.

Reflections on Australia’s response to the COVID-19 pandemic

While Australia’s response to the coronavirus pandemic has been effective in part, the Government’s response has been too slow, reactive, and confusing to the public.

From the outset, Australia’s Prime Minister said the main objective was to slow the spread of the virus. At the beginning of March, Australia’s confirmed COVID-19 cases were growing more than 20 per cent per day, doubling our total cases every 3-to-4 days. By the start of April, this has fallen to less than 5 per cent. The limited testing regime makes it difficult to estimate the true underlying infection rate.

While Australia was comparatively quick to ban foreign nationals coming from China, its subsequent actions have been slow. Despite the huge risk of international travellers bringing the virus into Australia, it was more than six weeks after the first confirmed case before the Government introduced any serious travel restrictions, such as self-isolation of all international arrivals. Prior to this, travel restrictions were targeted only at specific countries (such as Iran and South Korea), despite other countries such as Italy and the United States also posing a risk. Significant government resources were invested in moving vulnerable Australians from Wuhan to special quarantine facilities, despite none of these Australians showing any symptoms. The Government was also very slow to introduce spatial distancing requirements; they were seriously implemented only once Australia had more than 2,000 cases.

A key event that undermined public confidence was the failed handling of the Ruby Princess cruise ship. Thousands of passengers were allowed to freely disembark in Sydney on 19 March, despite some showing COVID-19 symptoms. Now, 30 per cent of Australia’s deaths and 10 per cent of all cases (as at 6 April) are linked to the ship.

The Australian Government has not explained its overall long-term plan or ‘endgame’ in response to the crisis. The national Government’s rhetoric is mainly about ‘slowing the spread’, but other messaging, particularly from some state governments, supports ‘stopping the spread’. It is not clear whether the Government intends to let the virus run through the population to build herd immunity, or whether it intends to stamp it out altogether until a vaccine arrives.

The national Government has not communicated a series of progressive stages to respond to the crisis. Instead, some government decisions appear reactive, resulting in mixed messages and confusion. For example, governments in Australia have not been consistent about how long the spatial distancing measures will be in place. Without clear messaging, Australians may lose trust and confidence in the Government’s approach, which requires citizens to make significant sacrifices.