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A leaked document shows that national cabinet has shifted its focus from vaccinations to working out how well hospitals will cope with Covid-19 surges. By Rick Morton.

Leaked doc: National cabinet counts ICU beds, underestimates cases by 50 per cent

Covid-19 positive patient Dr Isaac S. Mordecai in the ICU.
Credit: Kate Geraghty / St Vincent’s Hospital / AAP

A leaked paper from Scott Morrison’s secretive national cabinet has forecast Covid-19 patients requiring ventilators in outbreak-ravaged New South Wales will double in just one week, while intensive care admissions will rise by 70 per cent in the same time frame.

The document, discussed at the quasi-cabinet involving state and federal leaders, also analyses total intensive care unit and ventilator capacity in all jurisdictions and predicted increased demand. In NSW, 51.5 per cent of the state’s total staffed ICU beds – 444 of 863 beds – are already in use.

“While increasing hospitalisation and ICU rates are manageable in the short-term, continued growth in the transmission of Covid-19 cases would put ICU baseline capacity under strain,” the paper, marked “sensitive”, says.

“This would impact all patients requiring intensive care.”

While the paper notes NSW has the capacity to establish surge arrangements, which would more than double the number of “ventilator-equipped ICU beds”, it is careful to point out that this does not include staff.

“Staff remain in shorter supply than beds and ventilators to meet ICU demand,” it says.

There may come a point where “interventions” such as moving staff across state borders to “facilitate” surge capacity is required, the document says, especially if healthcare workers are “furloughed” for isolation, either as close contacts or because they have contracted the virus.

Authorities are also “currently exploring” the use of private hospital sites in the event an entire nursing home is struck by the Delta variant. Unlike last year, where hundreds of elderly aged-care residents died in homes due to a policy of leaving them on site during an outbreak, it is now the practice that residents are moved into hospitals when they contract Covid-19.

“Should a major, ie: whole facility, decant [the bureaucratic term for moving people from one facility to a hospital] be required, private hospital sites will be required,” the paper says.

Forecasts were kept to just a seven-day period due to dramatic uncertainty in the numbers, but even those case number estimates were outstripped within days.

On Wednesday, NSW recorded its single biggest jump in daily numbers since the pandemic began, with 633 new infections. On Thursday the figure jumped again to 681. The paper discussed at national cabinet on August 13 predicted just 391 cases for the same time.

At Friday’s teleconference of Australian leaders, new modelling was provided although it is unclear what this data says.

While the prime minister and state and territory chief ministers have bickered over suppression strategies in already seeded outbreaks – especially in NSW – attention has increasingly turned to vaccination rates and compounding past mistakes.

Intensive care admissions due to Covid-19 infection are inextricably tied to the vaccination status of individuals. Australian National University infectious diseases physician Peter Collignon noted that the “distribution of cases [in hospital] is now very influenced by vaccination rates”.

NSW Health data shows the single largest age cohort in hospital due to Covid-19 infection is those aged 30 to 49, accounting for almost 30 per cent of all admissions. Almost half of all hospitalisations have occurred in those with the least access to vaccinations so far: people 49 and under.

There are, of course, many factors influencing this data, including the increased transmissibility of the virus and apparent clinical susceptibility of young people to it.

“The World Health Organization now call [Delta] the fittest and fastest variant of concern,” UNSW Sydney epidemiologist Mary-Louise McLaws tells The Saturday Paper.

“We need to be not one step behind, as we have been, with our contact tracing – and that is because this virus is so fast – but we now need to constantly be a step ahead with the science of the rollout of the vaccine.”

McLaws, who is also a member of the WHO’s expert advisory panel on the global Covid-19 response, has been arguing since the end of last year that Australia ought to be vaccinating its most mobile, socially connected residents.

“Our pattern in Australia, which wasn’t too different from anywhere else in the world, was that the 20- to 39-year-olds were having most of the infection and at that stage [last year] it was 40 per cent but now it is 49 per cent,” she says.

“WHO told me that the [vaccination] framework could be adjusted to anything that the member state wanted, so I then started to push the idea of an epidemiological framework that would be able to ring fence those that are at risk, such as the immunosuppressed and the elderly because it is the young transmitting it and the elderly dying from it.

“We have sometimes failed to remember who is spreading it. You don’t need to do a mathematical or statistical model to be able to identify the obvious.”

Allen Cheng, the co-chair of the Australian Technical Advisory Group on Immunisation, told this newspaper in January: “If we knew that the vaccinations could control transmission, then in theory you might actually give them first to the most socially active people.”

As evidence emerged that this is indeed the case, there was no opportunity to pivot the vaccine strategy because the nation’s rollout, which purported to prioritise the most vulnerable groups, was plagued by critical supply shortages from day one. Not even the priority groups were adequately protected.

If it wasn’t clear before, it is now beyond doubt that the original phases of the vaccine road map – from 1a and 1b for the most vulnerable to 2a, 2b and then the rest of the population – ceased to have any meaning months ago.

The deadly outbreak in NSW has also surged into rural and remote communities in the past few weeks, including the regional hub at Dubbo, which connects scores of Aboriginal and Torres Strait Islander communities across the far reaches of the state. Vaccination rates there are dangerously low.

Last weekend, Scott Morrison announced the federal government had secured one million Pfizer doses from Poland, which were due to expire later this year. That country’s vaccination rate has stalled and is far behind other European states. More than 530,000 of these doses were sent straight to NSW and explicitly earmarked for 20 to 39-year-olds in the 12 local government areas of most concern in Sydney. This is enough to deliver at least one dose to every person who fits the criteria.

A problem has emerged, however, as the state battles to control both hospitalisations and transmission of the Delta strain. Despite initially pushing the dosage interval for Pfizer from three weeks out to six weeks, NSW Health is now telling young people their second dose will be in eight weeks. It is a wait time baked into the state booking system.

The interval for AstraZeneca, which was renamed Vaxzevria this week to bring it in line with Europe and Canada, has been reduced from 12 weeks to between four and eight weeks in outbreak settings. That’s good news on the AZ / Vaxzevria front but less than ideal for Pfizer.

“That is just outbreak management madness,” McLaws says.

“Yes, you won’t die; but you are in the group that can spread it and you’re not going to get that [transmission] efficacy until the second dose. Quite frankly, we have gone outside the protocol of extending that dose between dose one and two of the mRNA vaccines and that prevents us from seeing fewer transmissions.

“We’ll see much less death and hospitalisation – and much less burden on the healthcare system – but it’s not maximising the prevention of the infection transmission cycle.”

Essentially, a person will still transmit the virus in the weeks between first and second doses – and the lack of supply has caused the government to extend that dangerous window. Vaccines won’t be the way out of lockdown in NSW, McLaws says, “unless you can get your second dose fast”.

Again, McLaws notes, current options for vaccination are being constrained by the foundational flaw in the vaccine program: supply. This was later compounded by “mixed messaging” on the approved drugs.

“We didn’t have supply and then the wheels fell off following the mixed messaging,” she says.

The issue with both the Pfizer and AstraZeneca / Vaxzevria vaccines is not ultimate protection or even adverse reactions; on both counts they are remarkably similar. But McLaws says she has always favoured Pfizer for the young because it offers greater protection and interruption of transmission after the first dose and, until recent changes to dosing intervals, a much faster pathway to full vaccination.

If there had been better supply, she says, there is no reason why Australia couldn’t have vaccinated young people at the same time as its vulnerable populations. But that point is now entirely hypothetical.

“If we had an endless supply, there should have been no reason why we couldn’t do both – which is have the compassionate framework, vulnerable people and front-line workers, plus those who acquire and transmit it effectively, and that is the 20- to 39-year-olds,” she says.

“There should be no reason why we can’t do both right now. We’ve got some Pfizer coming in. It has, I believe, an expiry date in November, and that’s not a problem if we start rolling it out as soon as possible.”

State and territory leaders are mulling the implications of the recently released Doherty Institute modelling that has been used by Morrison to underpin a reopening strategy for the nation. The critical vaccination threshold in this work is 80 per cent of the adult population.

It’s not good enough, McLaws says.

“There are ways to speed up the uptake but you don’t set a low bar of 70 or 80 per cent of adults,” she says. “Because we are seeing everybody from zero to over 100 years old is now at risk of Delta.”

The Saturday Paper can reveal at least one state is not comfortable with the vaccine thresholds and has begun working on plans to push coverage even further.

“There is a view festering among some state officials that 80 per cent is not enough,” a high-ranking Department of Health source says. “That is still 20 per cent unvaccinated, which we think is too many people.”

Although the Doherty Institute led the modelling effort, it was a multi-institution effort involving scores of staff from the Walter and Eliza Hall Institute, Monash University, Curtin University, Telethon Kids Institute and UNSW Sydney. One of those team members tells The Saturday Paper that the modelling necessarily has flaws as a result of poor data access.

“The issue at the moment, particularly in NSW but ultimately across the country – we are not a monolith population and there are going to be differences in the uptake of any prevention strategies,” the modeller said.

“You can talk about modelling that says 70 per cent this and 80 per cent that – the monolith of the population – where in fact we are a number of different segments. And it’s particularly hard to pull those things apart when we haven’t got really good data on those different relationships.

“There has been a gap in our whole response between the data that we need to collect to inform the modelling and the actual modelling – and we have not been very proactive at the national level at trying to make sure we dig into those different relationships that underlie the potential for transmission.”

In fact, the source says, there has been an unwillingness on behalf of political decision-makers to back away from the notion that the Doherty work is some sort of gospel.

“It is compounded,” the source says. “It is very clear that those areas with a lot of people who are working outside the home, especially people doing so-called essential services, interface with populations that have had issues about vaccination.

“We could have predicted that better but we haven’t really put the resources into looking at these questions.”

For its model, the Doherty team assessed the “effective” reproductive rate of the Delta variant in NSW in March, when there were relatively few restrictions in place. The number represents how many people each infected person passes the virus on to. At the time it was 3.2. More than four months later, two of which were under lockdown, NSW Premier Gladys Berejiklian said that number had more than halved – but still needed to be lower. “Every person that has the virus is spreading it to 1.3 people,” she said. “We need that number to be below one.”

At the national cabinet meeting on August 13 – which Morrison described as “collegiate” and state leaders have privately said was filled more with a mood of “deflation” – leaders agreed that international arrival caps would remain in place until at least October 31 when they will be re-evaluated depending on “progress of Australia toward phase b [70 per cent vaccination] of the National Transition Plan”.

Commonwealth, state and territory chief health officers were then sent away to “consider mandating vaccination of interstate freight workers”.

It was a tacit admission that perhaps the uniform assumptions about the nation in the Doherty modelling were not nearly close enough to reality.

On Wednesday, NSW chief health officer Dr Kerry Chant was resolute. There was another group that needed focus in the rapidly changing pandemic: children.

“I cannot stress enough that even with high vaccine coverage, we cannot do well with the case numbers we have got,” she said. “I firmly believe that we need to get in and vaccinate our 12- to 15-year-olds at the moment ... Given the transmission of Delta, it may well be that in future we do provide vaccines in the younger age groups.”

Late on Thursday, the prime minister announced his government has agreed to open Pfizer and Moderna vaccinations to those aged 16 to 39. As if answering Dr Chant, he signalled 12 to 15-year-olds could be inoculated later this year.

Morrison bought himself a little bit of time to allow a still uneven vaccine supply to trickle in after the announcement. Bookings will open this week, with the program beginning at the end of this month.

This article was first published in the print edition of The Saturday Paper on Aug 21, 2021 as "Exclusive: National cabinet counts intensive care beds".

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Rick Morton is The Saturday Paper’s senior reporter.