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As the eastern states emerge from lockdowns, the pandemic isn’t over, it’s just changing shape. By Rick Morton.

Opening up: Covid-19 cases could still reach 750,000

Pedestrians in Sydney this week, after the city’s lockdown lifted. Melbourne emerged from its sixth lockdown on Friday.
Credit: Reuters / Loren Elliott

The virus that causes Covid-19 is endemic. It is expected it will reach every state and territory, even those whose borders are closed. People who are vaccinated can still contract and spread the virus, although they may not become as sick from it. This is Covid normal.

As the nation reached its first major vaccination milestone of 70 per cent of the 16-plus population double-dosed on Wednesday, attention is now turning to those who will be most at risk of infection, illness and hospitalisation in the next six months.

“Importation of the Delta variant into every Australian jurisdiction is now inevitable,” the modelling consortium led by the Doherty Institute said in its updated infection scenarios released last month.

“It can no longer be assumed that even stringent lockdown measures will achieve local extinction given the demonstrated importance of small area foci where such measures have reduced impacts (eg: high proportion of essential workers, large household size, etc).

“These local effects are combined with an anticipated general decline in population co-operation with restrictions, even in jurisdictions with relatively low baseline [transmission potential].”

On Monday, Queensland Premier Annastacia Palaszczuk announced a staged reopening of the state’s domestic borders for fully vaccinated people, beginning November 19. Borders will be fully opened for travellers by road with no quarantine requirements on December 17.

Palaszczuk said the state has less than two weeks to get about 400,000 Queenslanders a first or second dose of the Covid-19 vaccine, to ensure better protection come those milestones. “This is absolutely a critical time in dealing with this pandemic, that we get those 400,000 people to come out and get vaccinated,” she said in Rockhampton the next day.

“And we know that when we’re at 80 per cent vaccinated it gives a lot more certainty to your community.”

Western Australian Premier Mark McGowan indicated there would be no such relaxation of his state’s border rules, at least until after Christmas.

Even using the most reliable models currently available, it is impossible to forecast with any accuracy what the numbers will look like over the next half-year. The Doherty-led work taps out at 80 per cent vaccination thresholds, even though it is now clear the two largest states and the ACT will eventually achieve more than 90 per cent double-dose coverage.

These rates will make a significant difference in any projections, as they have already made a critical difference in the rates of hospitalisation between the earlier stages of the New South Wales Delta outbreak and the current Victorian wave of the same variant.

Victoria reached 1000 daily cases on September 30 with a first-dose vaccination rate of 80.1 per cent. NSW, which had an outbreak start earlier in the nation’s vaccination rollout, had just 62.8 per cent of its population vaccinated with one dose when it hit the same daily caseload on August 21.

Victoria began this outbreak with a hospitalisation rate about half that of NSW, and it has managed to slash that rate within weeks to well below 4 per cent with increasing vaccination coverage.

Using the Doherty modelling as a guide, however, it is clear there will be many Covid-19 cases in both vaccinated and unvaccinated people as Australia moves to a delicate balancing act between baseline or low-level public health measures and opening up. While the vaccines limit transmission and infection, they do not entirely prevent it. People who are fully vaccinated can still get the virus.

Assuming an 80 per cent coverage, baseline public health and social measures, optimal test, trace, isolate and quarantine levels, and low seeding of an initial outbreak, the Doherty model says 5627 people could develop symptomatic Covid-19 infections in the next six months. Of these, 175 would be admitted to hospital, 31 to intensive care and 27 would die.

The modelling does not explicitly report asymptomatic cases, although the Doherty team relied on international research from last year examining susceptibility to clinical infections. It also assumes asymptomatic cases – which more recent research shows can account for between one-quarter and one-third of all infections – are 50 per cent less contagious.

Under the same Doherty assumptions but with a mid-sized initial starting outbreak – as is currently the case in NSW though not in Victoria, which is high – the number of symptomatic infections will rise to 73,189 in a six-month period. Of those, 2407 would end up in hospital, 372 would be admitted to ICU and 374 would die.

In reality, though, the projections are not so simple. The Doherty-led work deliberately manufactures uniform, national figures at a very high level. And while the starting outbreak size does influence the final numbers, these will fluctuate over time. In NSW, for example, there were about 1000 cases a day towards the end of September but within weeks this dropped to about 300.

Victoria recorded a near record again on Thursday, with 2232 cases and 12 deaths, but, as in its neighbour state, these numbers will reduce as vaccines take effect.

If states and territories manage to reform test, trace, isolate and quarantine measures, this could again have significant impacts on future numbers. Already the two largest jurisdictions have signalled, or begun implementing, changes to the way casual contacts are notified of potential exposure. Should these efforts be suboptimal, even with low initial seeding of cases, the Doherty-led consortium estimates there would be 750,000 symptomatic Covid-19 infections in a six-month period. Among this cohort, 27,000 would end up in hospital, 4358 in ICU and 4108 would likely die.

Since the beginning of the pandemic last year, there have been 150,000 cases of Covid-19 in Australia.

“In reality, the national Covid-19 epidemic has been and will continue to be a ‘fire’ fought on multiple fronts,” the updated modelling report says.

“Public health units are aware that small areas and subpopulations with different age and household structures and levels of advantage have different risks of infection transmission and adverse health outcomes.

“Throughout the pandemic, we have also observed that such individuals may also be disproportionately engaged in essential service occupations that cannot be safely performed at home, meaning that broadly applied social measures and lockdowns provide less effective protection.”

UNSW Sydney senior lecturer in the faculty of medicine and health, Ben Harris-Roxas, says there is a “heightened state of agitation” for many people amid the uncertainty of the transition to a new Covid normal.

“And it is really unclear who needs to be [worried] and who doesn’t need to be,” he says.

“The social anxiety is not going to happen in an even way. But for some groups, who I think have legitimate concerns about the world reopening or might not have had access to vaccination yet, things are going to look different for quite a while.”

There are certainly groups of people with higher risk factors, even after receiving full vaccination. Australian authorities have already begun issuing booster shots to severely immunocompromised people and are likely to extend this program by the end of the year for others.

According to the NSW Health Critical Intelligence Unit, set up in response to Covid-19, those with increased risk of illness from the disease include the immunosuppressed (due to age, disease or drugs) or those with obesity, diabetes, cardiovascular disease, chronic airway limitations or cancer.

The Doherty modelling includes projections for those who will become ill even after being fully vaccinated, and in its most optimistic forecast that includes 407 people aged 16 to 39, 440 aged between 40 and 59 and 261 people 60 and over.

In this scenario, deaths among the vaccinated will always be lower than in the unvaccinated cohorts, but from ages 40 and up they will still occur in isolated cases.

“The problem from my perspective is the existing conditions, the multimorbidity issue, hunt in packs,” Dr Harris-Roxas says.

“You might think, ‘Oh, anyone who is obese tends to be at higher risk of these other   conditions.’ But if you look at it from the other way around, people with those conditions tend to be obese. That’s the problem.

“The other big thing with existing   conditions is that – we have to be real – by the time we’re 65 more than half the population has an existing chronic condition. When you say someone died due to an underlying condition, it’s not a small proportion of the population.”

Last weekend, The Saturday Paper reported confidential figures that revealed Aboriginal and Torres Strait Islander people had been infected with Covid-19 at almost twice the rate of non-Indigenous people and although hospitalisation rates were mostly lower for this group, for those aged between 40 and 60 the death rates were about three times higher than the rest of the population.

Similarly, disabled people have been represented frequently in the statistics so far, at least in the ones that have been easily identifiable.

“The reality is those people have been inhabiting that headspace [of being forgotten] for quite a while,” Harris-Roxas says.

“I guess the challenge is, who else has Covid put into that category? And it’s a bit unclear. I think some of it will be on the basis of remoteness and, in addition, all the groups that, in health jargon, we would say have low health or systems literacy.

“So those are people who have trouble navigating our complex health systems, trying to figure out who they should be speaking to about their concerns, who they should be seeing about whether they should get the vaccine and people with psychosocial disabilities.”

There is a lot of scope for more “structured equity analyses” of reopening road maps now they are available, Harris-Roxas says, in terms of different cultural groups, ages and genders.

“This is now not an issue of theory or ideology. It actually becomes a practical issue and it is at that level on implementation where some of the real inequalities emerge,” he says.

“On one side of the risk ledger we can talk about things that are known and knowable and eventually even quantifiable, like hospitalisations or deaths or even cases of long Covid.

“But what is missing is also the other side of the picture, which is also a source of inequality. Like, what is happening in terms of the life-course impacts of kids who have effectively had disruption to their education for two years? And these are not easy things to weigh up.”

The shifting fortunes of this particular pandemic include wins and losses. The Delta variant emerged dramatically, altering the likelihood of serious illness. But vaccines were developed and rolled out to fight it, demonstrating similar efficacy with this strain compared with its predecessors.

New drugs to treat Covid-19 infections have come on to the market, including sotrovimab, which can be administered in at-risk groups at onset of even mild illness. Earlier this month, Australia purchased 300,000 doses of Merck & Co’s experimental antiviral treatment molnupiravir, which comes in pill form and could halve the chance of serious illness or death among the most vulnerable groups.

Evidence about the longer-term effectiveness of vaccines continues to emerge. A new study published in The Lancet this week shows that although Pfizer’s vaccine efficacy against infection by the Delta variant falls from a high of 93 per cent one month after being fully vaccinated to 53 per cent five months later, there is no erosion of protection against hospitalisation. AstraZeneca’s vaccine, which Australia intends to stop manufacturing next year, might have longer-lasting overall protection.

In a preprint paper uploaded to medRxiv.org on Monday, yet to be peer-reviewed, researchers from Britain “found no substantial differences in the incidence of SARS-CoV-2 infection or Covid-19-related hospital events following vaccination with BNT162b2 (Pfizer) or ChAdOx1 (AZ) in a cohort of health- and social-care workers in England.”

What is clear, in a sea of uncertainty, is that the scientific tools currently available to fight the coronavirus are working well. These measures will be improved by care and attention to those most at risk.

Last week, a 63-year-old woman named Jenny with an intellectual disability became a close contact after her disability support worker visited while unknowingly positive for Covid-19. The worker, who has had only one vaccination dose, contracted the disease from another client who was fully vaccinated. Jenny has returned a negative result but has become anxious about what the future may hold.

There is no current requirement for these outsourced disability support workers to wear any protection other than a surgical mask when visiting people who are not confirmed Covid-19 positive.

“We are coming out of lockdown and there will never be another lockdown to protect people like Jenny,” says Kate Krombach, her advocate of 25 years.

“But the settings we have right now are designed to protect the workers, which is great, but they aren’t there to protect people like Jenny.”

A spokesperson for the Department of Health says the National Medical Stockpile continues to provide protective equipment to “support workers in the disability care and home-care environments who may be at risk of exposure to Covid-19”.

But if National Disability Insurance Scheme participants like Jenny want that extra layer of protection, they have to pay for it themselves out of their existing support packages.

Jenny’s case is a window into the anxiety of many. The pandemic isn’t over, it has just changed shape. 

This article was first published in the print edition of The Saturday Paper on Oct 23, 2021 as "Opening up: Covid-19 cases could still reach 750,000".

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Rick Morton is The Saturday Paper’s senior reporter.