Pearls and Irritations

There have been many mistakes in many countries hindering efforts to control the COVID-19 pandemic. None has been more counterproductive than the premature easing of public health containment initiatives. Time and time again this has breathed new life into infections by the SARS-Cov-2 virus. This is especially so when dealing with the “Delta” variant.

By early next week we will have delivered ‘six million jabs’ into NSW arms to have 31% of the adult population fully vaccinated and 56% partially vaccinated against COVID-19. Premier, there is no modelling anywhere that suggests that this achievement should  trigger an easing of any restrictions. Please abandon your plans to do so. More so when new cases of community spread are actually increasing. Only 55% of people over 70 in NSW have been fully vaccinated. Many thousands over 70 remain highly vulnerable.

When should we ease restrictions? According to our Prime Minister “Under our national plan where we start hitting 70 per cent and 80 percent vaccination targets, we can start claiming back what COVID has been taking away from us. When we do  we must not be intimidated by the case numbers that will inevitably increase”.

Well, that will be determined by the level of intimidation our community will accept. Let’s look at a current real world example and see if this would be acceptable to us.

In the UK, which has 75% of its  adults fully vaccinated, that achievement triggered the removal of all public health restrictions as the country embraced the freedom associated with the decision to go forward  “living with Covid-19”.  The result? Hospitals in crisis as each day about 800 admissions for Covid-19 are required with an average of 90 deaths day after  day. In the last seven days the UK has diagnosed 227,391 new infections and of those 687 have died. To my mind that’s ‘Dying with Covid’ not “living with Covid” The obvious point if you find that unacceptable, is that even high rates of vaccination need to be supplemented with continuation of evidence based public health initiatives.

So the suggestion in the Government’s master plan that, with 70% of the population over 16 fully vaccinated we can move into a ‘transition’ program as we head for pre-Covid life is certainly challenged by current data.

The reality is that there is no one ‘magic’ percentage figure for vaccinations that when achieved would guarantee the end of our woes.  There are too many variables  for that. We need an outcome wherein the number of new infections in the community is not growing, deaths are minimised, the diagnosed cases can be well contained by our contact tracers and our hospitals are able to function efficiently not being overburdened with COVID cases. This will be achieved and maintained by vaccination and the continuation of appropriate public health strategies. At that point we can look at the percentage of vaccinations and say ,“Well that was the number”

We are learning of many circumstances that now need to be figured into our modelling.

Overtime many who are vaccinated and well protected from the most serious consequences of COVID-19 are experiencing ‘breakthrough infections’ during which they may be highly infectious.

Recent data makes it clear that the effectiveness of all the available vaccines wains with time so much so that there is near universal agreement that long term protection will require a third injection of vaccine.

Both the Pfizer and Astra Zeneca vaccine produce most protection if two doses are given 10 weeks apart .Our policy of shortening the interval between first and second doses of vaccine to  boost the response achieved by the first injection as we struggle with an ever increasing number of community infections is understandable but results in sub optimal protection.

We can expect to see ‘breakthrough’ infections in NSW. We will almost certainly need to have a third injection about six months after the second to induce the best possible immune response.

That is happening in a number of countries even as the WHO points out that it would be highly unethical for developed nations to start delivering third injections now when in so many poor countries only a tiny percentage of the population has received one dose.

Around 11 billion doses are needed to fully vaccinate 70% of the world’s population against COVID-19. 3.2 billion doses had been administered. At the current vaccination rate, this will increase to around six billion doses by the end of the year.

But so far, more than 80% of the doses have gone to people in high-income and upper-middle-income countries. Only 1% of people in low-income countries have been given at least one dose, according to the WHO

Did you feel as uncomfortable as I did when Poland gave wealthy Australia a million doses of the Pfizer vaccine it did not need?

Global data reveals that the delta variant is infecting and causing serious illness in the young. Our own ICU figures demonstrate this clearly and the world is noting more infections with serious consequences in children under 12 years of age. “Long Covid” which can debilitate those who have recovered from an acute infection for many months is now being noticed in 10% of infected children in the US.

There is an important message for us within these statistics. There are 1,200,000 children under 12 in NSW and while our major effort at this time must be directed to immunising the most vulnerable we need to start planning now for how we will immunise our children when vaccine is available for them.  Ongoing trials suggest that we can expect approval for vaccinating our youngest by the end of the year. We need to protect them and reduce their ability to be spreaders of virus. A report published this week documents efficient spread by asymptomatic ‘toddlers’! Twenty-five percent of our Sydney cases on Saturday where in children.

So while the current acceleration of vaccinations is to be applauded we are at a stage where we need to do all we can to broaden as well as accelerate vaccinations and combine that with evidence based restrictions that realise maximum pain achieves maximum gain.

The Prime Minister and the Chief Health officer were right in advising NSW that maximally effective lockdown will in the short term do more to diminish infections than will vaccinations.

New restrictions announced by the Premier are no less welcome because they are so overdue, frustratingly however, those new measures are again not structured to be maximally effective.  Surely they should have been applied to all of greater Sydney with an evening curfew starting at 7 pm not 9 pm. A lot of social/family interactions occur between 7 and 9 pm. The limitation on outside exercise to just one hour should again be required for all, of Sydney. The travel limit of 5 kms should include travel within one’s LGA. Also welcomed would have been a further examination of just what is an ‘essential business’.

Finally, we need to know how the 800 or so new infections each day occurred. If the majority of infections continue to result from intra-family spread this surely is not the result of a wilful disregard of the mandated public health initiatives but rather involves ignorance. It is important  that we ask if English not being a first language for such families is a contributing factor.  It is possible that despite efforts  to distribute information in many languages we have not had sufficient levels of comprehension.

What circumstances are causing infections is even more important than the number of infections.