What is a workable alternative to an elimination strategy?
Prominent public health commentators, Drs Duckett, Dwyer, Blakely and Dore, have urged the Victorian government should go for a elimination strategy. These calls have attracted media commentary, asking ‘If we are to live with COVID-19 then Australia’s leaders need to tell us what that means’. We have not been given a counter argument in favour of suppression, nor clear guidance on what a suppression strategy involves.
What is needed is a clearly understood strategy about how to manage suppression. A close look at the Victorian Department of Health’s website shows that this is lacking. The website does not have any document spelling out what the test and trace strategy involves to suppress the virus. Nor does the source of national public health advice offer relevant guidance. None of the 43 Statements issued since 17 March by the Australian Health Protection Principal Committee (AHPPC) mention what standards should apply to testing and contact tracing.
Our confidence as citizens in the capacity of the state to protect our health depends on knowing that government has a clear strategy in place. It also requires being given regular information about how well that strategy is performing so we can build trust in how it is working.
My professional interest as a public policy academic is in ensuring that we adopt a strategy that will not only minimise the spread of the virus but also allow us to engage with our immediate neighbouring countries in the Pacific and Timor-Leste. I have also put the case for setting up a managed pathway for tourists to travel to the Pacific to countries such as Fiji and Vanuatu which are heavily reliant on tourism to generate paid work and export revenue for their economies.
Those who have argued for elimination strategy have used shallow one-sided arguments based on a lack of evidence about the harm that a prolonged lockdown strategy would cause. It is also a strategy that depends on an exaggerated fear of the unknown to achieve compliance. It is not a strategy that enables us to operate as a federation, with states applying strict border closures against each other. It is certainly not a strategy that enables us to act as good neighbours to the countries we have close relations with.
What an appropriate strategy should look like
Neither Victoria or the Commonwealth Health Departments have a simple document like the one produced by Scotland called Covid-19: Test, Trace, Isolate, Support: A Public Health approach to maintaining low levels of community transmission of COVID-19 in Scotland. The UK’s Independent Scientific Advisory Group for Emergencies (SAGE) has offered a critical assessment of the lessons they have learned from their poor handling of the pandemic. Their report entitled Final Integrated Find, Test, Trace, Isolate, Support (FTTIS) response to the Pandemic (17 June) urges adoption of a more comprehensive five-step strategy than the overly simplified ‘test and trace’ approach.
The success of a comprehensive five-step FTTIS system is based on trust. This trust needs to be based on clarity, transparency and communication. The steps need to be expressed in simple terms and widely promoted as a package. Transparency is needed for all aspects of the policy with the accuracy of the tests to how quickly the test results are being processed. The system also requires measures so those in charge can know how it is performing. If the contact app is not effective, there is a need to say what is effective so people have trust in the system of contact tracing. Also needed is effective community engagement to build trust in why the tracing and isolation are necessary and what support will be made available such as food and finance for vulnerable groups and appropriate guarantees from employers.
Trust also comes from having contact tracers who are connected to and part of local communities. The UK report notes that testing and tracing alone using a centralised system simply will not work. The report recommends local involvement in contact tracing and ownership using existing public health and primary care teams, general practitioners, local hospital laboratories, and local government health officers to ensure the community can respond quickly to outbreaks and build local trust.
The report recommends a turn around of test results of 24 hours to ensure rapid isolation of positive cases and their contacts within four (4) days of initial contact, the estimated time a contact is likely to become infectious. The timetable is very demanding as it includes going from recognising possible COVID-19 symptoms to getting tested, getting a result, telling the contact team who they have been in extended contact with and getting those contacted to isolate themselves. But this is the organisational challenge we face.
Not least, clear and detailed state-wide performance indicators are needed to support local decision-making. The report proposes these performance measures:
- Tests: what percentage of tests results are returned within 24 hours?
- Tests: what are the testing rates for high-risk vulnerable groups such as aged care homes, multi-generational households in densely population neighbourhoods, meat processing plants
- Contacts: what percentage of people with a positive test are successfully contacted within 24 hours?
- Contacts: what percentage of people share their close contacts with a contact tracing team?
- Contacts: what percentage of named contacts are contacted within the next 24 hours?
- Isolation: what percentage of contacts comply with isolation?
- Support: what percentage of cases in isolation require/request support?
- Support: what percentage of these receive support during isolation?
- Support: what percentage of contacts in quarantine require/request support?
- Support: what percentage of these receive support during quarantine?
The way a comprehensive testing and tracing system is organised is complex because of the number of players involved and the high level of trust required for it to be accepted and to work. However, this does not mean that it is too hard or impossible. It is possible with lots of feedback and refinement based on evidence of how well it is working.
Richard Curtain is a Research Fellow, Development Policy Centre, Crawford School of Public Policy, The Australian National University.