The latest New South Wales ‘Roadmap to recovery’ outlines the relaxing of restrictions in three stages: at the 70%, 80% and 90% double dose (persons over 16 years) vaccination marks (about 56%, 64% and 72% of the total population, respectively).
OzSAGE commends the rapid vaccination campaign in NSW and the high rates achieved already, including in children 12 years and over. This bodes very positively for our future. However, other countries with high vaccination rates such as Israel and Singapore already tried relaxing restrictions and relying mostly on vaccines to suppress COVID-19 – and have had to reimpose restrictions.
In Denmark, mask mandates were removed about three weeks ago, and cases have begun rising slightly again. Time will tell, but real-world experience suggests that vaccines alone are not enough, as they are less effective against Delta and wane after six months.
NSW may face a Delta resurgence and repeated stop-start lockdown cycles if multiple restrictions are simultaneously relaxed. This is because the health system may become overwhelmed, prompting lockdown.
The transition period between 70% and 90% double vaccinated in people over 16 years (56-72% of the whole population) is especially critical, as increased mixing of people will result in increased cases. OzSAGE notes the transition between Premiers in NSW and urges the new premier to maintain a staged plan to release restrictions and heed the advice below.
The period around February 2022 is also important, as waning of vaccine-induced immunity is expected to be apparent by then for people vaccinated around August 2021 (the peak of vaccine uptake in NSW).
For health workers vaccinated in March, waning is already occurring and fully vaccinated health workers have been infected. In Israel, in a 96% Pfizer vaccinated group of health workers and patients, a large hospital outbreak occurred at about the six-month mark after vaccination.
Layered, combined protections such as safe indoor air, testing, tracing and mask wearing will provide a much greater chance of safer and sustainable re-opening until we await the promise of second generation and Delta-matched vaccines, boosters and smarter vaccine strategies.
OzSAGE encourages the NSW Government and incoming premier to adopt the following measures:
1. Higher vaccine targets for at-risk groups as a requirement for re-opening*
Equitable risk management implies that vaccination rates and other protection measures in disadvantaged communities should be raised above those of typical urban centres before free movement is permitted between them. No group should avoidably be at higher risk of contracting COVID-19, or have greater difficulty accessing optimal healthcare. For those whose circumstances make it harder to access adequate care, for example, in regions, in isolated communities or where disability makes transportation logistically more difficult, additional efforts should be made to reduce their chances of contracting COVID-19. This includes Aboriginal and Torres Strait Islander people and other groups such as people with disability, particularly those living in residential care or group settings. We recommend at least 85-90% double dose targets for all such persons 12 years and older. Along with the Rural Doctors Association of Australia we recommend a staged opening of regions outside Greater Sydney. Each region outside Greater Sydney should only open up to Sydney and other regions when it achieves 80% double-dose coverage in people 12 years and over.
2. Enable rapid vaccination in regional NSW and high-risk groups
An urgent effort is needed to take vaccination services to at-risk rural and remote populations and other at-risk groups including people with disability and disadvantaged people who have difficulty accessing hubs.
3. Make indoor air safer
NSW needs an indoor ventilation plan, because the SARS-CoV-2 virus is airborne. The plan should ensure homes, schools, businesses, and other public venues have safe indoor air, and that the community is as well informed on safe air as it is on handwashing, so that people and businesses are empowered to mitigate risk in their own settings.
4. Maintain high rates of testing and tracing, retain QR code scanning
Testing, tracing, isolation and quarantine need to be fully maintained. We should maintain high testing capacity, make rapid antigen testing widely available, and improve contact tracing capacity. Suggestions of stopping QR code scanning and thereby reducing contact tracing capacity are misguided, and will result in a resurgence of infection. NSW undertakes contact tracing routinely for all serious infections such as tuberculosis, meningitis and measles, and need to continue this for COVID-19.
5. Implement booster doses for high-risk individuals and workforce six months after the second dose
must also be addressed with proactive about booster doses, particularly for those with reduced immunity or who are immunocompromised, and for health care workers. This approach is supported by the increasing numbers of infections in health care workers following vaccinations. There is enough real-world evidence from other countries that protection starts to wane as early as five to six months after vaccination, and examples of outbreaks in highly vaccinated patients and health workers within hospitals. It is urgent we address this for health workers and other priority groups such as aged care residents, many of whom were vaccinated six months ago or longer. This is not only for their own safety but to prevent health system collapse from under-staffing due to illness or burnout or furloughing of staff.
*A list of key at-risk groups is provided overleaf.
Over 3 million (at least 40% of NSW) at-risk: Key at-risk groups
About 20% of the population is aged under 16 years. The 80% adult double-dose target corresponds to only 64% of the whole population, leaving plenty of room for Delta to spread. More than one in two children aged 12 to 15 in NSW have already had at least one dose of vaccine, which is excellent.
Another 1.2 million NSW children under 12 will remain unvaccinated. This is the largest unvaccinated group. With no requirements for unvaccinated primary school children to wear masks, and plans to adequately ventilate classrooms still being formulated, outbreaks will almost certainly occur. In the US, counties with school mask mandates had much lower rates of COVID-19 in children than counties that did not mandate masks. One unvaccinated teacher who took off her mask to read to a primary school class resulted in 26 people becoming infected.
While children typically get mild infection compared to adults, around 2% of children who get Delta are hospitalised. Of these, some will require ICU care and a proportion will die. This becomes more apparent when there is high community transmission, and high case numbers in unvaccinated children. The Doherty report estimates 276,000 Australian children will be infected in the first six months after reopening in the most likely scenario, with 2,400 hospitalisations, 206 ICU admissions and 57 child deaths in that time – but assumed no vaccination in this group. If all children 12 and over are vaccinated, these estimates would be lower, but still significant and important to prevent.
2: Aboriginal and Torres Strait Islander people
NSW has the largest Aboriginal population of any State, about 265,700 people. Aboriginal communities in NSW are at risk in epidemics, contracting COVID-19 and getting severe disease. There are relatively more children in the under 12 age category in Aboriginal communities, which leaves a much higher proportion of the community unvaccinated. We saw in the Wilcannia outbreak that a high proportion of cases were in children. Despite this, vaccination rates for Aboriginal and Torres Strait Islander people continue to lag behind the rest of NSW. Allowing unrestrained travel into these communities before vaccination rates are high enough to afford protection may be disastrous. Over 50% of Aboriginal and Torres Strait Islander people in NSW also live outside the major city areas compared to almost 25% of the non-Indigenous population. Limited access to health care services along with increased risk factors further compounds potential impact upon this population.
3: Regional NSW
About 35% of the NSW population (2.8 million people) live outside Greater Sydney. Regional and remote communities are also at risk, because of fewer health services (primary care, paramedical and hospital services) fewer options for ICU care, contact tracers and difficulties with access to care. The regions are reliant on the ability to transfer very sick and complex cases to tertiary level metropolitan services. An outbreak would disproportionately affect rural and regional NSW health systems and communities, and lead to adverse outcomes for COVID-19 and non-COVID-19 cases
Vaccination levels vary across regional areas and within regions, and are generally lower than metropolitan areas. At-risk populations in rural and remote areas (elderly, socially disadvantaged, indigenous and remote populations) have not had the same access to vaccinations through primary care or vaccination hubs.
Movement of metropolitan populations to regional areas after relaxation of public health measures, without adequate protection of the regional populations, affords considerable risks in overwhelming regional health services. Regional and rural health services need additional resources and retrieval services need to be better coordinated for time critical COVID-19 and non-COVID-19 conditions. Detailed suggestions are set out in our forthcoming Rural and Remote Health Recommendations.
4: People with disability
About 18% of people in NSW live with disability, and 145,000 are in the NDIS scheme. People with disability, many of whom have significant health conditions, are at high risk of serious disease and death. Vaccination rates for NSW participants in Australia’s National Disability Insurance Scheme lag state rates despite being prioritised in the national rollout. Rates of vaccination among people with disability who are not in the NDIS is unknown.
In the UK, 58% of COVID-19 deaths in the United Kingdom were among people who had a disability. People with intellectual disability were eight times more likely to die of COVID than the general population.
5: people with cancer and other conditions
About 17% of people in Sydney live with moderate to severe immunosuppression. Adults and children living with cancer and other conditions that suppress the immune system may have a poorer response to COVID-19 vaccines, and may need a third dose. The need for a third dose in susceptible people is recognised and programs to deliver these are underway in many countries.
Some are vaccinating specific groups: the United States and United Kingdom are providing boosters to all people 65 and 50 years and over, respectively. Others, such as Israel and many European nations, are starting with older adults and immunosuppressed people, and later including the rest of the population.
Australia is yet to formulate such a plan. Children under 12 years with cancer (not yet eligible for vaccination), also deserve to be protected, by vaccines and/or other measures to stop the spread of COVID-19 in the community. The consequences of overwhelmed health systems on timely diagnoses and treatment of cancer and other serious illness are already being seen in NSW.