The Virus Strikes Back.
Around 4 weeks ago Australia ‘the lucky ‘country’ had almost stumbled to eradication of Covid-19, but and I had the feeling that the luck was in danger or running out. Now, 4 weeks later, the situation has deteriorated. That deterioration calls into question the the official ‘suppression not eradication’ strategy. This posts looks at what has happened, together with the suppression/eradication debate.
There may be lessons for any country trying to address Covid-19 at low case numbers in considering the risks posed by allowing a small number of cases that can form clusters requiring suppression, and the difficult of achieving local suppression.
Here is what has happened since my previous post.
- The Suppression vs Eradication Debate Continues
- Meanwhile Cases Rise: Predictable?
- Victoria: Measures ineffective?
- NSW: Deja Vu?
- The Steps To Achieve Suppression
- Lockdown Announced in Key Melbourne Postcodes (June 30)
- Lockdown extended plus ‘towers’ hard lockdown: July 4
- Melbourne Re-enters Lockdown
- NSW Victoria border restricted
- Masks required in Melbourne: From July 22
- Payment to Address Non-Compliance: July 23
- Melbourne Lockdown, ‘the stick’: July 24
- Conclusion / ‘Editorial’
The Suppression vs Elimination Debate Continues
In my previous post on Covid-19 in Australia I discussed how Australia moved from an initial policy of containment, to a policy not of eradication, but instead suppression.
There is a debate between those advocating moving to a policy or eradication or staying with a policy of suppression. Reality this is about politics more than science, and in this case the politics could be important.
To be frank, neither ‘containment strategy’ or ‘suppression strategy’ actually mean anything specific, without giving upper and lower boundaries. I believe explanations given for the terms set a range of possible meanings:
- suppression is generally identified as the application of strict lockdown measures once case numbers exceed government upper limits, but in explanations in Australia has been explained as less aggressive in eliminating cases, at lower economic cost than eradication, as in place in New Zealand. But what numbers of cases are ‘acceptable’ is perhaps deliberately vague
- eradication is taken to range in meaning from the actual ‘eradication’ policy as followed by New Zealand, through to being described as a far more extreme policy that would be impractical for any country to follow
In fact there is an overlap. You could describe a practical eradication policy as ‘suppression’ and describe even a ‘herd immunity’ strategy as pursuing ‘eradication’ (at least eventually).
In politics, the goal is to keep the greatest number of people believe you will do what they want, and having labels with no precise definition allows a range of views to identity with the label you promote.
Suppression could be described as a practical implementation of eradication to those who are concerned about health outcomes, and as a pragmatic ‘tolerate some cases/deaths to achieve financial goals’ strategy to the fiscally conservative.
The government moving to the label of ‘eradication’ would send a clearer signal to the public that any level of community transmission presents as a problem, but the government could fear alienating the more fiscally conservative.
For reference as to how the two labels are perceived now consider the debates between ‘eradication’ and ‘suppression’ as presented on the current affairs program ‘7.30’ on July 13 and 15.
Those arguing for a move to eradication/elimination are requesting specific policy (which could even be accommodated without a change of label).
Here are some arguments for eradication/elimination:
These first quotations are from this Australian ABC coverage.
The next four of five weeks will shape how Australians will live until a vaccine comes along. Will we continue with the national policy of covid-19 suppression? With the risk of outbreaks? Or explicitly aim for zero community spread in Victoria and New South Wales to match the other states and territories? The Victorian Chief Medical Officer seemingly has this in mind.Dr Norman Swan. July 13 730 Report
As a public health person, I’d be happy if elimination were a feasible thing to achieve. It is not the national decision at the moment, I would hope as we move through this phase in Victoria, and look at everything else occurring across Australia, that we dont close outselves off to an evaluation and reapraisal of what’s feasible and what the pros and cons are.Dr Brett Sutton (Victorian Cheif Health Officer). July 13 730 Report
We have 6 our of 8 states and territories that have eliminated community transmission.
There is not a lot of transparency about that advice [the advice to adopt suppression strategy], if we compare it to New Zealand or for instance cabinet papers which are, for example, public within six weeks, I think we need a more transparent system. We have more knowledge now, that can increase our chances of achieving elimination.Professor Tony Blakeley
One issue in Australia is even though the overall government strategy is suppression, every other [other than Victoria] state, except NSW, has achieved eradication, and as a country we want to open up borders internally, which means we need to get down to those levels, hopefully zero in Victoria.Professor Sharon Lewin Doherty Institute. July 13 7:30 report
Suppression or eradication, the strategy is the same right now, and that is to block transmission.Professor Sharon Lewin Doherty Institute. July 13 7:30 report
The argument against elimination of spread, is that it extracts a greater economic cost, with longer harsher lockdowns. But Tony Blakely argues that Melbourne is already taking steps that could lead to eradication. Schools are closed except for year 11s and 12s, and the city is in lockdown for 6 weeks, the same length as New Zealand. Plus people are now being encouraged to wear masks. This debate will affect our lives in the foreseeable future, but one of the issues in the way is that the national position favours suppression. How the experts advising the Federal Government came to that position, it now clear. The big question is, given the success in every state except NSW and Victoria, is whether now is the time to aim higher. Because in a months time, it will be too late.Dr Norman Swan. July 13 730 Report
And from a debate two days later:
Well, elimination in the first instance, it is costly. Put in six weeks of hard lockdown, yes it would be harder. However you then get a clear runway, a clear place where you can then return to a more normal functioning society, and a more normal economy, at least until such point as you have a viral re-incursion or you decide to re-open your borders. So elimination in the medium to long term could be a lot better economically.
Elimination is no community transmission of the virus, you can still get stuff from quarantine. Well six of eight states and territories have got there with the conditions of the last lockdown, but they were the least populous and less dense. States like New Sound Wales and Victoria will probably need more. That would mean tightening up the definitions of essential workers, not allowing children back to school because although children don’t get very sick they transmit the disease. Going harder on shops. Having hardware or butcher shops open for example may not be necessary. Those types of measures.
But above the is leadership. Something like Premier Andrews coming out and saying “we are going for elimination”, because we know from the New Zealand experience that changed the cultural norms. Rather than when we get to 10 cases a day in 3 or 4 weeks, rather than us saying “Let’s go back to the pub”, we’ll be going “let’s knock it on the head because we’re working to a goal”.Professor Tony Blakeley: 7:30 July 15
And replying to “but there is another cost, a human cost to elimination” following the comments by Peter Collington (see below)
Well, there is a cost but the reason I have come out now to argue for elimination, we’re in lockdown anyway. We’re in a six week lockdown. I am advocating for going harder to maximise the change of achieving elimination. If you achieve elimination we go back to near normal living. We still want to see people practicing hand hygiene and keep physical distancing where possible in case the virus gets back in.Professor Tony Blakeley: 7:30 July 15
And here are some arguments for ‘suppression’:
That [eradication] would mean obviously, no gatherings, no protests, no trade, no returnees from overseas, no family reunion,Greg Hunt. Federal Minsiter for Health
I think the term elimination is a worry because if you eliminate an infection, everybody’s expectation we can go back to normal. Well I think that’s unrealistic because this virus is around everywhere in the world. For us to think we can keep it out I think is not realistic. Plus I think it is in so many people, particularly in 20 and 30 year old’s that you will have to wait a long time before you can be fairly sure that it is eliminated. Probably a couple of months with no transmission at all. And it think the problem is even if you get elimination in some areas, which we probably have already achieved in Australia I might say, it is so easy for it to come back. If people believe it is eliminated and aren’t continuing to do the practices of hand hygiene, but particularly physical distancing, keeping crowds down inside, when it does come back it will bite you much harder. I think its much more sensible to go for a suppression policy. It may well cause elimination eventually because if you look at most of Australia, we have very low levels and probably elimination in most of Australia and without doing the hard lockdown that Victoria did. You can argue that the hardest lockdown has had the poorest results. Do you go with an even harder lockdown for longer? There were even community outbreaks occurring at the beginning of May which was still when there was a lockdown in Victoria. I’m very sceptical well be able to achieve elimination anyway. The costs socially, ecomonically and everything else are substantial and I don’t think it guarantees were not going to get a problem again in the future.Professor Peter Collignon, 7:30 July 15
Mostly about posturing?
New Zealand implemented an eradication strategy without requiring a single one of the ‘would mean obviously’ requirements raised by Greg Hunt.
These arguments seem to be unjustified just defending a position.
To complicate matters further, the Prime Minister then on July 24 added:
The suppression strategy that we have been working to nationally now for many many months from the outset, the goal of that is obviously, and was[sic] always been no community transmission.Prime Minister Scott Morrison: July 24, 2020.
There will always be cases the come because Australia has not shut itself of completely from the world, to do so would be reckless. But no community transmission, the vast majority of states and territories have been at now effectively for some time, and that is certainly where we want to get back to in Victoria and New South Wales and that is where our efforts are focused.
This seems to contradict other statements. It seems the goal now is eradication of community spread, which is generally described as ‘eradication’. However, despite claims this was always the goal, it is the first time official policy has stated eradication being a goal. The main lesson to be learnt from comparing Victoria with other states, is that eradication is far better than tolerating even a small number of cases.
So why not declare the policy of ‘eradication’ more clearly? Or at least declare the boundaries for suppression: where the low level is eradication?
Lack Of Conviction?
Another interpretation of government thinking based on the arguments for ‘suppression‘ by Greg Hunt and Peter Collington, is that no matter how desirable eradication, there is a fear of failure in terms of achieving and maintaining eradication. Stating ‘suppression’ as a goal, provides an excuse for failing to achieve or maintain eradication. The problem with this lack of conviction on the need for eradication, is community complacency.
Cases Rise: Predictable?
Victoria: Measures Ineffective?
There could be temptation for me to claim ‘just as predicted’, except the prediction may have been obvious as it is fact that at any given point in time, the next 2-3 weeks usually fairly easy to predict: unless circumstances changed during the previous 2 week, the current trend will continue. Of course, the trend did continue. The highlighted areas simply continues the previous spread rate. Steps were put in place starting around July 1, and it is only now (July 20) that those changes would be starting to have any real impact.
Now updating the post 3 day later (July 23). Lockdowns should be having their impact, and the impact is ‘containment’ and not driving cases back down. It does seem that the city limits as a boundary does work, but the lockdown has not been as successful as the earlier lockdown.
- exit lockdown and let cases skyrocket
- remain in lockdown until there is a vaccine
- find a way to make lockdown effective
NSW: Deja Vu?
NSW is now in very much the same situation as Victoria was 4 weeks earlier. One difference, there is a source of new cases even if all ‘clusters’ can be eradicated: the imperfectly locked Victorian border. Unless something different happing in NSW in the next 4 weeks than happened in Victoria in the last 4 weeks, there will soon be two states in the same situation: indefinite lockdown.
Lockdown Announced in Key Melbourne Postcodes (June 30)
Within two days of my feeling concerned that Covid cases in Victoria were likely to spiral out of control as the government would be rsistant to re-introduce lockdowns– it was announced ten key postcodes in Melbourne would enter lockdown! I was wrong about whether the government would react… but unfortunately not fully wrong. People from the locked-down areas were allowed to leave the area for:
- for reasons of employment: to go to work
- for study or education (school/university)
- for shopping
While in the lockdown area measures may be sufficient, the easy rules on traviling from within the lockdown to outside creates a risk or spreading infections to areas without necessary controls in place.
To me, it seems logical that while behaviour to reduce spread is in place in the locked down areas, it seems very likely that people from those areas will bring infections to areas where there is no lockdown, and thus nothing to prevent spread rising in new areas.
Lockdown Expanded: July 5.
It did not take long for before it was clear the lockdown required expansion. Hopefully the problem was that the wider spread occured prior to lockdowns commencing, as the same ‘ringfence’ provisions are now in place for the expanded lockdown.
Housing Towers Lockdown: July 6
The nine towers involved are now closed and residents are required to stay in their homes at all times. This will be in place to ensure we can test every single resident. The lifting of this restriction will be determined by our success in testing and tracking this virus.Health and Human Services: July 6
NSW-Vic Border ‘Closure’: July 9
NSW announced the border with Victoria would ‘close’ after July 8. However, like the lockdown of specific postcodes within Melbourne, the border has major leaks with respect to being ‘closed’. Most to the NSW-Victorian border is defined by a major river that historically was a major transport link as well as a source of water, which resulted in many principal towns or cities of the area being located on the river. As a state border, the river divides these towns technically into ‘twin towns’ with a ‘town’ each side of the border, but the reality in each case is a single community spanning the border. Essential services are generally not duplicated. People cross the border multiple times per day to go to school, work, visit local stores. or the doctor, hospital and other key medical services. This means many locals to the towns require exemptions that allow them to cross the border, as drivers of freight. The border is restricted, but spread between states is lowered rather than prevented. If there is are cases on the Victorian side of a border community, it is highly likely to infect someone on the NSW side, who is free to move around the state. There is also potential ‘leakage’ due to need to move freight between the two states.
Melbourne Lockdown extended to be Citywide: July 9
Making the lockdown citywide addresses the problem that postcodes do not provide practical lockdown boundaries.
Victoria (Melbourne, mandates mask wearing): July 22.
Announced July 19, to come into effect midnight July 22.
Residents in Metropolitan Melbourne and the Mitchell Shire will soon be required to wear face coverings in public or risk a fine, as Victoria extends its state of emergency by another four weeks.Abc
Payment to Address Non-Compliance: July 23
Victoria has announced a $300 support payment for people who have to isolate after being tested for coronavirus, after record-breaking days of new case numbers.ABC
Melbourne Lockdown, ‘the stick’: July 24
To address the problem of people testing positive and then becoming uncontactable.
Australia’s Victoria state will send in the army to question people who have tested positive for COVID-19 as it battles to control an outbreak that claimed a record number of lives on Friday.Jakarta post.
There are two major problems:
- Vague Government Policy
- Non Compliance with Isolation Requirements.
The question of vague government policy comes down to the political strategy of being vague to appeal to the widest audience backfiring. Clear policy is needed, and even if the label ‘suppression’ kept, it needs to become ‘suppression to eradication’. While people feel lockdowns will end without the need to eliminate community spread, a more lax culture is likely to result.
Then there is the question of non-compliance. How do you get people to self isolate in the lead up to being tested, test as soon as possible and then continue isolation until test results arrive. And then if positive, continue in effective quarantine! I suggest ‘the stick’ is not the answer, and will add an additional post on this topic. The solution to this problem would be at least helped with clear policy, but given the importance, that is not all that should be done.