Coronavirus Report 61: Australia's third wave, NSW Part 1

 

Australia's Third wave, NSW. Part 1.

Australia is the only country in the world to have suppressed two substantial outbreaks of the dangerous Covid-19 respiratory disease - the original Ruby Princess fiasco spreading from New South Wales (NSW) in March 2020, and the hotel quarantine failure in Victoria in July 2020. It suppressed both by brute-force total lockdowns in the China style. Since then, as shown in Chart 1,  it has stopped many small hotel quarantine outbreaks with an increasingly sophisticated trace-and-test apparatus. 

Chart 1. Australia's three waves 2020-21

Given that Australia has continued to accept around 5000 returning citizens a month from parts of the world wracked by coronavirus, it is a marvel that over 18 months it has managed to restrict coronavirus cases to around 30,000 - less than some small island communities like Hawaii, Malta, Cape Verde and Trinidad. 

Total coronavirus deaths in Australia have been below a thousand. Each one has been a tragedy, and the mortality has been unacceptable, almost double the lives lost in the Vietnam War. However it is less than the larger European and American countries were suffering in a single day at the peak of their coronavirus epidemics.

From June 2021 however, Australia has been subject to a dangerous outbreak of a new more infectious variant, which mutated during the huge Indian outbreak in April. At the time, the suppression of the 2020 waves had been widely regarded as touch-and-go and something of an exemplar to the rest of the world. Could it be possible Australia could manage a third time? Especially when assisted by much more sophisticated tracing, and a partial vaccine rollout that is now reaching most of the elderly population? 

This draft report describes the first seven weeks of Australia's third coronavirus wave - the one that might finally penetrate the defences of Fortress Australia and might show that a serious new global human respiratory infection may at best be delayed, never stopped. It expands and extends the coverage up to July 2 in the earlier report Pandemicia #59.

The Bondi Cluster

On 16 June 2021, NSW's first case of the highly infectious Delta variant of Covid-19 was detected. Patient Zero, a Bondi limousine driver, had become infected carrying unspecified flight crews to overnight shelter. He was neither vaccinated, wearing a mask nor being tested regularly - nor did he need to under regulations. On the previous six days he and family members had shopped in the large Bondi Junction shopping centre, and around Vaucluse, an expensive eastern suburb. 

NSW had been described by Prime Minister Scott Morrison (also LNP) as "Australia's Gold standard" with relatively limited lockdowns and strong contact tracing. "That is where we have to get everybody to to ensure that Australia can be open", he said. NSW had preparedness on its side. "They've had a proud history of many, many years of advanced investment in public health … they've had embedded public health units in all their local health districts. They've had very good outbreak response teams".

By 22 June there were 22 confirmed cases in this Bondi Cluster, with numbers increasing at about 5 per day. 

One of the more significant results during the first phase was the first clear evidence of 'fleeting transmission' - and possibly the first time anyone had been observed actually catching Covid-19. Surveillance video in a Bondi Junction shop followed a customer who subsequently tested positive briefly walking past an infected person for five to ten seconds. Several others are suspected to have done the same in the shop. 

The South West cluster - superspreaders

The current epidemic really began to get moving once it passed into the lower income regions of the city where there are large families, many immigrants, and 'key workers' on casual pay, quite often working multiple jobs to make ends meet.

Uncontrolled outbreaks of Covid-19 generally begin with several sequential superspreader events, which move too fast for contact tracers. Overnight on 22 June, 13 new cases were reported, as the epidemic moved to the west of Sydney, into Liverpool and Bankstown. These cases were associated with a birthday party superspreader event, where almost everyone became infected except for six fully vaccinated health workers. The carrier, a man in his 30s who works in Bondi Junction, had not attended any venues of concern, was asymptomatic when he attended the party and was tested immediately after developing symptoms.

On 23 June, with 31 cases, the Health Minister issued a first round of restrictions in Greater Sydney to cope with the 'emerging outbreak'. These included wearing masks indoors, no singing or dancing, limited gatherings and a 'person per four square metres' space rule in venues. People in LGAs in the east (where the cases were then concentrated) could not travel outside of Sydney. 

However, five other LGAs in the west soon became the focus for the disease. As a community member said, "A lot of people from this area aren’t very wealthy. Most are working for every meal, or working a loan off. Everyone is in a very tough situation. Some people need to work every day to earn their living."

From 26 June, stay-at-home Level 3 lockdown orders were placed across the city. People in the Greater Sydney Metro Area could only leave home for the usual four reasons - shopping, medical/care, exercise (group of 10) and 'essential work' that could not be performed from home. People were instructed not  to enter Greater Sydney.

On 9 July, with nearly 500 cases, the Premier Gladys Berejiklian defended lockdown, saying that with low vaccination and the rapidly spreading delta variant, there would be 'thousands of thousands of hospitalisation and deaths' without lockdown. Restrictions became much tighter with exercise only within 10 km of home and only two people exercising. Nobody from outside was allowed into a house. Only one person was allowed to leave home for shopping and no browsing for goods was allowed. Tradesmen leaving the five critical LGAs in the west had to be tested every three days - causing massive lineups in various testing centres. By this time over 50,000 people were being tested daily - and over 100,000 by the end of July.

But despite the lockdown and ramp-up in tracing, daily cases continued to rise steadily - by over 7 per cent per day, as Chart 2 shows: a slow exponential rise with new cases doubling every 9-10 days. This appeared to indicate larger outbreaks of the Delta variant could not be stopped by non-pharmaceutical interventions. An editorial in the Murdoch flagship the Australian said that if lockdown was not working it should be discontinued - but of course this would only result in a massive jump in the daily increase to the usual unconstrained 30% a day. 

* it should be made clear that while a 7% daily rise is 'slow' it will eventually have a similar impact as a 30% rise, it just provides extra time and lower maxima in cases and hospitalisations. From Pandemicia #60, new cases in Malaysia were rising at 6% up to mid-July and Indonesia at only 2% per day, yet complete disasters ensued.

Chart 2. Daily cases NSW, to 28 July

It took until 18-19 July, with a total of 1400 cases, before NSW forced closure on non-essential retail enterprises and paused construction – something which Victoria had done for most of its long lockdown in 2020. The range of shops that could open remained quite large, NSW had always taken a fairly relaxed attitude to lockdown, and left the definition of ‘essential worker’ to employees and businesses. Now only well-defined categories of essential, health and emergency services workers could leave the 'red' areas. These workers needed to test every three days, regardless of whether they had symptoms.

On 23 July, a 'shock and awe' press conference was held, in which the NSW Premier stated that lockdown was not working. Two more LGAs, Cumberland and Blacktown, were now 'red' zones. A national state of emergency was under way, she said, and NSW was asking other States to donate their vaccines (they all subsequently refused). 

Others pointed out that many critical national supply chains were in the affected region, which held more workers than Perth or Adelaide. By leaving it locked down the whole country would be affected. 

On the positive side, the epidemic in Eastern Sydney had largely disappeared, proving Delta really could be suppressed with a good tracing system, sufficient vaccination, work-from-home, and compliance with controls. 

As pressure built, criticism began to arise of the handling of the situation, some saying the State government had not acted quickly enough, while anti-lockdowners sniped for discontinuation of lockdown altogether.

Sydney infection map 1 August - showing very low numbers in original locations to the east, and heavy concentration to the west and south west along major transport corridors.

In truth, Western Sydney was now heavily locked down. From 1 August the army was deployed to assist in policing, doorknocking those who were supposed to be in quarantine and issuing fines for failing to wear masks. Drones were employed to check for people without masks. 

Chart 3. Hospitalised Covid cases in NSW up to August 7

From Chart 3, hospitalised cases rose at least as rapidly as positive tests, though cases in ICU remained relatively flat during the last week. Almost all of these were unvaccinated so this was probably because vaccinations were moving ahead of infections. 

Five people died on 4 August, including one in his twenties, and another 5 on each of the following days. Five patents had died in Liverpool hospital after being infected by a staff member. Following the closure of a large 10-storey apartment block in Liverpool, Gladys Berejiklian all but conceded NSW would not reach her earlier target of 'zero cases circulating in the community', stating that the State would "now have to live with Delta". This was a substantial about-face in Australian Covid policy. 

According to the Prime Minister, "living with it" would mean having low-level L1 rules such as social distancing almost indefinitely, as it was going to be very hard to meet Doherty Institute targets of 80% vaccinated to trigger the national strategy for opening.

Spread beyond Sydney 

Spread along transport routes

In New South Wales, as the map shows, the spread outside Sydney followed the major land transport routes to the south, west and north. These smaller outbreaks could be stopped by contact tracing and quick lockdowns. A small outbreak in Orange to the west carried by twin removalists and a truck driver caused a temporary lockdown, which was lifted by August. The mother of the removalists was found dead at home soon afterwards on 19 July, only three days after testing positive and the fifth death of the NSW outbreak. 

In Newcastle, the second city of NSW, Pfizer vaccinations, including those for priority workers, were cancelled and redirected for use by Year 12 students in Sydney. "The hell you have to go through to get the appointment in the first place and then all of a sudden it's gone," one Newcastle resident said. 

A few days later the virus was detected in Newcastle sewage. A gathering on Blacksmith beach, on the narrow strip between Lake Macquarie and the coast, was the source of infection for five students in three schools and a university student. This may be the first fully confirmed case of an outdoors superspreader event. 

Stay-at-home orders were extended to the Hunter and Upper Hunter regions on 5 August and all non-critical businesses were closed. Hundreds of people  who attended a busy Lake Macquarie shopping centre on 12 July were isolated. Several cases attended emergency at the John Hunter Hospital in Newcastle, provoking controls. Cases had increased to 26 in the Hunter-New England region by 7 August.

[It turns out the infection spread from Sydney was actually by a young woman who took a train to Newcastle, was stopped by police and told to return, but continued and went to two parties and various other establishments in Newcastle, spreading Covid-19 as she went. By 13 August Hunter cases were 102] .

With cases having extended to regional NSW, coronavirus soon jumped further by 9 August. Two cases were recorded in Armidale, which was locked down, as were the Tamworth and Byron Bay regions. About 80% of the NSW population is now under restrictions.  Traces have also been found in sewage in Dubbo and Mudgee.

Interstate Delta outbreaks

Chart 4. Victoria new cases, May-August

In Victoria, an earlier outbreak of Kappa variant (closely related to Delta) was probably brought in by a Sri Lanka traveller in hotel quarantine in Adelaide. About 60 people were infected in Melbourne's north. At the same time a family who had travelled to Jervis Bay were found to be infected with the Delta variant. In Chart 4, cases in the "West Melbourne cluster' rose rapidly up to 26 May and plateaued, but in a familiar pattern, cases soon fell and both outbreaks were quashed by late June. 

However, interstate incursions of COVID-19  'embers' from NSW in July produced more than 75 exposure sites, around 1500 primary close contacts and more than 5000 secondary close contacts. 

Melbourne red and orange sites 1 August

A trio of removalists left Sydney on 8 July and left a trail of infection across three States, travelling through Melbourne to South Australia. They infected a family of four in Craigieburn when they dropped off their furniture, and a Coles Cragieburn cluster developed. Tenants of Ariele Apartments in Marybyrnong were forced to lock down for a fortnight after the removalists picked up a second load. Ultimately, 11 cases were notified after a family breached quarantine, and a second period of complete isolation in the apartments ensued. 

Ten cases notified on 14 July led to a fifth lockdown on 15 July, while other States and New Zealand closed their borders to Victoria. All travellers from NSW were subsequently required to isolate, and these were checked by defence personnel. This lockdown concluded on 27 July, with schools and venues re-opening. 

The opening was premature and cases rapidly began to rise again. Hundreds of anti-lockdown supporters took to the streets of Melbourne on 5 August, when a sixth lockdown (of seven days) was declared in Victoria following 12 cases in metropolitan Melbourne who had wide community contact. Some 5000 people were already in quarantine. 

The following day, a record number of cases for 2021 were registered, with three schools infected. It was soon found that there were two separate Delta outbreaks in Melbourne's west. One was known as the Hiobsons Bay cluster, and stemmed from a teacher in Al-Tacqa college (where there had been a significant outbreak of 200 cases in 2020) and her partner - with 28 linked infections, a number in the school. The other came from a warehouse worker in Marbyrnong in the inner NW, with seven infections.  

Coronavirus was detected in wastewater across the east - probably indicating considerably more cases to come. Greater Melbourne was declared a COVID hotspot for purposes of Commonwealth support. However, despite 29 cases in Melbourne, the lockdown in regional Victoria will be lifted tomorrow (August 9) as there had been no cases. 

In Queensland, a cluster in South Brisbane expanded substantially with 27 new cases on 5 July, while most of SE Queensland was locked down from 31 July till 8 August. Twelve thousand quarantine notices were active, mostly in Brisbane and the Gold Coast, and there were 122 active infections on 5 August, half in hospital. More than half of those infected were children or teenagers, and almost all were already in quarantine when they tested positive. 

As well as an expansion in land cases, seaborne cases on bulk container ships off the Queensland coast were common. A LNG tanker from Korea on which eleven of the crew was infected was held off the coast of Gladstone (fortunately, almost all the crew were vaccinated) - "one of many ships that we've had to deal with over the past 18 months with COVID on board". A week earlier, 19 crew out of 21 had been found infected on a Philippines bulk carrier off Weipa. 

 South Australia also called a seven-day lockdown on 20 July. A total of 22 cases were associated with the "Modbury Hospital cluster" before restrictions began to be lifted on 5 August.

Tasmania recorded its first Covid case in 238 days, though 30 people have been in hotel quarantine around the State. The man flew in from Sydney via Melbourne without a valid pass, was taken straight to quarantine and tested, then opted to fly home without receiving his results, which were positive.

Vaccination

Australia has come under heavy criticism for being almost the least vaccinated country in the OECD, as Chart 5 shows. One might argue that it was actually the other countries that showed unseemly haste in adopting largely untested vaccines and rolling them out at lightning speed - but fortunately for them the vaccines did work. Full vaccination reduced the chance of becoming infected by over 70% in practice, and most significantly, lowered the hospitalisation and death rates by over 90%. 

Chart 5. Vaccination rates, countries to August 6

To some extent Australia was the victim of its own success where vaccines were concerned. In other countries where coronavirus had become endemic, vaccines were the only choice to prevent hospitals being overwhelmed and the death rate from ballooning - so they were prepared to tolerate any expense, and their leaders directly contacted big pharma companies to ensure millions or even billions of doses became available. 

Australia was able to take a more leisurely approach, sending out relatively junior officials to cut deals while trying to ensure most of the vaccines were made in Australia by CSL. ABy June 2021, Australia even had the luxury of laying down a plan where the county would be progressively opened as theoretical vaccination targets were reached - see Pandemicia #59.

Like all the best military plans, this one did not survive the first few weeks of combat. From very early in the present wave, governments became concerned that lockdown would not work for Delta - though this was never exactly articulated. They pushed rapidly to accelerate the vaccine rollout in one of the largest logistical exercises in Australia's history. 

First, the Commonwealth caused great confusion by overturning medical advice that Astrazenica should have a three-month gap between first and second jabs, and that under-50's should use the (unavailable) Pfizer vaccine because of rare adverse effects of Astrazenica. Second, a very much wider range of clinics opened, with distribution through bulk centres and pharmacists rather than GPs (only about 300 pharmacies are involved so far). Third, direct representations were made to Pfizer to bring forward and increase supply. Fourth, a deal with cut with Moderna to introduce their vaccine. 

Full vaccination levels Sydney 1 August

By August, "all bets were on the vaccine". Weekday vaccinations in NSW rose from about 45,000 in June to about 90,000 in late July, and six million inoculations had taken place. Nationally, as of 7 August over 50% of over-70s were fully vaccinated and 80% had the first dose - while for 40-70 year olds, the figures were about 20% and 50%. Very few under that age were vaccinated. Overall, only about 17.5% of the eligible population were fully vaccinated, much greater than five weeks earlier when it was 4.7%, but still among the lowest in the OECD (Figure 5). 

As the epidemic has continued, resistance to vaccination has fallen rapidly in NSW. In May, 34% were hesitant,  but this has fallen rapidly to 14.6%. This makes reaching the 80% vaccination target a real possibility.

Spatial inequality has been very evident in the takeup of the vaccine. The wealthiest areas of Sydney and Melbourne had the highest vaccination rates, as shown in the map, whereas the poorer areas with key workers where it was most needed had low levels. 

Age care

As elsewhere, over two-thirds of total coronavirus deaths in Australia since 2020 have been in aged care. Most aged care residents have now been vaccinated, but only a third of staff - many of whom are in a demographic that may carry the disease widely. 

One might imagine that age care would be among the most heavily protected and secluded parts of the community, especially during an epidemic that disproportionately affects the aged. However, once the epidemic reaches the demographic from which age care workers are drawn, it almost immediately passes into private residential age care centres, within which it spreads quickly. The situation is much improved over the 2020 outbreaks, but it has been not been assisted by the general failure to vaccinate age care workers, although residents are now mostly vaccinated.

Summitcare

By 4 August, there were 26 confirmed cases in residents of age care facilities in NSW and three in Victoria. There were 15 active cases among staff on 30 July. The main outbreaks were at Summitcare in Baulkham Hills, where five workers and six residents were infected, and in Wyoming Residential Aged Care Facility in Summer Hill, where 18 residents and two staff members were infected. Seven other centres had one or two staff members infected, showing the typical very high incidence of infection among unprotected age care staff. 

Anti-mandate protestors

Misinformation and obstructive opinion by right-wing commentators has almost become a way of life within uncontrolled social media over several decades, and the pandemic has brought this to a head. As elsewhere, a fairly substantial coalition of  business owners and libertarians of otherwise widely diverging political persuasions has opposed lockdowns by continuing to promote 'fake news'. 

Alt-right radio commentator Alan Jones gave extended time to anti-lockdown groups to lambast State governments just when tighter controls were clearly becoming necessary. Senator Concetta Fierravanti-Wells stated on 15 July as Victoria began its fifth lockdown, "People are increasingly getting fed up with lockdowns and the Australian public will look for someone to blame. They’ve seen draconian measures put in place, their liberties removed often in the absence of discussion by parliaments both federal and state." Other 'rogue Coalition backbenchers' such as Christensen and Canavan have been interviewed by alt-right media in the USA.

On 24 July the streets of downtown Sydney were thronged by 3500 protestors against lockdown. Word of the protests was spread through a collection of Telegram, Instagram and Facebook posts, amplified by large anti-vaccination and conspiracy pages that have amassed followings in the tens of thousands - especially the alt-right WorldWide Demonstration group out of Germany. Bottles and were thrown and police horses were assaulted. Police arrested 60 people and promised to identify and fine lawbreakers using the very many videos taken during the occasion. The irresponsibility of running an unprotected protest  during a serious attempt to control Covid-19 was glaring, though the incident may provide a useful test of the limited extent of spread in outdoor events. Larger protests were held in France, Italy and Switzerland on the same day, and again on July 1, though police turned out in force to prevent an Australian repeat. 

Alan Jones continued his stream of misinformation on 29 July, when his Sky News program claimed, "deaths are greater after lockdowns are introduced than before. The deaths are a result of social isolation, drug overdoses, missed cancer screenings, and a whole range of things." (Pandemicia has shown that in fact the reverse is true; lockdowns result in a very substantial drop in deaths from many different causes). He suffered sanctions when Sky News was temporarily banned from Youtube and he  lost his Daily Telegraph column. [A few days later, Sky News removed dozens of videos from its websites denying the existence of the pandemic, promoting unproven miracle "cures" and alleging doctors were conspiring to kill Australians by concealing the "truth".]

Economic response

The two previous outbreaks had been accompanied by the novel $90 billion Jobkeeper program, which paid employers to keep employees on their books with very little oversight. About $25 billion went to organisations who used the money to avoid paying wages, maintaining or increasing their regular earnings or giving out large bonuses to executives. As well, substantial temporary boosts to social benefits and various one-off payments were provided until March 2021.

On this occasion the Federal government offered, as of 20 July

• a Covid-19 Disaster Payment of up to $600 a week for laid-off workers. 
• Pandemic leave of $750 a week for people in isolation

The NSW government has offered business grants from 28 June: 

• A Covid-19 one off grant of up to $15,000
• A micro business grant of $1500 per fortnight to very small businesses
• A Jobsaver payment of 40% of payroll for medium-size businesses
• Payroll tax deferrals and reductions

As in earlier outbreaks, an eviction moratorium for tenants and assistance for landlords to lower their rent levels are in place. Support for accommodation providers and the performing arts is also available.

From 8 July, banks offered 'loan lifelines' and various forms of support for troubled businesses. On 17 July, major banks offered two month deferrals in payments to customers in the heavily locked down Sydney LGAs.

As with the Victorian lockdown of 2020, some small businesses have begun to close permanently. The major air carrier Qantas stood down 2500 staff for 2 months. Much more of this lies ahead as the wave accelerates

The Australian stock market has not been concerned by the current outbreak and continues to rise to new records, as do property values. This is due to a) very free monetary policy b) more rapid introduction of new technology c) big savings by affluent retail investors who work from home and no longer spend money on travel or dining.

Conclusions

The Delta outbreak in Australia has provided a unique field experiment, an opportunity for both tracing the typical spread of an outbreak and testing the efficacy of lockdowns and a fully-developed test-and-trace system. The clarity is possible because Australia was free of the disease prior to the outbreak beginning June 15 (except for steady small numbers among incoming travellers in quarantine and fortnightly small hotel quarantine breaches). 

From Chart 1, the latest outbreak in Australia is small so far, and has risen considerably more slowly than the 2020 outbreaks. Nevertheless the outbreak is of great concern because it is rising exponentially and not flattening or declining - despite considerably greater in applying the various interventions. It raises the question of whether it is actually possible to stop a delta epidemic by the usual 'blunt force' non-pharmaceutical controls - lockdown and trace-and-test. As we outline in the forthcoming technical report, the Ro of the Delta variant is probably too high to bring below 1 by these means, once it is sufficiently advanced.

Another matter of concern is the higher level of infection of children and young people with the Delta variant - 223 children aged under 9 have been infected, and one in four infected are under 20 years old. Greater numbers of younger adults are also requiring hospitalisation, and several have died.

On the positive side, the examples in Queensland, the Eastern Suburbs of Sydney and possibly Victoria  show that a small outbreak of the Delta variant may be suppressed using trace, test and isolate. This is a strong tool in these limited circumstances, especially if assisted by a quick lockdown. The problems arise when the disease moves into populations with a higher level of personal contacts during lockdown or a lower level of compliance to distancing and quarantine - or when random superspreader events carry the disease too broadly and rapidly for tracing to keep up. 

Another positive is that NSW really does have 'gold standard' test-and-trace, and is able to jump upon 'embers' almost as soon as they appear. This makes it possible to lock down only part of the State - whereas early in the pandemic, partial lockdowns as in Italy were mostly unmitigated disasters. nevertheless it cannot be forgotten that the present wave rose only from a single case, and each 'ember' of Delta variant has the potential to do likewise. 

Finally, the high level of surveillance now in place has been able to show several things that have so far eluded researchers. First, a superspreader event has now been observed outdoors, almost for the first time - though it seems very likely the participants around a winter fire were huddling and breaching social distance. 

Second, possibly the first case of transmission of Covid-19 has been directly observed. This supports Pandemicia's opinion since the outset that coronavirus is largely transferred through the air indoors in significant viral load by sufferers during the short period they are most infectious. This was, incomprehensibly, not the consensus opinion of epidemiologists in early 2020, and arguably the main reason why the original epidemic became a global pandemic. 

Popup clinic Bondi, first phase

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