Winter Greetings from Australia: Good Tidings of Comfort and Joy
Australia is an island continent, situated in the Southern Hemisphere and home to 25.5 million people. At least 10% of Australia’s gross domestic product (GDP) is spent on health with annual growth in health expenditure in the last decade ranging from 2-8%.1 In contrast, with a population almost 13 times the size of Australia’s, the United States (USA) spends 17.7% of its GDP on healthcare.2 Regardless, Australia and the USA have traditionally adopted similar strategies and public health measures for preventing and mitigating the risk of infectious diseases among their populations. For hospital-based infection control this has been the case for at least the last 25 or more years.
What’s in a number?
In a recent publication3, the Centers for Disease Control and Prevention (CDC) provided a fine example of how northern and southern hemisphere seasonal experiences with infectious diseases, in this case influenza, often provide the other with early insights into their likely next season. The authors noted substantial reductions in circulating influenza virus in three Southern Hemisphere countries during their traditional peak winter influenza periods during 2020.3 The exact reason(s) for these reductions are less clear with the authors suggesting increased community-based infection prevention measures such as home-based lock-down, social distancing, mask wearing and increased hand hygiene were probable contributing factors. Importantly, they also note reductions in the overall number of influenza tests and increased influenza vaccination may have also influenced presentations of patients with respiratory illness and positive cases.3
During Australia’s winter season of June to August 2020 there were a total of 536 laboratory confirmed influenza cases in Australia compared to 164,643 for the same period in 2019.4 The dramatic reductions in 2020 influenza cases were first evident in March and have continued through to December. On December 1, 2019, Australia had 309,154 laboratory confirmed influenza for the year. One year later the total number of 2020 laboratory confirmed influenza cases is 21,266.4 This reduction coincides with periods of increased infection prevention measures and restrictions in community, education, commercial and healthcare settings.
Early Infection Prevention Measures Implemented
In an effort to inspire colleagues in the Northern Hemisphere the remainder of this blog briefly outlines the key SARS-CoV-2 prevention measures taken by Australia since its first case which was confirmed on 25th January 2020. It is hoped that lessons learned from the 2020 Australian SARS-CoV-2 Winter may give encouragement, hope and support to our colleagues in the USA as they face similar challenges.5 Data is current as of the 2nd December 2020.
An expert in Australian healthcare public policy and analysis, Professor Stephen Duckett describes the first four months of Australia’s SARS-CoV-2 response as a five-phase model:
- reassurance amid uncertainty
- cautious incrementalism
- escalated national action
- transition to a new normal6
Containment efforts included a country-wide ban on Chinese arrivals, increasing controls for persons arriving from countries reporting, and by mid-March all international arrivals were subjected to automatic two-week self-isolation — which was strengthened to mandatory quarantine.
Self-isolation required passengers arriving from international destinations to remain at home, unmonitored and separated from other occupants for 14 days. Non-hospitalized SARS-CoV-2 positive cases and their close contacts were also and still are, required to self-isolate. Self isolation of arrivals to Australia was revised and upgraded to 14 days mandatory supervised quarantine typically in a hotel or government defense force facility during the second half of March 2020. Persons in mandatory quarantine were subjected to multiple SARS-CoV-2 tests during their quarantine. In the event of a positive test, quarantine is continued for a further 14 days. This remains in effect and whilst expensive and purposefully restrictive it has enabled the early identification and inhouse containment of SARS-CoV-2 positive cases.6
In early April as supplies of PPE declined and SARS-CoV-2 cases rose, hospitals across Australia were required to immediately suspend elective surgery. This measure was designed to reduce non-essential demand for PPE and to ensure the contingency plans for reducing the demand for Australia’s limited healthcare resources including in particular health care workers and intensive care unit beds were enacted.
By May, with the formal start of the Australian winter just around the corner,increasing cases of SARS-CoV-2 among elderly institutionalized Australians lead to urgent mandates, including the restriction of visitors to aged-care facilities and compulsory influenza vaccination for staff working in these settings. As usual, frontline workers in Australia’s publicly funded hospitals were encouraged but not mandated to undertake free seasonal flu vaccination. This same offer is available to all Australians aged 65 or over from their primary care physician regardless of the patient’s living arrangements.
As a World Health Organization (WHO) member state Australian leaders followed WHO’s advice irrespective of the worsening global crisis; however its impact on the Australian community was mixed particularly as directions from senior Australian politicians and public health experts called for Australians to continue life as normal.
Australia is a federated country and from a public health perspective each state and territory is empowered to manage their own state including stay at home orders, closure of state borders, requirements for social distancing and public gatherings, school attendance, mandatory wearing of masks and opening or closure of non-essential businesses and purchasing of additional personal protective equipment to bolster state PPE stockpiles in the likely event that allocations from the national stockpile would quickly run dry.
The response of Australian citizens to these various measures and strategies varied greatly between states, between generations and even within local communities. Personal and anecdotal observations during March to May confirmed that perhaps the only common belief shared by Australians was that toilet paper would inevitably be in short supply. Reports of citizens refusing to comply with state-specific mandates — which in Victoria only included a mandate that anyone over 12 years of age wear a face covering (face mask, scarf, bandana or face shield, later upgraded to a fitted mask) in public spaces .
Each Australian state or territory enacted different pieces of temporary legislation giving the state specific short term authority to mandate specific prevention measures within their relevant Public Health Acts or equivalent. The specific mandates varied across the differed jurisdictions according to the severity of local COVID-19 transmission. Several declared a state of emergency and in doing so enabled enforcement of quarantine measures, restrictions in place and size of public and home gatherings and mandatory use of masks. Enforcement of these laws was in the main undertaken by police or members of Australia’s defence force. Border crossing restrictions were, and remain, common in several Australian states. In many instances these have resulted in the need for increased policing and issuing of fines for breaching such orders. In Victoria the fine for not wearing a fitted mask in public spaces unless a person has a lawful reason is $200 AUD. Refusing or failing to comply with other public health SARS-CoV-2 directions may result in fines between $ 1652-20,000 AUD. In Queensland persons breaching the border restrictions may be subject to an on the spot fine of $4,003 AUD, a court-imposed penalty of up to $13,345 AUD- or 6-months imprisonment. Despite the financial and court-imposed penalties, some Victorians breached (or continue to breach) orders. Thankfully, compliance by the vast majority has resulted in Victoria’s first five consecutive days of zero SARS-CoV-2 cases since early 2020. This is a major milestone for Victoria and the entire country.
The Winter Months: How Australia fared
Over the Australian winter, community transmission of SARS-CoV-2 continued. As of 12/02/2020, there have been 223 SARS-CoV-2 outbreaks across the country, with 2,027 residents (in Australian aged care homes) effected and 678 deaths. Additionally, there were over 2,200 aged care staff infections.7 .
To date, Australia has 27,912 confirmed cases of SARS-CoV-2 from the more than 10.02 million tests conducted. More than 20% of those cases were acquired overseas, another 16% were locally acquired and just over 63% of all cases were contacts of a confirmed case. The total number of Australia SARS-CoV-2 deaths is 908.8 The total number of infected healthcare workers in Victoria is thought to be around 3,577.9
Very few, if any, usual pieces of PPE are manufactured locally in Australia. Many of these items are manufactured in China or South East Asia and distributed via large multinational corporations typically based in North America. Representing less than 1% of the global health market Australia’s appeal as an infection prevention market is unquantified despite being — a long-term contributor to global infection prevention initiatives and currently one of a few countries leading the much-needed development of a SARS-CoV-2 vaccine.
Insufficient supply of high-quality PPE, lack of pre-SARS-CoV-2 mask fit testing and overwhelming unprecedented demands on frontline healthcare workers have characterized Australia’s 2020 winter SARS-CoV-2 experience10. In Victoria, the only Australian state to experience an unrelenting second wave of SARS-CoV-211, despite the efforts of a robust infection prevention community, saw a 12% surge in cases affecting Victorian healthcare workers.
What have we learned?
Possibly the only brightness from the 2020 SARS-CoV-2 pandemic is the confirmation for infection preventionists that mitigation measures based on confinement and containment work. For Australia,, it clarified that standard measures such as the availability and correct use of appropriate, quality PPE, as well as an increase in hand hygiene, along with separation of cases and non-cases, can be effective. Further the dramatic and obvious reductions in Australian influenza in 2020 compared to 20194, even without vaccine uptake data, most likely showed that increased influenza vaccination coverage combined with other measures for preventing respiratory and airborne spread are among the best measures to prevent transmission of SARS-CoV-2.
The still unresolved determination of whether SARS-CoV-2 is spread more efficiently via the droplet or airborne routes continues to baffle healthcare workers. It undermines their confidence and willingness to follow infection prevention measures and potentially places believers and disbelievers against each other. Now is not the time for distraction or disharmony. It is instead a time when every infection preventionist, in fact every healthcare worker, must unite and stand firmly beside each other offering ongoing empathy, compassion and hope. Until a safe, effective SARS-CoV-2 vaccination is available globally, we only really have each other and as the US buckles in for its SARS-CoV-2 winter, may the sun that exists over both our hemispheres provide at least a little ray of sunshine.
(data provided as of December 8, 2020)
- Australian Institute of Health and Welfare [Internet]. Canberra: Australian Government; 2020. Health expenditure. 2020 Jul 23 [cited 2020 Dec 02]. Available from: https://www.aihw.gov.au/reports/australias-health/health-expenditure
- Centers for Medicare and Medicaid Services [Internet]. Baltimore: U.S. Centers for Medicare & Medicaid. National Health Expenditure Data: Historical. 2019 Dec 17: Centers for Medicare and Miedicaid Services,; 2019 [cited 2020 Dec 02]. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical#:~:text=U.S.%20health%20care%20spending%20grew,spending%20accounted%20for%2017.7%20percent
- Olsen SJ, Azziz-Baumgartner E, Budd AP, Brammer L, Sullivan S, Pineda RF, et al. Decreased Influenza Activity During the COVID-19 Pandemic – United States, Australia, Chile, and South Africa, 2020. MMWR Morb Mortal Wkly Rep 2020;69(37):1305-9.
- Department of Health [Internet]. Canberra: Australian Government; 2020. Number of notifications of Influenza (laboratory confirmed), Australia, in the period of 1991 to 2019 and year-to-date notifications for 2020. 2020 Dec 02: Australian Goverment,; 2020 [updated 2nd December; cited 2020 Dec 02]. Available from: http://www9.health.gov.au/cda/source/rpt_3.cfm
- The Commonwealth Department of Health [Internet]. Canberra: Australian Government; 2020. First confirmed case of novel coronavirus in Australia. [Media release] 2020 Jan 252020 [cited 2020 Dec 02]. 25 January 2020:[Available from: https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/first-confirmed-case-of-novel-coronavirus-in-australia
- Duckett S, Stobart A. Australia’s COVID-19 response Part 1 of 2: the story so far. [unknown]: John Menadue; 2020 [cited 2020 Dec 02]. Available from: https://johnmenadue.com/stephen-duckett-and-anika-stobart-australias-covid-19-response-part-1-of-2-the-story-so-far/
- Department of Health [Internet]. Canberra: Australian Government; 2020. COVID-19 outbreaks in Australian residential aged care facilities – 27 November 2020. 2020 Nov 27: Australian Government; 2020 [cited 2020 Dec 02]. Available from: https://www.health.gov.au/resources/publications/covid-19-outbreaks-in-australian-residential-aged-care-facilities-27-november-2020
- Department of Health [Internet]. Canberra: Australian Government; 2020. Coronavirus (COVID-19) current situation and case numbers. 2020 Nov 30 [cited 2020 Dec 02]. Available from: https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers#cases-by-source-of-infection
- Paul M. Victorian doctors say some hospitals yet to complete coronavirus respiratory protection plans. ABC News [Internet]. 2020 Nov 1 [cited 2020 Dec 02]. Available from: https://www.abc.net.au/news/2020-11-01/melbourne-hospitals-covid-respiratory-protection-plan-ama-warns/12835728
- Muhi S, Irving LB, Buising KL. COVID-19 in Australian health care workers: early experience of the Royal Melbourne Hospital emphasises the importance of community acquisition. Med J Aust 2020;213(1):44- e1.
- Blakely T, Thompson J, Carvalho N, Bablani L, Wilson N, Stevenson M. The probability of the 6-week lockdown in Victoria (commencing 9 July 2020) achieving elimination of community transmission of SARS-CoV-2. Med J Aust 2020;213(8):349-51 e1.