EXPERT REACTION: Melbourne returns to stage 3 restrictions

Though Victoria's rise in cases is very concerning, the stage 3 restrictions have worked previously to bring numbers down.  And Victoria is in a much better position to manage this spike than it was in March - with good testing, trained contact tracing staff, international border controls, and other public health infrastructure now in place. However, we should expect a lag of 5-10 days before numbers drop substantially, and a few weeks before good control returns.

The problem we’re facing is that the increase in cases across Melbourne now is the result of what happened about 10 days ago, due to the virus’ long incubation period, and this roughly coincides with when restrictions were lifted.  

One could argue we’re still in the first wave because we’ve protracted it by suppressing the curve through lockdown measures earlier this year. However, this has given us the time to get our health services ready, prepare for increase hospitalisations and intensive care cases. Because of the delay in symptoms and disease manifesting, it may be another week before we see the corresponding increase in cases that require hospitalisation.  

Historically, the New South Wales and Victorian state border was closed during the 1919 Spanish Flu outbreak. We’ve been there before. As a country we need to close this down as much as is practically possible so we can reduce the infection across the rest of Australia. How effective these measures will be remains to be seen, but it will certainly help minimise further transmission in the community. The virus hot spots we’re seeing now is something that we knew was coming, and it could easily be another part of the country or state in this position. We need to remain vigilant against this virus given how persistent it is in the environment.

The unique challenge of a six-week lockdown of metropolitan Melbourne will test both urban and social resilience. The public can reasonably query – ‘why so long’?; where is evidence that this period of time is effective in controlling the pandemic?; How will the Government recover the economic cost as a result of this social sanction?

The national communication plan initially provided ‘ timely, factual and consistent information’ which in the short term encouraged the public to comply with and adopt behaviors to mitigate the spread of COVID-19, and whilst well-intentioned lacked the flexibility and  targeted communications as required.

In Victoria, ‘message’ and ‘compassion’ fatigue and lack of resilience among sectors of the population, compounded by contradictory messages from Government (“constrain social behaviours, but it is ok to mass protest”) led to confusion and lack of trust in our mandated leaders.

With 38% of the Metropolitan Melbourne residents speaking a language other than English at home with disparate levels of language, media and health literacy,, without the alleged inclusion of key stakeholders such as community leaders at the local level in the implementation of the communication strategy; with the amplification of ‘the infodemic (or mis/disinfodemic) challenge it is not surprising that the national communication plan did not sufficiently meet the needs of large numbers of people, vulnerable to infection due to dense living habitats.

Faced with the evolving uncertain and emergent nature of the COVID-19 threat the overall governance of the city is fundamental to urban resilience. The  abrupt  lockdown of habitats of our inner-city populations and allegations that  community leaders were not consulted to sufficiently educate their communities has fragmented this resilience, and deepened stigmatisation.

Governments have a responsibility to minimise  uncertainty. As Cheshmehzangi (2020) states, ‘Education of resilience is as important as city operations… prioritis[ing] broad consultation to create a sense of share ownership in decision making’. With sanctions of a 6 week restriction the social mindset is ill-prepared for this lengthy prohibition. Key stakeholders led by  government now have a crucial role in the maintenance in supporting the societal and urban  resilience, to avoid uncontrollable social and economic dislocation well beyond the impact of COVID-19.

For people with mental health issues, the mantra of ‘staying at home’ may trigger elevated feelings of uncertainty, anxiety and panic. They will be feeling even more isolated that they would ordinarily, and this will likely lead to feelings of immense uncertainty and sadness.

I do not believe that the current strategy will be enough to contain the outbreak in Victoria. Furthermore it is likely that despite border controls it will spread to other states. Once community transmission takes hold, it is almost impossible to control the spread with the currently implemented measures. The good news is that the health systems in Victoria and other states are sufficiently prepared to deal with the probable influx of symptomatic patients in the near future.

Lockdowns and movement restrictions will only be partially effective and further actions are required to minimise the spread of the virus. In my opinion, the most effective, and so far largely neglected strategy, is universal wearing of masks in public. This should be implemented immediately and will certainly enhance the current strategies. It was well understood and accepted by the scientific community and general public that complete elimination of the virus is not possible. “Flattening the curve” was always the aim and I feel that it was successfully achieved to allow the healthcare system to cope. The current outbreak in Victoria is but the first of many to come and we need to learn how to live with this virus until an effective vaccine or cure is found, which will take months and possibly years, if ever.

The situation is extremely serious, and we have seen outbreaks in a wider area over the past week, from north-west Melbourne, to inner Melbourne and even at the border in Albury-Wodonga. The surge in cases to 191 today despite the measures taken over the past week is worrying. It is possible there has been seeding of infection to other states, and silent epidemic growth which has not yet been detected. I would not be surprised to see epidemics detected in NSW and other states within the next few weeks. The situation we are in is more serious than late March, because we have community transmission, which is much harder to track than infection in returned travellers.

The Victorian government has done all the right things and made considered, difficult decisions which will help contain the growing epidemic. 

It is not an option to take the Swedish option - that has been a failure, and they failed abjectly to achieve herd immunity, because they followed a pseudoscientific theory that was never achievable. All they achieved was preventable deaths and hospitalisations and reports of alleged euthanasia of infected old and frail people.

Individuals should also do their bit for the country - it is easy to ignore the pandemic because we have been fortunate in Australia, but the reality is grave. People all over Australia must accept the gravity of the situation and play their part - that includes downloading the COVIDSafe App, maintaining physical distancing, wearing a face mask and getting tested if they think they may be infected or at risk. It’s time we adopted community mask-wearing and provided people with positive and constructive messaging on using masks. In states that are not affected, it may make the difference between needing a lockdown versus not, in the near future.

We also have to protect the health systems and make sure our health workers are left standing to care for the sick. This has been one area we can do better. A large epidemic could overwhelm the health system and leave many nurses and doctors infected or even dead. One infected health worker could result in hundreds being quarantined and reduced workforce capacity.

Q: Will this (along with the border closure between NSW and Vic) be enough to contain Victoria’s cases?

"Yes – I believe it is the right move. The big decision was whether to apply the restrictions to the whole of Victoria, or just Melbourne. Since the outbreak is pretty much confined to Greater Melbourne, their decision is sensible."
 
Q. Is six weeks long enough - or too long?

"Based on the success of the original three step lifting of restrictions, six weeks is reasonable, certainly not too long. Restrictions could be lifted earlier if the situation warrants it."
 
Q. Should this impact the relaxation of restrictions in other states and regional Victoria?

"No – COVID-19 is pretty much eliminated elsewhere. However, a careful eye will have to be kept on regional Victoria to make sure that the outbreak has been contained.

The border closure with NSW will do nothing to improve Victoria’s case load but may reduce spread from Victoria to NSW. However there is no scientific evidence that blocking movement of people between two infected states reduces overall disease burden. Hence border closures remain a highly controversial issue in such cases.
 
It is a different story for border closures between states and/or countries that have no COVID-19 and those that do, as obviously a single infected case crossing the border could reintroduce the virus to an otherwise virus free community that consequently doesn’t need to socially isolate. This might apply for example if allowing an open border between a virus-infected state such as Victoria and a virus free state such as South Australia – making closure of that border easier to support on a scientific basis. It is particularly relevant if both adjacent states wish to operate different levels of restrictions based on what they know about the virus in their population. Allowing free movement of people increases the uncertainty factor.
 
It takes 2-3 weeks just to see if the restrictions are having a major impact on cases loads, and a few more weeks after that to see suppression of virus spread to negligible levels. Hence from a practical and scientific perspective 6 weeks is likely to be close to the minimum period for an increase in restrictions to be fully effective. Of course the period of the restrictions may be able to be shorter if combined with other control measures such as intensive testing, quarantine of infected subjects, mask wearing, use of disinfectants and ultimately application of vaccines.
 
Each state is different in terms of amount of cases and level of virus spread and hence each state is likely to make decisions based on local data rather than just follow the lead of a badly affected state.
 
Ultimately, the COVID-19 outbreak will only be brought fully under control in Australia and globally with availability of an effective and safe vaccine. Our vaccine candidate is the first developed in the Southern hemisphere to enter human clinical trials last week, with a readout on the current trial expected within the next 2 months. With appropriate support there is no reason that a COVID-19 vaccine cannot be developed and made available before the end of this year. This could then be used to target hotspots such as those currently occurring in Victoria using a strategy of ring fencing to bring the outbreak under control. Indeed, as soon as the Phase 1 safety and immunogenicity data is shortly available there is no reason that our vaccine could not be used in an experimental setting by Victoria in just such a manner, with this ring fencing approach being taken in recent years to confirm the effectiveness of Ebola vaccines.
 
It is not true that there is no evidence of an effective coronavirus vaccine – there is a commercial vaccine against cat coronavirus, and our group and others have also demonstrated effective vaccines against SARS and MERS coronaviruses. Whilst all these other coronavirus vaccines have not yet been tested in humans, there is no scientific reason to believe they would not be equally effective in humans as they have already been shown to be in mice, ferrets, monkeys and alpacas (the model we used to show a MERS coronavirus vaccine could be highly effective). The Australian Department of Health needs to get briefed on the solid science that supports the effectiveness of coronavirus vaccines.

It is hard to say if this will be enough to contain Victoria's cases. The success of these measures will hinge on individuals personally following what is required of them, and government agencies making these clear for all. It appears that poor communication of these requirements and individuals, either knowingly or unknowingly, not following the required precautions have caused this increase in transmission.

Six weeks is a good place to start as we know that it will take 2 to 3 weeks to see if these actions limit or reduce community transmission. Once that is ascertained, changes in restrictions can be considered. Other jurisdictions should be carefully watching the situation in Victoria and planning for the possibility that they may see cases increasing. While they are seeing a stable situation it is reasonable for restrictions to ease given that importation of cases from Victorian hotspots should be limited. Regional Victoria should continue at the current level until it is shown that community transmission is limited to metropolitan Melbourne.

Q: Will this (along with the border closure between NSW and Vic) be enough to contain Victoria’s cases?

"Hopefully yes. We know full lock down was effective last time, so it is highly likely to be effective again." 
 
Q. Is six weeks long enough - or too long?

"We know that there is a delay between the intervention and the response. So 6 weeks does make a lot of sense. It needs to be long enough to a: stop further infections and b: long enough for people who have the virus to recover and not be contagious."

Q. Should this impact the relaxation of restrictions in other states and regional Victoria?

"At this stage no. However seeing how rapidly this cluster has taken off may require other states and territories review their response plans. We are in a situation that we will get further clusters. How we respond and quickly we respond to these clusters is critical.

Q: Will this (along with the border closure between NSW and Vic) be enough to contain Victoria’s cases?

"We certainly hope so. If we all follow the advice and limit our activities and keep social distancing then we should be able to suppress transmission as we have done previously." 
 
Q. Is six weeks long enough - or too long?

"What we don’t want to do is to go down this path and to lock down for too short a time so that we don’t get on top of transmission, and of course we don’t want to lockdown any more time than is necessary. This seems like a sensible length of time to get on top of transmission."

Q. Should this impact the relaxation of restrictions in other states and regional Victoria?

"It shouldn’t affect what happens in other states, although it should act as a stark reminder that we are not over the pandemic and it should highlight how quickly things can turn.