EXPERT REACTION: South Australia to begin 6-day "circuit breaker" lockdown

Well, here we go again! Whether this turns out to be a major spreading incident for COVID-19 in South Australia or, with considerable inconvenience, stress and expense, a containable disease outbreak - this will be the pattern for the foreseeable future unless there is a new strategy for quarantine testing and containment.

Australia has been relatively untouched by COVID-19 so far (not to minimise the misery and mortality for those families) in stark comparison with the unfolding international pandemic catastrophe and the unique global medico-economic coupling to this disease. The comparative safety of Australia so far is due to its relative isolation more than its’ medical excellence, although that absolutely exists and is contributing in many ways to solving the world COVID-19 problem.

This comparative “safety” has led to complacency in populations that have not been severely affected, and there is a push to reopen for business as quickly as possible that is felt everywhere. We all want normal back. But take a look at Europe and the USA right now to work out the cost of trying to behave normally in the middle of a pandemic. The disease abroad is rampant and getting worse, safe and approved vaccines are still many months away at best, and distribution problems at scale will limit global availability of vaccines in many countries for years.

Currently, the testing approaches and isolation paradigms are weak (a global problem) with far too many false-negative test results. Thus a new scientific and coordinated quarantine logistical strategy is required if the borders are to open and Australia is to stay safe. Such approaches do exist, at least at the technical level, such as orthogonal phenotype conversion testing for the early specific biochemical effects of the virus rather than its direct physical presence (developed in our own laboratories with international collaborators). But these tests are probably most effective when the case numbers are relatively small and we are trying to keep them small. The UK is now spending hundreds of millions of dollars on novel testing and tracing technology, but this has all come too late and the virus is out of control again.

If the Government wants to open borders safely, then it needs to invest properly in testing and tracing using novel technologies and translational research programs integrated into the healthcare system and to do so with an agility that has so far eluded most governments. Australia is still in a better position than most countries to avoid the worst of the future pandemic turns, but the current lockdown solutions will not hold for too long and the virus will break through repeatedly until this is done. Politicians are looking at the disease in the context of their next election dates, COVID-19 is going to be around and threatening us for a long time beyond any elections and it has the potential to become a global endemic disease i.e. here forever… We need to avoid that if at all possible and that means more science, timely investment in medical research and agile translation into practice.

South Australia’s COVID-19 quarantine outbreak mirrors the previous Victorian quarantine outbreak but hopefully with early aggressive intervention will be brought under control rapidly. However, it does raise serious questions about the lax infection control policies around workers in contact with infected people in quarantine. These workers given their high risk of exposure should be properly trained and treated in the same way as “contacts” – hence they should be self-isolating from fellow family members when not at work and should be regularly tested to ensure they are not being infected.  Another concern is the number of infected individuals in hotel quarantine in Adelaide hotels reported to be 19 active cases inside the city’s hotel quarantine facilities - more than a quarter of Australia’s total.

These individuals may have different strains of COVID-19 coming from all over the world depending where returning travellers came from.    The more positive virus cases there are in hotel quarantine the higher the risk one virus will break out and cause an outbreak.  Not surprisingly the most contagious virus of the 19 potential different strains in the infected hotel  guests would be the one most likely to break out and cause an outbreak.   This is a form of selection pressure and explains how pandemic viruses tend to evolve into ever more infectious and easily transmissible strains over time.

Once again this highlights the need for an effective COVID-19 vaccine that could be used to ring fence and help control such outbreaks, rather than have to lock down an entire city.  Vaxine’s Covax-19 vaccine was shown to prevent nasal virus shedding in the ferret infection model (manuscript in preparation), suggesting it could be beneficial in stopping virus transmission as well as preventing clinical disease.  Transmission blocking vaccines are what is urgently needed to curtail such outbreaks and ultimately end this pandemic.  Unfortunately not all COVID vaccines are equal in this regard with neither of CSL’s government-funded vaccines from University of Queensland or Oxford demonstrating an ability to block nasal virus replication in their published animal data

The unique challenge of a six-day lockdown of metropolitan Adelaide will test both urban and social resilience. Heed needs to be taken to avoid the missteps in Victoria, particularly with key messages to culturally and linguistically diverse population groups with limited English language and health literacy.

The national communication plan initially provided ‘timely, factual and consistent information’, which in the short term encouraged the public to comply with and adopt behaviours 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; wear a mask for some activities but ok not to for others) led to confusion and lack of trust in our mandated leaders.

Over one-third of Metropolitan Melbourne residents speak a language other than English at home with disparate levels of language, media and health literacy. The Victorian Government was slow in including key community leaders at the local level in the implementation of the communication strategy.

Faced with the evolving 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 requires time for community leaders to sufficiently educate their communities to ensure compliance. Governments have a responsibility to minimise uncertainty through risk minimisation resourcing central to the needs of diverse language groups.

With sanctions of a 6-day restriction, the social mindset is ill-prepared for this sudden prohibition. Key stakeholders led by the government now have a crucial role in the maintenance in supporting the societal and urban resilience, to avoid uncontrollable social dislocation well beyond the impact of COVID-19.

It is hard to know where to start apart from that they are doing the right thing. That being said it probably should be 14 days. Furthermore, their testing and contact tracing needs to be fully in gear to get ahead of the curve.

Advice to students:

“To be resilient and help others be resilient during lockdown, manage your thoughts, your relationships, and feelings. Your thoughts are under your control – focus on the good and the things that you can change. The media can make you feel more negative about events. Consider how much media you consume, the type of media, and your use of social media can make your thoughts more negative. Watch where your thoughts are going and make choices.

Make a plan to invest in relationships that matter and be intentional. Each day, plan to send out texts, emails, or make phone calls to connect with people. A word of encouragement can be a great investment in someone’s life. It is also important to ask for help and support if you need it. People would love to support you if they knew you were lonely.  

It has been a long and difficult year for many people. It is okay to feel worried, frustrated, and/or intolerant. Feel those feelings but then go and do something useful. Going over and over negative feelings will make you feel worse. Become the master of feeling and then shaking it off and looking for the good in life.

The early decision to lockdown and recommend masks is a wise one that may prevent a much larger epidemic and save further pain and more prolonged lockdowns than would be needed if things spiral out of control. In Victoria we saw a more measured response that started with expanded testing, then localised lockdowns, and finally widespread lockdowns when it became clear the epidemic was far more widespread than originally suspected. I think the Victorian approach was reasonable at the time, as they wanted to spare people a total lockdown and see if it could be controlled with more localised measures. Localised lockdowns were used successfully in South Korea, for example.

However, SA has utilised the lessons from Victoria and gone with an early lockdown. I think this is an excellent strategy that may result in a return to freedom much sooner than a wait-and-see approach, but should also be accompanied by a mask mandate - people can make face masks at home, so supply should not be a problem. The recognition that substantial transmission is possible from people with no symptoms or minimal symptoms is supported by the scientific evidence, and is a strong argument for a mask mandate.

These measures are especially important given we are close to the end of the year, when risk of transmission will increase due to festive celebrations. The one concern I have is the limited testing capacity currently, with people reportedly waiting for hours in lines to get tested, and people deemed “worried well” being turned away. This should be urgently addressed and anyone who presents for testing should be tested, without delays. Testing must be made easy and accessible, or there is a risk infected people will not be identified. I note the comments about an apparently short incubation period of the virus - it is unclear if there is genetic data showing some change in the virus, but it is possible infected people have been exposed to a very high dose of virus, such as during a super spreading event, which may also shorten the incubation period. A short incubation was also seen at the Crossroads Hotel outbreak in Sydney.

Preventing Panic Buying 

Ongoing vigilance and preparedness have proven to be essential qualities in limiting the spread of the COVID-19 virus. It has been noted with concern that panic buying of consumables returns with every new outbreak. A 3x3 coordinated approach can help build public awareness and reduce panic buying as Australia continues its adaptation to living with COVID-19.

1. Before an outbreak occurs: 

• Regularly remind the population to keep fridges, freezers, and kitchens well-stocked.
• Regularly ask supermarket chains to report the stock of essential items.
• Create a task force to regularly discuss the flow of essential items.

2. In the case of an outbreak: 

• Automatically announce buying restrictions on essential items, shopping hours for the elderly, deliver to home options.
• Inform the public about actions taken and the current stock of essential items.
• Prioritise the flow of essential items.

3. After the outbreak: 

• Revert to the actions from ‘before an outbreak occurs’.
• Discuss improvements in the emergency response based on feedback from industry, government, universities, and the public.
• Work with the press to build a resiliency culture with the public.

Vigilance is key, recognising the importance of public psychological safety and the need to promote effective actions to support the transparency and resilience of supply chains in Australia.

The lockdown in South Australia is needed to control the outbreak but it includes closing schools. School closures are harmful to children and families. We have found this is Victoria. The action by the South Australian Government to close the schools highlights that all states and territories need to have a plan to keep schools open and be adequately prepared in the event of an outbreak, which for COVID, can happen at any time. It is vital that schools are kept open.

Based on the international literature and what we saw in Victoria, this can be done. Iceland beat two waves with schools remaining open. Ireland is in lockdown but based on the advice of the Victorian CHO, kept schools open and already the case numbers have dropped by 75 per cent in one month. School mitigation strategies need to be developed in advance and be dialled up or down depending on the degree of local community transmission. Closing schools in South Australia should have been avoided if a pandemic plan that involved the Education sector was developed in anticipation.

Over the last couple of days, there were a number of cases of COVID-19 identified in Adelaide, SA. The cluster appears to be originating in the hotel quarantine hotel, similar to the recent outbreak in Melbourne.

It is worth noting that it took three months of harsh lockdown measures to get the Melbourne outbreak under control. South Australia appears to have an effective tracing and isolation strategy with only two new cases reported today. Nevertheless, the proposed lockdown for six days will allow further extended testing, identification and isolation of infected individuals to take place. This will likely stop this outbreak from spreading further in the community and will hopefully prevent the need for further extended lockdown measures, such as the ones that were necessary in Melbourne.

The idea of locking down hard and early is most likely the correct one for two reasons. Firstly, it limits the viral spread in the community and secondly it allows for much more effective contact tracing, identification of active cases and isolation of affected individuals. This will most likely result in a much-reduced number of exposed individuals which in turn will stop this outbreak from becoming more widespread.

Our research, and other similar studies conducted in Australia during prior lockdowns, have shown that the lockdown experience is associated with a decline in emotional well-being for many people (e.g., Rogers & Cruickshank, Newby et al., Fisher et al.).

Therefore, for those about to enter the current lockdown in South Australia, if you are experiencing negative thoughts during the experience, please be aware that this is a typical response, and you are not alone. In our research (i.e., Rogers & Cruickshank), we found that people who kept up their social interactions with friends and family fared better during the lockdown period than those who did not.

There is an array of communication technologies (e.g., phone, email, social media) that you can make use of to keep in contact with your friends and family. Based on the research, we encourage you to support others during this time, and allow others to support you as well, to get through this current lockdown experience together.

This lockdown was always on the cards. The two key reasons for triggering a lockdown are a rapid increase in cases that would swamp the contact tracing team, or some cases with unknown contact, the 'mystery cases'. It is the first reason that has triggered this new move. Clearly, SA Health are concerned about the case-load on the contact tracers. Short, sharp lockdowns can and do work, and the SA Government is making a very sensible move to try and crush this outbreak so that people can have a half-normal Christmas.

The lockdown aims to successfully bring this small outbreak under control and prevent wider community transmission. The fast response from South Australia to impose this lockdown gives a greater chance of eradicating the virus from the community before it becomes established.

Stopping further spread of the virus will also buy time for contact tracers to identify persons who have been in contact with those infected in this outbreak. A short lockdown now will lower infection rates, avoid overwhelming the health system and likely avoid a longer lockdown.

South Australia is going hard and fast to contain the COVID-19 outbreak. A 6-day lockdown has quickly been implemented, which appears to have learnt from the Victorian experience. Travel, work, education and recreation are all being limited with a plan to relax these in 6 day if all goes well. The plan differs a little from Victoria in the speed of implementation and less of a focus on judicial enforcement. Care will need to be taken to ensure the social, emotional and financial supports are being implemented just as quickly, with input from a broad group of advocates on these supports, the restrictions and how they are implemented. We must use safe practices with compassion. South Australia has ramped up testing and tracing and this is producing results. The effort of South Australian citizens cannot be understated in how they have responded. Details on how South Australia will protect those in health facilities are needed as we do not want to see a repeat of the 3000+ worker infections that occurred in Victoria. Protecting health care workers protects those they care for and the wider community.