Healthcare capacity and the economic ramifications should be considered when making choices on localised or state-based lockdowns, writes Katarina Milovanovic, Dr Shannen Higginson and Dr Francesco Paolucci.
Is your postcode poised for a lockdown?
As metropolitan Melbourne entered Stage 4 restrictions from 2 August 2020, with restrictions for regional Victoria including Mitchell Shire in place from 5 August 2020, the rest of Australia awaits in suspense — who is next?
The reintroduction of second wave restrictions in Victoria was made in response to significant increases in community transmissions, with suburbs forced into lockdown with gradually increasing restrictions.
Victorians are limited to essential activities with an added curfew on the timing and reasons that people can leave home, while businesses that were able to resume operations on 1 June were forced to close or limit trade of goods and services once again.
As the economy slowly returns to normality, increases in COVID-19 cases can be expected. Imposing restrictions, however, may benefit from using indicators such as ICU capacities and COVID-19 health-profile data that are now available.
Initial lockdowns aimed to prevent the spread of the contagion and reduce both social and economic costs while buying time to prepare our healthcare system for anticipated COVID-19 hospitalisations and ICU admissions. These measures were implemented at a time of significant uncertainty surrounding the severity and spread of COVID-19.
Improving lockdown decisions
Although decisions to reintroduce Stage 3 and 4 restrictions were driven by the number of cases, we can now incorporate significantly expanded ICU capacity into decision-making. Since the start of the pandemic, Australia’s highest ICU admissions were in the A.C.T., which peaked at 15% of existing ICU capacity. Considering surge capacity, ICU admissions have remained below 3% as seen in Victoria, South Australia, Western Australia and the A.C.T.
Table 1: Highest number of COVID-19 patients in ICU compared to bed capacities.
On 1 July, as Victoria started to reimpose restrictions, the state had two COVID-19 patients in ICU and a maximum of 51 patients admitted to ICU on 11 August; to gauge the perspective that a median patient stay in ICU is eight days, we erred on the side of caution and estimated a ten-day moving average that again showed us that we are far below the 499 ICU beds Victoria had before COVID-19 and even further below the expanded COVID-19 capacity of 1,166. This gives us insight into the significant preparation of our healthcare system to meet demand.
Victoria has a 0.9% positive test rate
Testing capacities have also increased since the COVID-19 outbreak. In Victoria, the expanded testing criteria and volumes have enabled 2,224,887 tests to be completed by 31 August. On 5 August, Victoria recorded the highest number of confirmed COVID-19 cases at 693, on the day that an average of 18,002 tests was completed (with an average of over 20,000 tests per day since 29 June).
Despite having 16,964 cases in Victoria as at 28 August, the Victorian positive test ratio has mostly remained below 1% since 4 May. The careful consideration here is that increases in testing will likely identify more cases of both symptomatic and asymptomatic persons; if you look for it you will find it.
Case numbers not a reflection of COVID-19 severity
It is to be expected that increasing test numbers are associated with increased case numbers; what is interesting is that we aren’t seeing equally increasing case presentations to hospitals or ICUs. This is likely because the 20-29 age group experiencing the highest rate of infection can more likely stay at home and recover without medical support. It could be that the infection-to-hospitalisation rate is lower than the originally anticipated 4.3-8.6% that was modelled by the Doherty Institute to inform transmission reducing measures and health system preparedness.
Factors such as testing, healthcare system capacities, along with the new information known about the demographic and health profiles of COVID-19 confirmed cases all need to be considered in strategic plans designed to provide economic support while containing transmission.
The decision to reimpose restrictions based on the number of COVID-19 cases can be improved, particularly now that we know a great deal more and are far better prepared for the virus. Lockdown decisions can have a strong basis on ICU capacities, in addition to case numbers, as our healthcare system has greater capacity. Restrictions are incredibly costly on all outcomes — health, employment, international trade and education and more; careful consideration is of the essence.
Each pandemic requires a unique response
This is the first human coronavirus in history that significantly affects the 40+ age group. Targeted policies that keep those who are more likely to be impacted by COVID-19 can be considered before implementing widespread lockdowns. This is to avoid “blanket” policies affecting Australia’s youth disproportionately to prevent an increase in the intergenerational gap.
The youth unemployment rate is double the national rate, consequently impacting the compounding nature of superannuation contributions. Differential policies integrating age and co-morbidity specific measures could more effectively tackle this virus.
Leveraging our primary health networks
Implementing such a targeted policy that encourages people over the age of 40 or people who have co-morbidities that place them at higher risk of mortality (such as obesity, heart disease or asthma) could be aided by GPs. Based on medical history and potential risk, a GP could issue a medical certificate requesting home-based work, or that pre-emptive sick leave is needed.
Australia has the opportunity for even greater leadership on this issue
Taking on board such foresight and diligence, decisions to lockdown should be jointly based on epidemiological data, economic implications and healthcare system capacity, taking into consideration potential hospitalisations and ICU admissions.
Katarina Milovanovic is a Master of Economics graduate from The University of Sydney and Company Director of Epione Advisory. Dr Shannen Higginson is a PhD candidate in Health Economics at the University of Newcastle, NSW, Australia. Dr Francesco Paolucci is Professor of Health Economics & Policy at the Faculty of Business & Law, University of Newcastle and the School of Economics & Management, University of Bologna.
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