Victoria’s medicine: is Daniel Andrews asking the state to swallow too big a pill?

Something close to normal life won’t return in Victoria until at least October 26, with curfews lifted, home visitors allowed, and restaurants and cafes open — though this is contingent on case numbers dropping to less than five a day on average. 

New infections continue to fall: this morning, Victoria recorded a 10-week low of 41 new cases.

But experts are divided over whether such harsh restrictions are the right way forward, whether elimination is feasible, and if lockdowns are the way to do it.

Is Victoria’s strategy essentially elimination? 

Victoria is calling its strategy “aggressive suppression”. But under Victorian Premier Daniel Andrews’ plan, Victorians won’t get to enjoy “COVID-normal” until there are no new cases for 28 days straight.

That looks a hell of a lot like an elimination, rather than suppression, Australian National University professor and infectious diseases physician Peter Collignon told Crikey.

“The final stage is basically no community transmission for 28 days,” Collignon said. “I think that’s very difficult to achieve, and I don’t think that’s sustainable.”

Deakin University epidemiology chair Catherine Bennett said the goal of complete elimination was farcical — especially with daily flights arriving into Australia. 

“We won’t pick up every COVID-19 case,” she said. “There’s always the risk you have asymptomatic cases, and cases arriving from abroad.”

Waste water testing, for instance, has found COVID-19 in Victoria’s Apollo Bay, where there have been no recorded cases. 

“But we can shut down local transmission … especially if we sort out aged care and health care transmission,” Bennett said.

Does science support the restrictions? 

World Health Organization expert Dr Maria Van Kerkhove has said blanket lockdowns are no longer the preferred response to COVID-19 outbreaks — calling them a “blunt, sheer force instrument”.

Instead, she said, countries needed to adopt a “tailored, specific, localised” approach. 

In the same vein, Bennett said Victoria’s broad rules ignored epidemiological data. 

“I’m surprised we’re staying with a strong blanket approach to lockdown. The approach could be more specific,” she said.

“We have rich data we could base restrictions off on where transmission happens most.” 

Outbreaks have most commonly be reported in residential aged care settings, workplaces, educational facilities and healthcare facilities. 

Victoria uses the number of new daily COVID-19 cases, averaged across 14 days, as the key to lifting restrictions. This approach has also been used in Denmark.

Other Australian states did not make their lifting of restrictions contingent on specific case numbers.

New Zealand used the likelihood of community transmission to determine restrictions.

Bennett stressed that flexibility was key to enforcing Andrews’ plan. 

“According to the road map, if regional Victoria still has four cases on average, metropolitan Melbourne has no room to move … We need a nuanced approach to enforcing the steps. There’s still a bit of work to do.”

But University of South Australia biostatistics chair Adrian Esterman told Crikey that Victoria’s data painted another picture. 

“If anything, Victoria should have gone harder. In hindsight, they should have gone into stage four lockdown when they went into stage three,” he said. 

“Lockdowns have worked, and we’ve seen it work … I think Victoria is doing the right thing. Cases have dropped substantially.” 

In contrast, Grattan Institute’s health policy expert Stephen Duckett said restrictions should be less specific — not more. 

“The good news is the road map aims for zero,” he said, though added it was more complex than necessary, with some criteria based on politics over science. Curfews, for example, have a weak evidence base. 

“Simpler is better for criteria,” he said. “In the meantime, we need to ramp up testing.”  

But Victoria’s success also relies on good, quick contact tracing. That’s an area where Collignon says Victoria’s record has been “really poor from the start” compared to the rest of the country, the result of a highly-centralised and under-funded public health structure. Even now, Victoria has cases from weeks ago without a known source of transmission.

NSW, overseas tell a different story

Still, Victoria’s plan seems more draconian than any other state in the country. Under the plan, NSW, which has so far managed a low but steady number of new infections, would still be locked down.

“NSW is in a different situation, they don’t have the levels of community transmission that Victoria’s got, they haven’t have the kind of numbers we’ve had to move through,” Victorian chief health officer Brett Sutton told ABC News Breakfast this morning. 

“Wherever there are grumbling cases that just continue along, there’s always a risk of it taking off again, is it did in South Korea, in Singapore.”

But Collignon said the NSW approach, to accept and manage low-level community transmission until an effective vaccine is widely available, was more sensible and realistic.

“I reckon a good strategy is to have suppression down to really low levels,” Collignon said. “And by doing that, you’ll get elimination in some areas.”

New Zealand appeared to lead the way in COVID-19 elimination — for more than 100 blissful days, the country recorded no locally-acquired cases of COVID-19.

That all changed on August 11, when a new case emerged in Auckland and quickly spread to a cluster, forcing the city back into lockdown. 

Taiwan and Fiji both successfully pursued an elimination strategy, though have had limited numbers of imported cases.

Collignon said the outbreaks in New Zealand and Victoria — jurisdictions which both favoured an elimination approach early on — added to the growing body of international evidence that managed suppression was a more sustainable approach than hard lockdowns.

“Hard lockdowns haven’t correlated with medium- to long-term success,” he said. “Look at Japan, look at Korea. Meanwhile, New Zealand and Victoria had the hardest lockdowns and not necessarily the greatest success.”

South Korea, cited by Andrews and Sutton as a cautionary tale about opening up too early, did not go into lockdown when cases started rising again in late August. Instead, churches, outdoors rallies, nightclubs and bars were closed. Since August 27, daily case numbers have continued to fall.