Jus St John

Submission to Independent Review of the Response to the North-West Tasmania COVID-19 Outbreak

My comments and analysis below focus on the North West outbreak. They solely represent my conclusions based on my analysis of the situation.

To provide context in respect of this submission, I live in Somerset on the North West Coast of Tasmania with my family. However, I am employed by the University of Adelaide as a professor and medical researcher where I lead a program of research related to genetics and molecular biology. I primarily work from home in Somerset but, until COVID-19 resulted in the Tasmanian borders closing, I commuted to my laboratory in Adelaide on a biweekly basis where I spent two to three days per fortnight.

I have an active research program funded by the National Health and Medical Research Council (NHMRC) and serve on the NHMRC’s Embryo Research Licencing Committee (a Principal Committee) that is appointed and reports to the Federal Minister for Health. I have had some experience of working with viruses, namely HIV. In my previous and current work, I have used some of the early antiretroviral drugs that were first used to treat HIV. My findings have been published in peer-reviewed scientific and medical journals.

Whilst my laboratory and group members are based in Adelaide, and it has not been possible for me to travel to Adelaide for quite some time, I understand and fully support the need to isolate the Tasmanian community from this very serious and dangerous virus. Indeed, my view is that complete eradication should be a major consideration. Although the first wave has severely affected very many economies in the world, a second wave would result in a significantly greater cost in terms of the health risk and damage to the economy.

From the beginning of the outbreak in the North West of Tasmania, I have been deeply concerned about the level and targeting of the testing program for COVID-19 across the whole of Tasmania. I relayed my concerns to the Premier in four separate emails (dated April 29th, May 8th, May 15th, July 8th).

At the time of the outbreak in North West Tasmania, it was generally accepted that the mean incubation period for the COVID-19 virus (i.e. the time between exposure to the infection and onset of symptoms) ranged from 1.8 to 7.2 days (1). These data are based on 11 studies published before March 30th. The study also reported on two pre-published reports that suggested longer incubation periods.

Incubation will give rise to two types of carriers of the virus, namely pre-symptomatics and asymptomatics. Pre-symptomatics are carriers who will present with symptoms after incubation whilst asymptomatics are carriers who do not develop symptoms or, potentially, do not recognise that they have symptoms. Prior to the outbreak in North West Tasmania, there were published reports of pre-symptomatic transmission in, for example, tight clusters (2) and work environments (3). Furthermore, a news report in the Guardian dated March 20th highlighted how wholesale testing in the Italian town of Vó determined that a large number of infected individuals were asymptomatic (4). The work was subsequently peer-reviewed and published; and showed that 42% of infected individuals were asymptomatic (5). Furthermore, others have shown that infected patients were highly infectious in the first five days after onset of symptoms with a peak on Day 4 (most prolific shedding time point) (6). However, there was usually no replicative virus present after Day 10 of onset of symptoms (6).

Figure 1 in the North West Regional Hospital Outbreak – Interim Report (7) shows there was a progressive build up of symptomatic cases. The report states that a total of 114 people were affected, comprising 73 staff, 22 patients and 19 household contacts (7). The rapid onset and cumulative build-up of cases fall within the mean incubation and post-onset of symptom timeframes described above. Given this knowledge and had on-site testing of all staff and patients across the North West Regional and Private Hospitals been immediately introduced from March 27th onwards, this would have allowed rapid detection of any infected staff and their isolation. This would have avoided the peaks in symptoms reported for April 5th, April 7th, and April 9th to 10th. Furthermore, if Public Health Services had initiated testing from April 3rd, the peaks from April 7th, and April 9th to 10th could have been avoided.

Testing of all staff and patients would have been through the highly sensitive technology known as Polymerase Chain Reaction (PCR), which, if implemented on-site, could have provided results in less than 24 hours. In my laboratory, we can achieve a PCR result within 6 to 8 hours, which is standard practice for most laboratories. This information would have been very useful in determining which, if any, wards in the hospitals should have been shut down and who should have been isolated (both pre-symptomatics and asymptomatics) to prevent the spread of the virus.

Consequently, the rapid testing of all staff and patients would have meant that the transmission within the hospitals would have been significantly reduced and, potentially, a number of related deaths. However, the guidance and approach chosen by Public Health was to apply and primarily focus on the use of contact tracing. This meant that the whole process was reactive rather than proactive. This is not to say that contact tracing is unimportant. It has a vital role to play but in conjunction with testing when outbreaks occur. In the case of pre-symptomatics or asymptomatics, testing would have rapidly identified these individuals and close contacts could have been traced – a proactive approach which would have halted the spread of the disease. In the case of those presenting with symptoms, testing would have confirmed whether the individual was presenting with COVID-19 infection or not; and, if positive, close contacts could have been traced – a reactive approach. This approach takes longer to bring COVID-19 under control and would allow new infections to accumulate as those with symptoms could still continue to transmit the disease in their incubation phase or during the initial phase of being symptomatic.

At the time of the outbreak and for a while after, there appeared to be an ambivalent attitude to testing in Tasmania. Tasmania had achieved the lowest rates of testing per million across the nation as of May 15th (8). However, there was sufficient knowledge to warrant the use of testing from the readily available published medical and scientific literature before the North West outbreak took off with regards to asymptomatic and pre-symptomatic transmission (1-3, 6).

Finally, I find it quite remarkable that the interim report on the North West outbreak was, in part, written by those directly involved in controlling the outbreak. Whilst not explicitly laying blame, the report implied where it lay. The report failed to mention the shortcomings of the authors. This includes the failure to implement appropriate testing - indeed, ’testing’ was only mentioned four times in 29 pages of documentation.

References

1. Kong TK. Longer incubation period of coronavirus disease 2019 (COVID-19) in older adults. Aging Med (Milton) 2020; 3: 102-09 (Only data published prior to 30th March, 2020 cited)

2. Li P, Fu JB, Li KF, Liu JN, Wang HL, et al. Transmission of COVID-19 in the terminal stages of the incubation period: A familial cluster. Int J Infect Dis 2020; 96: 452-53 [Epub 2020 Mar 16]

3. Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med 2020; 382: 970-71 (published on January 30, 2020, and updated on February 6, 2020)

4. https://www.theguardian.com/commentisfree/2020/mar/20/eradicated-coronavirus-mass-testingcovid-19-italy-vo (Publsihed on March 20th, 2020).

5. Lavezzo E, Franchin E, Ciavarella C, Cuomo-Dannenburg G, Barzon L, et al. 2020. Suppression of a SARSCoV-2 outbreak in the Italian municipality of Vo'. Nature 2020 Jun 30. doi: 10.1038/s41586-020-2488- 1. Online ahead of print.

6. Wolfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020; 581: 465-69 (Published online April 1st, 2020)

7. Department of Health. COVID-19 – North West Regional Hospital Outbreak – Interim Report. 29th April, 2020.

8. https://www.theguardian.com/australia-news/datablog/ng-interactive/2020/may/13/coronavirusactive-cases-australia-how-many-new-numbers-today-map-stats-statistics-hotspots-postcode-covid-19- deaths-death-toll. (Published May 15th, 2020).