New South Wales’ latest roadmap to recovery outlines a range of freedoms for fully vaccinated people in the state when 80% of people aged 16 and over are vaccinated.
Unvaccinated people will remain restricted, but will have the same freedoms by December 1, when 90% of adults are expected to be vaccinated.
The easing of restrictions will come in three stages, at the vaccination threshold of 70%, 80% and 90%, with many restrictions dropped by December 1.
This includes relaxing the density rule from 4 square meters to 2 square meters in most interior rooms; and no indoor mask is mandatory in most locations except public transport, airports and reception staff.
The problem is that other countries like Israel have already tried to rely primarily on vaccines to ease restrictions – and have failed, albeit at lower vaccination levels than NSW is targeting.
Vaccines alone may not be enough to protect against the highly contagious Delta variant.
So who is most vulnerable under the current plan, and how should the plan to reopen NSW change to protect these groups and the general population?
Read more: NSW risks second larger COVID spike by Christmas if it eases restrictions too quickly
Vulnerable group 1: children
About 20% of the population is under the age of 16. The target of 80% adults matches less than 70% of the overall population, leaving plenty of room for Delta to spread.
One in three children aged 12 to 15 has received a single dose of the vaccine, but it may be next year before this age group is fully immunized.
1.2 million children under 12 in New South Wales will not be vaccinated. This is the largest group of the unvaccinated. With no requirement for unvaccinated elementary school students to wear masks and no plan to ventilate classrooms, epidemics will almost certainly occur.
In the United States, counties with school mask warrants had much lower rates of COVID among children than counties that did not require masks. An unvaccinated teacher who took off her mask to read in an elementary school classroom has infected 26 people.
While children get a mild infection compared to adults, about 2% of children with Delta are hospitalized. Of these, some will need intensive care and a proportion will die. This becomes more apparent when there is high community transmission and a high number of cases in unvaccinated children.
The Doherty report estimates that 276,000 Australian children will be infected in the first six months after reopening in the most likely scenario, with 2,400 hospitalizations, 206 intensive care admissions and 57 child deaths during that time.
Vulnerable group 2: Indigenous people
Indigenous communities in New South Wales are particularly vulnerable to epidemics, contract COVID and contract serious illness.
There are relatively more children under 12 in Aboriginal communities, leaving a much higher proportion of the community unvaccinated.
We saw during the Wilcannia epidemic that a high proportion of cases involved children.
Read more: COVID in Wilcannia: a national disgrace we all saw coming
Despite this, vaccination rates in indigenous communities continue to lag by around 20% compared to the rest of New South Wales.
Allowing unlimited travel in these communities before vaccination rates are high enough to provide protection can be disastrous.
Vulnerable group 3: regional NSW
Remote and regional communities are also vulnerable, due to the decline in health services and difficulties in accessing care.
An outbreak would disproportionately affect the regional NSW.
Vulnerable group 4: people with disabilities
People with disabilities, many of whom have significant health problems, are also at high risk.
Vaccination rates for New South Wales participants in Australia’s National Disability Insurance Scheme are around 14% behind state rates, although they are a priority in the national rollout.
In the UK, 58% of COVID deaths in the UK were among people with disabilities. People with intellectual disabilities were eight times more likely to die from COVID than the general population.
Vulnerable group 5: people with cancer and other conditions
Adults and children living with cancer and other conditions that suppress the immune system may have a weaker response to COVID vaccines and may need a third dose.
Read more: Why is a third dose of COVID-19 vaccine important for people with compromised immunity?
The need for a third booster dose in susceptible people is recognized and programs to administer it are underway in many countries.
Some vaccinate specific groups: the US and UK provide boosters to all people 65 and 50 and over, respectively.
Others, like Israel and many European countries, start with the elderly and the immunocompromised and then include the rest of the population.
Australia has yet to formulate such a plan.
Children under 12 with cancer (not yet eligible for vaccination) also deserve to be protected, with vaccines and / or other measures to stop the spread of COVID in the community.
The consequences of overwhelmed health systems on the timely diagnosis and treatment of cancer and other serious illnesses are already visible in New South Wales.
A layered plan for a safer reopening
The vaccines currently available alone will not be sufficient to control Delta. We will need layered protection including safe indoor air, testing, tracing and masks to continue our lives freely when the blockages are lifted.
Here is what we offer:
1. Implement vaccine targets for groups at risk
We need to ensure that no disadvantaged group is left behind and that vaccine targets are met for all of these groups.
For Aboriginal people, we recommend that the targets of 85-90% be met.
For other groups such as people with disabilities, especially those living in collective settings, higher vaccine targets should also be considered.
Read more: Immunizations must reach 90% of First Nations adults and adolescents to protect vulnerable communities
2. Make indoor air safer
NSW needs a plan to tackle indoor ventilation because the virus is airborne.
This has happened in Victorian schools before and should be a big part of lifting restrictions in New South Wales.
Read more: From vaccination to ventilation: 5 ways to protect children from COVID when schools reopen
The plan should ensure that homes, businesses, schools and other public places have healthy indoor air, and that the community is knowledgeable about clean air as well as hand washing, so that people are empowered to mitigate risk in their own home.
3. Maintain high testing and tracing rates
We need to maintain high testing capacity, make rapid antigenic testing widely available, and improve contact tracing capacity.
Suggestions to stop reading the QR code and thereby reduce the contact tracing ability are wrong and will lead to a resurgence of the infection.
We do regular contact tracing for all serious infections such as tuberculosis, meningitis and measles, and we need to continue this research for COVID-19.
4. Schedule booster doses
We must also tackle the decline in immunity due to vaccines and be proactive about booster doses, especially for people with reduced immunity or who are immunocompromised, and for healthcare workers.
For the rest of the population, there is sufficient real evidence that protection begins to decline as early as five to six months after vaccination.
We urgently need to address this issue for health workers and other priority groups such as elderly care residents, who were mostly vaccinated six months or more ago. This is not only for their own safety, but also to prevent the collapse of the health system due to understaffing due to illness or burnout.
Avoid future confinements
In the post-lockdown world, NSW will likely face a Delta resurgence if multiple restrictions are relaxed simultaneously, as we’ve seen in overseas countries.
Letting go of most restrictions is also likely to result in repeated stop-start lockout cycles, caused by strain on the healthcare system as cases increase.
Only stacked and combined protections will offer a safer and longer-lasting chance of reopening until we wait for the promise of second-generation vaccines, boosters, and smarter vaccine strategies.