5. Prevention

Overview

5.1Long COVID only occurs after a COVID-19 infection. If a person has not been infected with COVID-19, then they cannot develop long COVID. As the search for a possible cure for long COVID continues, the Committee recognises that at this stage, prevention is the best way to mitigate against long COVID.

5.2Australia’s healthcare system is jointly run by all levels of government (federal, state and territory, and local).[1] The Australian Government continues to cooperate with states and territories to support the response to COVID-19. In particular, the Australian Government is taking a national leadership role to provide COVID-19 vaccines, facilitate access to antiviral treatments for COVID-19, and support the distribution of rapid antigen tests (RATs).[2]

5.3Throughout the pandemic, the Australian Government recommended various methods to protect people from COVID-19 infection. These methods included COVID-19 vaccination, antiviral treatments for people at risk of severe illness from COVID-19, COVID-19 testing by polymerase chain reaction (PCR) or RATs, mask wearing, physical distancing, hygiene, and guidance about visiting high-risk settings.[3]

5.4The committee received evidence that emphasised that the best way to prevent long COVID is to prevent an initial COVID-19 infection.[4] For example, Professor Margaret Hellard, Director of Programs at the Burnet Institute, argued that while we don’t have a full understanding of long COVID, the most effective way to avoid it is to ‘try and stop COVID and reduce the number of COVID infections.’[5]

5.5This position is supported by the National Clinical Evidence Taskforce on COVID-19 (NCET), which recommended the Australian Government clearly communicate to the public and to health care providers ‘that prevention of COVID-19 is the most-effective method of preventing long term health issues’ resulting from the virus.[6]

5.6However, this is difficult to achieve without access to other preventative methods given the highly infectious nature of current Omicron variants circulating in the community.[7] The NCET summarised:

With the shift away from mandated mask use and regular reporting of COVID-19 cases, and the recent removal of the requirement for isolation following confirmed infection, people may have the highly inaccurate impression that COVID-19 is “over”. There is a lack of messaging that potential health risks related to COVID-19 continue to be relevant and that vaccines, mask use in crowded indoor spaces, testing and isolation are still a valuable way to decrease the transmission of SARS-CoV-2, and mitigate the impact of long COVID.[8]

5.7The importance of mask wearing, physical distancing, hygiene and taking other health precautions when visiting high-risk settings cannot be underestimated. However, the enforcement of these health measures is largely at state and territory government discretion, and to varying extents, now a matter of individual responsibility.

5.8This inquiry focused on long COVID from a federal health perspective. Accordingly, this chapter focuses on methods to prevent long COVID that are influenced by Australian Government decision-making, including:

• COVID-19 vaccines
• COVID-19 antiviral treatments
• indoor air quality and ventilation.
  9. Information presented in this chapter is based on current knowledge and literature available to the Committee. Research on long COVID is discussed in more detail in Chapter 3.

COVID-19 vaccines

5.10The Committee heard that COVID-19 vaccines may be an effective tool to prevent long COVID by reducing the severity and duration of acute COVID-19 infections. Professor Greg Dore from the Kirby Institute explained that people:

…with more severe, acute COVID were more likely to have long COVID. [However, having] said that, most of the people with long COVID had what is described as mild, community managed COVID, and that’s certainly what we’re seeing now with the omicron wave.[9]

5.11Vaccines may also help to prevent the spread of COVID-19 in the community and reduce the risk of repeated COVID-19 infections.[10] As stated above, the evidence suggests that reducing overall COVID-19 infections in the population should reduce the incidence of long COVID.

5.12There is emerging evidence that COVID-19 vaccines may prevent or reduce the severity of long COVID.[11]

5.13However, the extent to which COVID-19 vaccines may be effective in preventing long COVID remains the subject of medical research. In December 2022, the Australian Institute of Health and Welfare published a literature review on long COVID and summarised:

The overall picture suggests that 2 vaccination doses could reduce the risk of long COVID between 6% and 26%. Severity of acute COVID-19 infection is a major risk factor for long COVID… and it is plausible that the observed association between vaccination prior to COVID-19 and development of long COVID could be due to the reduction of severe disease during the acute infection…[12]

5.14Professor Brendan Crabb AC, Director and Chief Executive at the Burnet Institute, emphasised to the Committee that in addition to preventing COVID-19 hospitalisations and deaths, vaccines:

…do two other things. One is that it looks like they reduce the incidence of long COVID. The exact number is pretty variable, and you can see why. There are a lot of variables: different vaccines, different immune status in which you're vaccinated and, of course, different variants. But somewhere in the 10 to 50 per cent range of reduction in long COVID is where the current evidence is.

The second thing about vaccines is that they do actually reduce transmission. There's a lot of discussion about vaccines not reducing transmission… The most likely thing that vaccines are doing is reducing the viral load. We don't talk a lot about viral load. If any of us in this room get infected today, we might say, 'We've got COVID,' but we didn't get COVID. We don't often say, 'How much COVID did we get?' Less COVID is almost certainly better than more COVID, more virus. If it takes five days for the virus to reach a certain load in your body instead of two days, that's a lot better. Your immune system has had a chance to kick in and your chances of post-COVID sequelae are probably less.[13]

5.15DrLucas de Toca, First Assistant Secretary, National COVID-19 Vaccine Program at the Department of Health and Aged Care (the Department) commented on the role that COVID-19 vaccines may play in preventing long COVID. Dr de Toca explained that ‘studies that look at whether vaccines prevent long COVID… don't tend to account for the cases averted by vaccination, so they probably underestimate the impact of vaccination on the prevention of long COVID.’[14]

5.16Most of Australia’s population has now been vaccinated against COVID-19. As of 22 March 2023, 96.2percent of Australians have received two doses of the COVID-19 vaccine. In total, 65492360 vaccine doses have been administered nationally.[15] Statistics and information about eligibility for the COVID-19 vaccine discussed in this report are current at the time writing. The Committee encourages people to monitor advice from the Department of Health and Aged Care for updates regarding eligibility and booster doses.[16]

5.17Table 5.1 shows the percentage of people according to jurisdiction who have received first, second, third and fourth doses of the COVID-19 vaccine. These figures show that uptake of vaccines has reduced with every booster announcement.[17]

Source: Department of Health and Aged Care, Vaccination numbers and statistics, 22 March 2023.

5.18Booster doses of the COVID-19 vaccine are important to prevent waning immunity against the rapidly mutating COVID-19 virus.

5.19On 8 February 2023 the Hon Mark Butler MP, Minister for Health and Aged Care, announced that from 20 February 2023 all adults who have not had a COVID-19 booster or a confirmed case in the past six months are eligible for a COVID-19 booster, irrespective of how many doses that person has received.[19] Additional boosters for people under the age of 18 have not yet been announced, except where children aged 5 to 17 have health conditions that would put them at risk of severe illness.[20]

5.20Although COVID-19 vaccines are widely available and accessible, data suggests that many people are not electing to receive additional doses for which they are eligible. Professor Crabb AC suggested that this may be due to people becoming less aware of the risks associated with COVID-19 infections as the pandemic continues and commented on a general lack of motivation experienced by many people who received their first two doses but ‘don’t see the benefit’ in receiving booster doses.[21]

5.21The Committee also heard about low uptake of vaccines for children. The Australian Government currently recommends vaccination for everyone in Australia aged five years and over with some caveats.[22] In February 2023, the Australian Technical Advisory Group on Immunisation (ATAGI) announced that children aged five to 15 years old with either medical comorbidities that increase their risk of severe COVID-19, or disability with significant complex health needs, should consider a booster dose of the COVID-19 vaccine.[23]

5.22COVID-19 vaccination is only recommended for children aged six months to under five years who are severely immunocompromised, or have disability, as well as those who have complex and/or multiple health conditions that increase their risk of severe COVID-19.[24]

5.23Table 5.2 shows the percentage of children and adolescents aged five to 15 years old who have received first and second doses of the COVID-19 vaccine. Statistics on the uptake of booster doses for this group are not available.

Source: Department of Health and Aged Care, Vaccination numbers and statistics, 22 March 2023.

5.24Dr Brendan McMullan, Paediatric Infectious Diseases Specialist at the Sydney Children's Hospitals Network, told the Committee about some of the possible factors that may explain low vaccine uptake for children and adolescents. DrMcMullan explained:

…there is perhaps a perception among parents that the benefit of vaccination now is somewhat more limited if their child has had COVID. There's also… been some hesitation in the community about COVID vaccines. And of course, the vaccine rollout happening in a stage process has meant that as the age of the child comes down, the rollout of the vaccine has been later and later. So by the time we got around to being able to vaccinate five- to 12-year-olds, and certainly the under-fives, many people's perceptions of the dangers of COVID… had waned.[25]

5.25COVID Safe Schools Inc informed the Committee that the message that COVID-19 is mild for children may be another factor explaining the slow update of vaccines for this cohort.[26]

Improving public communication to encourage uptake of COVID-19 vaccines

5.26As noted above, emerging research indicates that COVID-19 vaccines may prevent or reduce the severity of long COVID. As a result, many submitters and witnesses called for improved public health messaging to encourage uptake of the COVID-19 vaccine, especially for the 20- to 50-year-old cohort.[27]

5.27This message is consistent with the findings of the review of COVID-19 vaccine and treatment procurements completed by the Hon Professor Jane Halton AO PSM in September 2022. The review stated that to maximise coverage and reduce confusion around COVID-19 vaccines, it is important to ‘align key public messaging, public health goals, and high-level COVID-19 vaccine policy.’[28]

5.28Professor Margaret Hellard, Deputy Director, Programs at the Burnet Institute explained that Australia ‘…would benefit from a vaccine program… to engage with people to get the vaccine.’[29]

5.29The Australian Patients Association told the Committee that public communication regarding COVID-19 vaccinations needs to be improved:

In Australia and around the world, the most effective management for preventing Long COVID is vaccinations and ensuring all Australians are up-to-date with their boosters. A cornerstone to this aspect of management is public education about the importance, efficacy and safety of vaccinations, as well as general education for patients about how Long COVID- 19 is safely managed at this point in time.[30]

5.30Professor Catherine Bennett, Chair in Epidemiology at Deakin University, emphasised that better evidence about the protections offered by COVID-19 vaccines would incentivise uptake.[31] Professor Bennett said that long COVID should be a key part of public communication:

It's something I always include just so that people can be mindful of the benefits of avoiding reinfection… [Y]our initial symptoms aren't necessarily a predictor of your potential for long COVID. People who might have had an infection and it was mild are less aware, less concerned and less likely to be contemplating vaccination, but in fact, if they have another infection, it might not be as mild, or it might still be as mild but it might be a precursor to long COVID.[32]

5.31Another submitter made a similar point and recommended the Australian Government ‘make the prevention of long COVID an explicit goal of Australia’s vaccination program.’[33]

5.32Similarly, Moderna Australia also advocated for the Australian Government to encourage uptake of COVID-19 vaccines, noting that early data suggests that vaccination reduces long COVID symptoms. Moderna argued that if this data is confirmed, it will be important for the management of long COVID to ensure that ‘all eligible Australians remain up to date with their vaccinations.’[34] Moderna suggested that:

Possible approaches could include continuing communication campaigns about the importance and value of vaccines in lessening risks of Long COVID to assist in preventing vaccine fatigue, as recommended by the Halton Review.[35]

5.33AstraZeneca echoed this sentiment, and submitted:

…given the known benefit of prophylaxis (vaccines or antibodies) in preventing SARS-CoV-2 infection and reducing severe COVID-19 illness, we strongly endorse the implementation of a sustained public campaign to encourage greater vaccine booster uptake and the availability of options for the prevention and treatment of COVID-19.[36]

Adverse reactions to COVID-19 vaccines

5.34The Committee received a small body of evidence from people in the community who are concerned about, and/or report having experienced adverse reactions to COVID-19 vaccinations.

5.35Some submitters and witnesses expressed that their adverse reactions to the COVID-19 vaccination included either the development of new symptoms mirroring long COVID, or a worsening of existing long COVID symptoms.[37]

5.36Dr de Toca from the Department of Health and Aged Care told the Committee that these reports regarding adverse vaccine reactions remain the subject of research:

What is a worsening of long COVID symptoms becomes a little bit difficult in that context. That involved a very small number of people. The majority of the studies show either no difference or a slight improvement [from COVID-19 vaccines] on long COVID outcomes. …we have not seen, either in studies or in the data reported to the TGA [Therapeutic Goods Administration], long COVID onsetting after vaccination. We have not seen evidence of that.[38]

5.37Lived experiences of adverse reactions to COVID-19 vaccines are discussed in Chapter 4.

Antiviral treatments for COVID-19

5.38Antiviral medicines help stop a virus infecting healthy cells or multiplying in the body.[39] The Committee heard that antiviral treatments for COVID-19 may be an effective tool to prevent long COVID by reducing the severity of acute COVID-19 illness.[40]

5.39The Department reported there is currently no conclusive evidence that antiviral treatments prevent long COVID.[41] However, it noted that severity of illness during acute COVID-19 infection is ‘an important predictor of long COVID’ and acknowledged emerging evidence that COVID-19 antiviral treatments may have a protective effect against long COVID.[42] The Department continues to monitor relevant studies.[43]

5.40Research into if and how antiviral treatments may prevent long COVID is ongoing. The Public Health Association of Australia highlighted the findings of emerging research indicating that antivirals may decrease the risk of developing long COVID by reducing the severity of COVID-19, and stated:

…in Australia, antivirals are mostly only prescribed to persons with vulnerabilities, particularly elderly populations; therefore there is minimal understanding of the benefits and risks associated with allowing younger and non-at-risk populations access to antivirals. The availability of antivirals to people at low risk should be reviewed and any subsequent decisions should be supported by the evidence. More diverse, long-term research of multiple population groups is required to investigate antiviral treatment of acute COVID and its impact on reinfection and Long COVID.[44]

5.41A recent study found that in people with at least one risk factor for severe COVID-19 illness, the use of Paxlovid® was associated with reduced risk of post-COVID complications.[45]

5.42Dr Anthony Kelleher, Director at the Kirby Institute, outlined one mechanism through which antiviral treatment may prevent long COVID:

…it [long COVID] might be due to the chronic persistent presentation of antigen to the immune system and that the resultant stimulation of the innate immune system, and it is plausible that, if you clear antigen more quickly by starting an antiviral early, you could turn off that innate immune response earlier and therefore truncate the condition—if it is that innate immune response that's driving the symptomatology—by turning off viral production and therefore reducing antigen production more rapidly… I think it is plausible that treatment with an effective antiviral that reduces antigen load rapidly would logically reduce the amount of persistent antigen that's there and also truncate any innate immune response, because that's been driven by the presence of the foreign antigen.[46]

5.43In considering the potential use of antiviral treatments to prevent long COVID, it is relevant to bear in mind the arrangements under which new medicines are listed on the Pharmaceutical Benefits Scheme (PBS) and subsidised.

5.44The Pharmaceutical Benefits Advisory Committee (PBAC) is an independent expert body appointed by the Australian Government and established by the National Health Act 1953 (Cth).[47] It recommends to the Minister for Health and Aged Care drugs for listing on the PBS and vaccines. New medicines cannot be listed on the PBS unless the PBAC makes a positive recommendation.[48]

5.45There are currently two oral antiviral treatments for COVID-19 approved and available in Australia: molnupiravir (Lagevrio®) and nirmatrelvir and ritonavir (Paxlovid®).[49] Lagevrio® and Paxlovid® can currently be prescribed to eligible patients by a general practitioner (GP), physician or nurse practitioner for access through the PBS for a cost of A$30.[50]

5.46As of 18 November 2022, 367 480 prescriptions for antiviral treatments had been dispensed via the PBS.[51] Based on current criteria, Pfizer estimated 4.2 million Australian adults are eligible to access antiviral treatments via the PBS.[52]

5.47Currently, the following groups may be eligible for antiviral treatments via the PBS:

• 70 years of age or older, regardless of risk factors and with or without symptoms
• 50 years of age or older with 2 additional risk factors for developing severe disease or have had past a COVID 19 infection resulting in hospitalisation
• First Nations person, 30 years of age or older and with 1 additional risk factor for developing severe disease
• 18 years of age or older and moderately to severely immunocompromised.[53]
  48. From 1 April 2023, people aged 60 to 69 years with one risk factor for severe illness can access Paxlovid® via the PBS.[54]
  49. For the purpose of determining eligibility for COVID-19 antivirals via the PBS, risk factors include if the person:
• lives in residential care (aged or disability)
• has disability with multiple comorbidities and/or frailty
• neurological conditions, including stroke, dementia and demyelinating conditions
• respiratory compromise, including [chronic obstructive pulmonary disease], moderate or severe asthma (requiring inhaled steroids), and bronchiectasis, or caused by neurological or musculoskeletal disease
• heart failure, coronary artery disease, cardiomyopathies
• obesity ([body mass index] > 30 kg/m2)
• diabetes type 1 or 2, requiring medication for glycaemic control
• renal failure ([estimated glomerular filtration rate] < 60 mL/min)
• cirrhosis
• reduced, or lack of, access to higher level health care and lives in an area of geographic remoteness classified by the Modified Monash Model (which categorises an area according to geographical remoteness and town size) as Category 5 or above.[55]
  50. In relation to COVID-19 antiviral eligibility via the PBS, moderately to severely immunocompromised’ currently means:

Any primary or acquired immunodeficiency including:

• haematologic neoplasms: leukaemias, lymphomas, myelodysplastic syndromes, multiple myeloma and other plasma cell disorders
• post-transplant: solid organ (on immunosuppressive therapy), haematopoietic stem cell transplant (within 24 months)
• immunocompromised due to primary or acquired (HIV/AIDS) [human immunodeficiency virus infection and acquired immune deficiency syndrome] immunodeficiency.

Any significantly immunocompromising condition(s) where, in the last 3 months, the patient has received any of these treatments:

• chemotherapy or whole-body radiotherapy
• high-dose corticosteroids (≥ 20 mg of prednisolone per day, or equivalent) for at least 14 days in 1 month, or pulse corticosteroid therapy
• biological agents and other treatments that deplete or inhibit B- or T-cell function…
• selected conventional synthetic disease-modifying anti-rheumatic drugs…

Others with very high-risk conditions, including:

• Down syndrome
• cerebral palsy
• congenital heart disease
• thalassemia, sickle cell disease and other haemoglobinopathies.

Any significantly immunocompromising condition(s) where, in the last 12 months, the patient has received rituximab.

People with disability with multiple comorbidities and/or frailty.[56]

5.51Patients not belonging to one of the groups eligible to access antiviral treatments through the PBS can seek private prescriptions at a cost of approximately A$1100.[57] Current advice from the Department discourages doctors and pharmacists from providing antiviral treatments via private prescriptions ‘to ensure that patients who meet the PBS criteria can access the treatments when they need…’[58]

Issues accessing antiviral treatments

5.52The Committee heard about various issues regarding access to antiviral treatments for COVID-19 in Australia.

5.53As mentioned earlier in this chapter, antiviral treatments can be prescribed to eligible patients via the PBS by a GP, physician or nurse practitioner. Given that it is recommended that antiviral treatments be commenced within the first five days of symptoms onset to be effective[59], timely access to a GP, physician or nurse practitioner is critical.

5.54The Pharmacy Guild of Australia submitted that ‘the United States, Canada and New Zealand allow pharmacists to initiate oral COVID antiviral treatments’ and called for the same access to be granted to pharmacists in Australia. The Pharmacy Guild of Australia recommended:

The community pharmacy network should be effectively used to provide patients with timely access to oral COVID antivirals. The Guild believes that enabling oral COVID antivirals to be pharmacist-initiated medications will improve patient access and extend access and use throughout Australia, including in rural and remote areas, leading to a decreased burden on public hospital emergency facilities and other health services.[60]

5.55As indicated by the PBS antiviral eligibility criterion outlined above, being diagnosed with long COVID does not make a person eligible to access subsidised antiviral treatment via the PBS.

5.56Some submissions disagreed with this and advocated that people with long COVID should be eligible to access antiviral treatments through the PBS. One submitter described the current eligibility criterion to access subsidised antivirals as ‘clunky and over restrictive’ and called for ‘those with Long COVID to be explicitly listed as being eligible for antivirals, in situations where COVID is contracted again.’[61]

5.57Many of these submissions advocating for broader access to antivirals were from people with long COVID who expressed their fears about repeated COVID-19 infections.[62] For example, one submitter explained:

Antivirals should be made available to those who have long Covid when they have another Covid-19 infection. If I am reinfected again, I am not eligible for antivirals, as long Covid is not currently considered as a significant underlying health condition by the government. Long Covid needs to be included on the list of eligible conditions to access antivirals. There is research that antivirals, such as Paxlovid, can lessen the risk of developing long Covid.[63]

5.58OzSAGE, who describe themselves as a multi-disciplinary network of Australian experts from a broad range of sectors relevant to the well-being of the Australian population during and after the COVID-19 pandemic, agreed that people with long COVID often want antivirals to prevent ‘potential further exacerbation of their condition’, but that any long COVID-related disability they have is not recognised. OzSAGE elaborated:

Patients may face significant costs if not in the limited subgroup currently eligible for subsidised antiviral medication. Antiviral therapies are not available to those who have had prior severe COVID-19 infection, despite evidence that SARS-CoV-2 can persist in the body long after acute infection.[64]

5.59The Committee received evidence indicating that this inability to access subsidised antivirals negatively impacts some individuals with long COVID. Bethany and Matthew Wormald highlighted in their submission that inability to access antiviral treatments limits various aspects of their lives:

We have been told that it would be dangerous to get a new Covid 19 infection, while suffering from LC [long COVID], but do not qualify for Paxlovid should a positive test occur. This limits ability to socialise, exercise, work, volunteer and most importantly to access treatment for [long COVID] in facilities full of sick people.[65]

5.60The Committee also heard from a submitter with long COVID who spoke about their fear of having to restart their recovery after repeated COVID infections:

One of my major fears is getting covid a second time and having to start the recovery from long covid all over again. There would appear to be some evidence that antivirals may help protect people from getting long covid… I realise not all the evidence is in, but I think as a preventative measure, those who have been diagnosed with long covid should be eligible for antivirals, regardless of their age or other health status.[66]

5.61It was unclear whether many submitters were aware that antivirals could be accessed privately off the PBS. However, at least some individuals did recognise this, but expressed concern at the cost. A submission from a person who developed long COVID symptoms after an acute COVID-19 infection highlighted the difficult choice they would need to make if reinfected:

As a fall back I have a prescription for Paxlovid, but if I fill it, I’m not entitled to cover under the PBS, as I’m under 70, not diagnosed as disabled and not considered immunocompromised I will have to pay $1000.00. This is money I will have to find on credit, but if my health deteriorates as a result of unprotected reinfection I will lose much more than that.[67]

5.62Antiviral medication as a potential treatment for people with ongoing long COVID symptoms is discussed in Chapter 6.

Indoor air quality and ventilation

5.63COVID-19 was not recognised as an airborne virus by the World Health Organization (WHO) until April 2021 – more than one year into the pandemic.[68] The Committee heard that as a result of this delay, the importance of safeguarding air quality and ventilation has been overlooked in Australia’s response to managing COVID-19.

5.64As mentioned previously in this chapter, the evidence suggests that at present the most effective method of preventing long COVID is to prevent an initial COVID-19 infection. The Committee therefore considered how improving indoor air quality and ventilation may play a key part in preventing acute and repeated COVID-19 infections, with the aim of ultimately preventing long COVID.

5.65Responsibility for monitoring and managing air quality in Australia is predominantly split between state, territory and local governments. However, the Australian Government has a role in the National Construction Code, which covers minimum ventilation requirements for new buildings, building work, new plumbing and drainage systems.[69] The National Construction Code is given legal effect by building regulatory legislation in each state and territory.[70]

5.66Australia’s states and territories have, throughout the pandemic, developed guidance on ventilation and air quality to assist with reducing COVID-19 transmission.[71] However, implementing this guidance is voluntary and different jurisdictions have taken different approaches, resulting in inconsistencies across Australia.

5.67Professor Crabb AC was of the view that the delay in recognising the airborne transmission of COVID-19 and the lack of controls to manage this was a ‘big failure’ in the pandemic response.[72] He elaborated:

There is a real opportunity there to do something practical that's going to help but also send a positive signal. No social licence is needed for clean air. There are tricky regulations and so on, but countries are tackling this in a step-wise manner, sometimes just regulating that all you have to see is the quality of the air; you don't have to do anything but you have to display the quality of the air in a venue. These sorts of things send strong signals to the population now that breathing clean air is very important.[73]

5.68The Committee heard from many submitters and witnesses who expressed concerns that poor indoor air quality and ventilation are unnecessarily contributing to or exacerbating COVID-19 transmission in a variety of settings, including workplaces.[74]

5.69The Committee heard from three ventilation experts, each of whom highlighted the risks of poor indoor air quality and how it enables transmission of COVID-19.[75]

5.70Associate Professor Robyn Schofield from the University of Melbourne told the Committee that ‘[b]asically all COVID transmission events have occurred indoors’ and added:

That's the cost of our inaction. The benefits and co-benefits [of potentially improving indoor air quality] are huge: productivity, educational success and performance enhancement, and a reduction in the population disease burden of this disease. We need safe indoor air for all. What the last three years of the pandemic have taught us is that our indoor air won't be improved for all without standards, education, monitoring and action.[76]

5.71Distinguished Professor Lidia Morawska from the Queensland University of Technology explained how that speaking and breathing can spread the virus:

Overall, if we are talking about this virus, SARS-CoV-2, smaller particles contain a higher load, particles smaller than one micrometre—not an individual small particle but as a body, because they are in the vast majority. Smaller particles come from the deeper parts of the respiratory tract, the location of the virus. By contrast, larger particles have less virus because they originate from the mouth, where there's less of the virus. Again, speaking and breathing are the main source of the small viruses.[77]

5.72Professor Geoff Hanmer, Director at OzSAGE (Adjunct Professor within the School of Architecture at the University of Adelaide), argued the need to ‘implement physical options’ to reduce the airborne transmission of COVID-19.[78] He said that wherever possible, people should be continuing to work from home and dine outdoors, events should be held outdoors, and people continue to use masks – ‘the key element is ensuring that shared indoor air is clean.’[79]

5.73Associate Professor Schofield also explained that the last assessment of the economic cost of poor indoor air quality was completed by Commonwealth Scientific and Industrial Research Organisation in 1998.[80] She said that at that time, it was estimated that poorly ventilated indoor spaces cost Australia $12billion per year; an amount which would have increased during the COVID-19 pandemic:[81]

I imagine the cost of it through the pandemic would be much higher because it would start to factor in all of the transmission events that brought about death. If we consider that most of the COVID transmission events happened in the indoor environment and you bring in all of those deaths, that is a really large number. The benefit of doing something to the air for productivity, for school test scores and for a healthier society are very large. One of my first recommendations was that analysis needs to be done because people say, 'It's too hard; it's going to cost too much.' It's not too hard. It will cost a lot, but the cost of inaction is huge.[82]

Indoor air quality and ventilation in high-risk settings

5.74The Committee heard from some submitters and witnesses about how poor indoor air quality and ventilation exacerbated COVID-19 transmission in high-risk settings, including schools and aged care facilities.

5.75Adjunct Professor Giorgio Buonanno wrote to the Committee about indoor air quality and ventilation in school settings, and to share the results of his study that investigated ventilation and COVID-19 transmission in Italian schools:

We investigated the strength of association between ventilation and SARS-CoV-2 transmission reported among the students of Italy's Marche region in more than 10,000 classrooms, of which 316 were equipped with mechanical ventilation. We explored the relative risk associated with the exposure of students in classrooms.

Findings: For classrooms equipped with mechanical ventilation systems, the relative risk of infection decreased with the increase in ventilation: classrooms with good mechanical ventilation reduced the likelihood of infection for students by 80% compared with a classroom with only natural ventilation.

The conclusion is clear - predictable ventilation of classrooms is a very effective measure which reduces risk of transmission of any airborne disease. I know the findings can be applied to any buildings which are occupied by many people for extended periods.[83]

5.76Professor Hanmer, Director at OzSAGE (Adjunct Professor within the School of Architecture at the University of Adelaide), described weaknesses of naturally ventilated spaces:

When it is not too cold, too hot or too noisy, the window or windows are open. But the reality is that, in most climates… there's a problem: too cold, too hot, too noisy, too polluted or too unsafe. Windows are closed and there's no ventilation. Basically, natural ventilation equates to no ventilation in situations like this. Of course, there is a disclaimer: 'no ventilation' means 'minimal ventilation', because there is always some penetration of air into the building.

…there's not enough ventilation, even if windows are open. But the very big problem is that energy invested in heating and cooling is lost. As a society, we cannot afford to invest more energy. We need to do it smarter.[84]

5.77COVID Safe Schools Inc echoed this point and submitted that schools with improved indoor air quality and ventilation had lower transmission of COVID-19 compared to the broader community. COVID Safe Schools Inc provided an example of low COVID-19 cases found in schools and childcare facilities with improved ventilation in Baden-Württemberg Germany.[85]

5.78Further, Ms Karen Armstrong, Acting President at Covid Safe Schools Inc argued:

The cost of installing this equipment should not be seen as a luxury... Air monitoring and filtration equipment should be seen as being as necessary as smoke alarms and fire extinguishers in public buildings…

[…]

…ideally what we want is a situation…where ultimately we have HVAC facilities in every classroom. That would be the ideal. In fact a school infrastructure investment where that could be rolled out would be the best possible scenario. In the short term, though, there could be sensible and very cheap and relatively easy things to do. In the short term, we need teachers to have the windows open and we need the teachers to be educated about how to use HEPA [high efficiency particular air/absorbing] filtration. In Victoria, you're probably aware, HEPA filters were rolled out, one for every classroom. There were some problems with that implementation, largely to do with education, and this is part of the problem. So ideally we would have, in the short term, air monitors and HEPA filters in the classrooms while the HVAC was being rolled out.

But we also need—and this is the critical thing—education. Staff need to be made to understand why they're using it and how to make it work. We read all the time, and I know through personal experience, that the HEPA filters often aren't turned on. You have a situation where the teachers don't know where to put them. The filters aren't replaced. The windows aren't left open with the HEPA filters on, which, by the way, even the WHO has said needs to happen: you need the change of air as well as the air being filtered if you're going to use that. It's the main way of managing the clean air.[86]

5.79Professor Hanmer, Director at OzSAGE (Adjunct Professor within the School of Architecture at the University of Adelaide), told the Committee that the current number of COVID-19 related deaths in aged care in Australia – about 300 so far in 2023 – is unacceptable, and he suggested that poor ventilation in aged care facilities is playing a part:

During the second winter wave in Victoria, about 700 residents died in residential aged care facilities. In the cold Melbourne winter, windows were shut, ventilation was minimal and COVID was able to accumulate in the air, a bit like smoke. When an infected person entered a facility it proved impossible to stop the infection spreading. An examination of the scientific literature at the time, including papers from Professor Morawska, showed that the probable reason for the high level of infections was airborne transmissions, exacerbated by low ventilation…

Many aged care residents died then and are continuing to die because the people who make recommendations on infection control are too stubborn to admit their early advice was wrong, despite abundant evidence to the contrary. [87]

The need for Indoor Air Quality Standards

5.80Noting the risk presented by poor indoor air quality and ventilation, many submitters and witnesses recommended that Australia establish national Indoor Air Quality Standards to improve the safety of indoor spaces and reduce transmission of COVID-19 and other infectious diseases.[88] These standards would be separate from the air quality and ventilation requirements set out in the National Construction Code.

5.81Professor Morawska made several recommendations to the Committee regarding the establishment of Indoor Air Quality Standards for consistent use across Australia’s states and territories:

1. Establish a consistent national regulatory infrastructure for Clean Indoor Air for Australians through the Federal Cabinet working with the States and Territories through the National Cabinet

2. Establish an interdisciplinary panel of experts, including scientists, engineers, architects and medical and public health professionals tasked with developing a foundation for [Indoor Air Quality] standards that can be legislated and enforced.

3. Legislate the [Indoor Air Quality] standards

4. Mandate that all new buildings are designed to meet the standards5. Review and improve the existing building design and building engineering standards, regulations and codes to ensure that they enable compliance with the [Indoor Air Quality] standards.

6. Establish a national fund enabling the rollout of indoor environment modernisation measures addressing both immediate emergencies as well as a long-term transition process towards all public interiors meeting [Indoor Air Quality] standards.[89]

5.82Professor Morawska said that these standards must:

…prescribe concentrations of indoor selected pollutants[,] be enforceable, monitored in every public space and legislated, and regulations sufficient and effective as a part of HVAC [heating, ventilation and air-conditioning] system must be an element of enforcement of these standards and regulations for public spaces. This must be supplemented by disinfection to control airborne infection transmission.[90]

5.83Associate Professor Schofield highlighted the human right to a clean, healthy and sustainable environment, which was recognised by the United Nations General Assembly in July 2022.[91] Highlighting the need for standards to enable monitoring, she said:

How do we ensure that this right is met for everyone? If you don't set standards and monitor those quantities, you're not managing that resource. Air is arguably the most important resource that we consume. Food standards generate compliance through education. They monitor for compliance, and there is a clear response to noncompliance. We need this for air. We need a litmus test telling us that the air is safe, given the occupancy and the use of a space. This is what CO2 [carbon dioxide] monitoring gives us…

We also need to regulate how much fresh air is coming in from outside... That's about 14 litres per second per person… We need to be really careful about airflows. Here, in this space [Malvern public hearing venue, Cabrini Hospital], it's very good. You've got air coming in and then the air exhausting there. The pathways are short. It's not coming in over there and coming through me to there, like the confluence of a river. That's what we need to be very careful of.[92]

5.84Professor Hanmer, Director at OzSAGE (Adjunct Professor within the School of Architecture at the University of Adelaide), also advocated for the establishment of Indoor Air Quality Standards and explained current ventilation requirements set out in the National Construction Code:[93]

…the National Construction Code requires a new building to be constructed with either natural or mechanical ventilation. If a building is naturally ventilated, the [National Construction Code] requires windows with the area of their openable elements to be five per cent of the floor area, regardless of the intensity of the occupancy of the space. …no laws or regulations require building operators to open the windows. Nearly all our schools, childcare centres, community centres, churches, medical waiting rooms, pharmacies and residential aged care facilities are naturally ventilated…

…with some simple tweaks to settings, nudged along by a regulator and some regulations, most of these buildings can perform acceptably. We urgently need a national standard for indoor air quality and a national indoor air standards code. This could operate like the national Food Standards Code referenced in the National Construction Code, with regulation by both state and territory governments, and enforcement by local government. In New South Wales, for example, the New South Wales Food Authority directly looks after high-risk issues, while hygiene and food standards at the local hamburger joint are monitored by local government. Most states are similar.[94]

5.85Another submitter made a similar recommendation that indoor air quality standards are needed for every indoor space such as day care centres, schools, libraries and businesses, ‘the same way we have food safety standards that prevent the transmission of diseases such as gastroenteritis.’[95]

5.86Associate Professor Schofield also addressed the issue of the cost of establishing Indoor Air Quality Standards, suggesting that more research into indoor air quality and ventilation would assist with bringing down costs:

We need research to ensure that we can deal with the fact that we can drive down the cost. We want to have energy efficient buildings. We want to make them resilient to climate change. Outside air, bringing that in all the time, will not always work when we have bushfires or outdoor pollution, for example. We do need to have innovation in this space. We do need to ensure that any technologies that we bring in to solve the problem don't create a new one.[96]

5.87Professor Hanmer, Director at OzSAGE (Adjunct Professor within the School of Architecture at the University of Adelaide), said the benefits of improved ventilation would ‘far outweigh the costs, including improvements in productivity, learning and general health, not to forget reducing COVID infections and mortality.’[97]

International examples of best practice in air quality

5.88Some submitters and witnesses discussed measures adopted in other countries seeking to improve air quality and ventilation. In particular, the Committee heard about measures in Belgium, Ireland, New Zealand and the Netherlands as examples of best practice.[98] For example, OzSAGE submitted:

Clean indoor air is essential to mitigate repeat SARS-CoV-2 infections and resultant long COVID. Peer countries are moving to set targets for unfiltered indoor CO2 levels (as a proxy for ventilation) in public spaces, such as schools, restaurants, and workplaces. For example, Belgium has recently passed legislation that requires all public places to monitor their indoor air quality and install a CO2 monitor that is visible to the public. In New Zealand, all schools have been supplied with a CO2 monitor and air purifiers are used when ventilation is insufficient. Australia should follow by mandating and championing indoor air quality standards and other clean indoor air technologies. More cost effective is investment in safe indoor air and other mitigations.[99]

5.89Another submitter told the Committee of progress in Belgium and Ireland:

Recently, the Belgian government recognised the importance of healthy indoor air, finding a legal framework to improve air quality: all publicly accessible premises (including bars, restaurants, cinemas, theatres and gyms) must monitor their indoor air, display CO2 readings, and have a "ventilation plan." Ireland is also taking serious steps to address indoor air quality: their Health and Safety Authority has drawn up a new code of practice to ensure workplace air quality, and this will be signed into law next year. Australia must do the same. In the short term, the government must acknowledge the importance of good ventilation in public indoor spaces and provide clear guidance on this…[100]

Committee comment

5.90The Committee believes that preventing COVID-19 infection is, based on current information, the most effective method to prevent long COVID. Consequently, the Committee considers that there is opportunity for Australia to respond to long COVID and reduce future cases by more effectively promoting COVID-19 vaccines, expanding access to antiviral treatments for COVID-19, and improving indoor air quality and ventilation.

COVID-19 vaccines

5.91The Committee notes emerging evidence that suggests COVID-19 vaccines prevent long COVID by reducing community transmission and the chance of severe acute COVID-19 illness.

5.92The Committee commends all Australians for achieving high double dose national vaccination rates amongst the adult population. However, the Committee notes that a diminishing percentage of Australian adults over the age of 16 have received each additional COVID-19 vaccine booster that is available to them. The Committee further observes that just over 50 per cent of children and adolescents aged between five and 15 have received two doses of the COVID-19 vaccine.

5.93Accordingly, the Committee is concerned that the limited uptake of COVID-19 vaccines may represent a missed opportunity to reduce and mitigate the future prevalence and severity of long COVID cases. Although long COVID is not common, it is real and millions of Australians could potentially be increasing their protection against it simply by receiving additional COVID-19 vaccinations, which are readily available and free. The Committee thus encourages all Australians who are eligible to keep up to date with booster doses.

5.94The Committee appreciates the ongoing work undertaken by the Department of Health and Aged Care to facilitate the vaccine rollout and ensure the ongoing supply of COVID-19 vaccine booster doses. However, the Committee considers that the Department must urgently improve its public communication to encourage all Australians who are eligible for the COVID-19 vaccine to keep up to date with booster doses as they are announced.

5.95Further, the Committee strongly believes that the Department of Health and Aged Care should work with the states and territories to improve public campaigns informing Australians of the benefits of COVID-19 vaccines. These campaigns should emphasise the role that COVID-19 vaccines have in reducing transmission and illness severity of acute COVID-19, and thus potentially in preventing long COVID. These campaigns should be updated to reflect emerging research regarding vaccines and long COVID.

5.96The Committee notes the Minister for Health and Aged Care recently released a new campaign to encourage uptake of COVID-19 vaccines prior to the 2023 winter season.[101]

5.97The Committee recognises the importance of ensuring that future public health campaigns on this topic are accessible and reach vulnerable groups in regional, rural and remote areas and culturally and linguistically diverse communities.

5.98The Committee would like to emphasise that the issue of adverse reactions to COVID-19 vaccinations was not within the terms of reference, nor a focus of this inquiry. However, the Committee acknowledges the small body of evidence received from people in the community telling of theirs or a loved ones’ experience of an adverse physical reaction after receiving a COVID-19 vaccination. The Committee acknowledges that adverse vaccine events, although very rare, do occur.

5.99The Committee encourages anyone who suspects they may have had an adverse reaction to a COVID-19 vaccine to report this to a health professional, a relevant state or territory health department, the NPS MedicineWise Adverse Medicine Events line or directly to the Therapeutic Goods Administration.[102]

Antiviral treatments for COVID-19

5.100The Committee notes that research on antiviral treatments for COVID-19 and whether they prevent long COVID is evolving.[103]

5.101However, the Committee acknowledges there is some clinical evidence on the effect of antiviral treatments, which suggests that these treatments may in certain populations reduce the severity of acute COVID-19 illness. Given that increased severity of initial infection (such as requiring hospitalisation) may put a person at risk of developing long COVID the Committee recognises the logic that antiviral treatments may play a role in preventing long COVID.

5.102The Committee notes though that it also heard from people who experienced mild symptoms during their initial COVID-19 infection, which later developed into long COVID. Given this, the extent to which antiviral treatments may prevent long COVID is unconfirmed.

5.103Despite this, the Committee agrees that access to antiviral treatments should be expanded so that as many Australians as possible have an opportunity to reduce the severity of their acute COVID-19 infections, and potentially reduce the risk of experiencing long COVID.

5.104The Committee notes that decisions regarding the eligibility of individuals to access antiviral treatments require a positive recommendation by the Pharmaceutical Benefits Advisory Committee, an independent expert body, and as such are not within the sole discretion of the Minister for Health and Aged Care.

5.105The Committee supports the recommendation of the Pharmacy Guild of Australia to enable pharmacists to initiate COVID-19 antiviral treatments and notes that such arrangements exist in the United States of America, Canada and New Zealand. This would ease the pressure on GPs and assist people who are not able to easily access an appointment with a GP within the first five days of their COVID-19 infection. This will also improve patient access to COVID-19 antiviral treatments and extend access and use throughout Australia, including in rural and remote areas, leading to a decreased burden on public hospital emergency facilities and other health services.

Indoor air quality and ventilation

5.106The Committee shares the frustrations of many submitters and witnesses that the WHO’s delay in recognising COVID-19 as an airborne virus ultimately weakened the initial global response to the pandemic. However, the Committee urges the Australian Government from this point on to consider improving Australia’s approach to managing indoor air quality and ventilation. The Committee believes that this will help mitigate the impacts of long COVID and repeated infections, and positively benefit the health of all Australians beyond the COVID-19 pandemic in readiness for subsequent airborne threats such as smoke and pathogens.

5.107The Committee wishes to emphasise that this report does not purport to traverse in any detail Australia’s framework or standards around air quality and ventilation, as the Committee only received a small volume of evidence on these issues.

5.108What the Committee did hear was compelling evidence that poor indoor air quality and ventilation leads to increased risk of COVID-19 infection. The Committee is convinced of the role that good air quality and ventilation play in preventing the transmission of COVID-19, and therefore in preventing long COVID and repeated COVID infections.

5.109Thus, the Committee is of the view that the Australian Government needs to act quickly to establish consistent indoor air quality regulation, working with the states and territories, while taking advice from ventilation and multidisciplinary experts and following international best practice.

5.110The Committee believes that national Indoor Air Quality Standards would be beneficial.

Footnotes

[1]Department of Health and Aged Care, The Australian health system, www.health.gov.au/about-us/the-australian-health-system, viewed 16 March 2023.

[2]Department of Health and Aged Care, Our response to the pandemic, www.health.gov.au/health-alerts/covid-19/government-response, viewed 16 March 2023.

[3]Department of Health and Aged Care, Protect yourself and others from COVID-19, www.health.gov.au/health-alerts/covid-19/protect-yourself-and-others, viewed 16 March 2023.

[4]See, for example: Mrs Mary Klestadt, Submission2, p.3; Namewithheld, Submission 97, pages 1, 4; MarkLeonard, Submission146, [p. 2]; Burnet Institute, Submission 149, p. 2; Name withheld, Submission 162, p.12; Australian Academy of Science and the Australian Academy of Health and Medical Sciences, Submission165, pages 1, 9; ProfessorMartin Hensher, Submission 175 (Attachment 1) p. 6; PfizerAustralia, Submission 225, p. 4; National Clinical Evidence Taskforce (Monash University), Submission 232, pages 16, 19; Long COVID Australia Collaboration, Submission235, p. 4; Pharmaceutical Society of Australia, Submission 293, pages3, 7; OzSAGE, Submission 299, p.18; Pathology Technology Australia, Submission 244, pages3,7; AstraZeneca, Submission 247.1, p. 2; Australia Long Covid Community Facebook Group, Submission 309.2, p. 3; Professor Linda Slack-Smith, Submission 320, p. 1; Australian Medical Association, Submission 328, p. 5; Associate Professor Nada Hamad, Submission 335, p.10; DrAnneFletcher and Dr Luke Fletcher, Submission 436, p. 19; Aboriginal Health Council of South Australia, Submission 439, p. 6; Name withheld, Submission 440, p.4; Name withheld, Submission 467, p.4; Australian Federation of Disability Organisations, Submission 486, p. 16; DrBenjamin Veness, Submission492, pages 1, 6–7; Name withheld, Submission494, p.2; ProfessorKerryn Phelps AM, Submission510, p. 14; Professor Tania Sorrell, Fellow, Australian Academy of Health and Medical Sciences, and Ambassador, Sydney Institute for Infectious Diseases, Committee Hansard, Canberra, 17 February 2023, p.39; Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20February2023, p. 22.

[5]Professor Margaret Hellard, Deputy Director, Programs, Burnet Institute, Committee Hansard, Canberra, 12October 2022, p. 23.

[6]National Clinical Evidence Taskforce (Monash University), Submission 232 (Attachment 1), p. 14.

[7]National Clinical Evidence Taskforce (Monash University), Submission 232, p. 19.

[8]National Clinical Evidence Taskforce (Monash University), Submission 232 (Attachment 1), p. 16.

[9]Professor Greg Dore, Professor and Epidemiologist, Kirby Institute, Committee Hansard, Canberra, 12October 2022, p. 36.

[10]See, for example: Pfizer Australia, Submission 225, p. 4; Professor Margaret Hellard, Deputy Director, Programs, Burnet Institute, Committee Hansard, Canberra, 12 October 2022, p. 23; Associate Professor Shidan Tosif, Consultant, General Medicine, and Clinical Lead, Post-COVID Clinic, The Royal Children's Hospital, Committee Hansard, Canberra, 12 October 2022, p. 10.

[11]See, for example: Dr Jason Agostino, Senior Medical Adviser, National Aboriginal Community Controlled Organisation, Committee Hansard, Canberra, 17 February 2023, p. 3; Professor Brendan Murphy AC, Secretary, Department of Health and Aged Care, Committee Hansard, Canberra, 17 February 2023, p.9.

[12]Australian Institute of Health and Welfare, Long COVID in Australia – a review of the literature, www.aihw.gov.au/reports/covid-19/long-covid-in-australia-a-review-of-the-literature/summary, p. 16, viewed 16 March 2023.

[13]Professor Brendan Crabb AC, Director and Chief Executive, Burnet Institute, Committee Hansard, Malvern, 20 February 2023, pages 4–5.

[14]Dr Lucas de Toca, First Assistant Secretary, National COVID-19 Vaccine Program, Department of Health and Aged Care, Committee Hansard, Canberra, 17 February 2023, p. 13.

[15]Department of Health and Aged Care, Vaccination numbers and statistics, www.health.gov.au/our-work/covid-19-vaccines/vaccination-numbers-and-statistics, viewed 30 March 2023.

[16]See: Department of Health and Aged Care, Who can get vaccinated, www.health.gov.au/our-work/covid-19-vaccines/who-can-get-vaccinated, viewed 13 April 2023.

[17]See also, Professor Paul Kelly, Australian Government Chief Medical Officer, Department of Health and Aged Care, CommitteeHansard, Canberra, 17 February 2023, p. 9. See also, AstraZeneca, Submission 247, p. 2.

[18]People aged 30 and over have been eligible for a fourth dose since 11 July 2022. See: the Hon Mark Butler MP, Minister for Health and Aged Care, ‘Expanded eligibility for fourth COVID-19 vaccine dose’, Media Release, 7 July 2022.

[19]The Hon Mark Butler MP, Minister for Health and Aged Care, ‘All adults now eligible for a 2023 COVID-19 booster dose’, Media Release, 8 February 2023.

[20]The Hon Mark Butler MP, Minister for Health and Aged Care, ‘All adults now eligible for a 2023 COVID-19 booster dose’, Media Release, 8 February 2023.

[21]Professor Brendan Crabb AC, Director and Chief Executive, Burnet Institute, Committee Hansard, Malvern, 20 February 2023, p. 5.

[22]Department of Health and Aged Care, COVID-19 vaccines, www.health.gov.au/our-work/covid-19-vaccines, viewed 16 March 2023.

[23]Australian Technical Advisory Group on Immunisation, ATAGI 2023 booster advice, www.health.gov.au/news/atagi-2023-booster-advice, viewed 10 March 2023.

[24]Department of Health and Aged Care, COVID-19 vaccines for children, www.health.gov.au/our-work/covid-19-vaccines/who-can-get-vaccinated/children, viewed 13 April 2023.

[25]Dr Brendan McMullan, Paediatric Infectious Diseases Specialist, Sydney Children's Hospitals Network, Committee Hansard, Liverpool, 5 December 2022, p. 24.

[26]COVID Safe Schools Inc, Submission 306, p. 31.

[27]See, for example: Department of Health (Victoria), Submission 87, p. 11; ModernaAustralia, Submission170, p. 3; Name withheld, Submission 231, p. 8; AstraZeneca, Submission 247, p. 2; AstraZeneca, Submission 247.1, p. 2; Australian Patients Association, Submission 256, p. 6; Pharmaceutical Society of Australia, Submission 293, p. 7; Rural Doctors Association of Australia, Submission 362, p. 7; Professor Catherine Bennett, Chair in Epidemiology, Deakin University, Committee Hansard, Canberra, 12 October 2022, p. 32.

[28]The Hon Professor Jane Halton AO PSM, Review of COVID-19 vaccine and treatment purchasing and procurement, 19 September 2022, pages 3–4.

[29]Professor Margaret Hellard, Deputy Director, Programs, Burnet Institute, Committee Hansard, Canberra, 12October 2022, p. 21.

[30]Australian Patients Association, Submission 256, p. 6.

[31]Professor Catherine Bennett, Chair in Epidemiology, Deakin University, Committee Hansard, Canberra, 12October 2022, p. 32.

[32]Professor Catherine Bennett, Chair in Epidemiology, Deakin University, Committee Hansard, Canberra, 12October 2022, p. 32.

[33]Name withheld, Submission 142, p. 1.

[34]Moderna Australia, Submission 170, p. 3.

[35]Moderna Australia, Submission 170, p. 3.

[36]AstraZeneca, Submission 247, p. 2.

[37]See, for example: Namewithheld, Submission 121, p. 2; ProfessorKerryn Phelps AM, Submission 510, p.8; COVERSE Ltd, Submission 516, p. 2; Dr Melissa McCann, Submission 547, p. 5.

[38]Dr Lucas de Toca, First Assistant Secretary, National COVID-19 Vaccine Program, Department of Health and Aged Care, Committee Hansard, Canberra, 17 February 2023, p. 14.

[39]New South Wales Government, COVID-19 antivirals – your questions answered, www.nsw.gov.au/covid-19/testing-managing/antivirals#toc-what-are-antivirals, viewed on 29 March 2023.

[40]See, for example: MrColin Kinner, Submission 186, p. 5; Australian Pathology, Submission 206, p. 3; Namewithheld, Submission 228, p. 7; National Heart Foundation of Australia, Submission 284, p. 5; OzSAGE, Submission 299, pp.2–3; Professor Kerryn Phelps AM, Submission 510, p. 11.

[41]Department of Health and Aged Care, Submission 196, p. 21.

[42]Department of Health and Aged Care, Submission 196, pages 31-32.

[43]Department of Health and Aged Care, Submission 196, p. 21.

[44]Public Health Association of Australia, Submission 351, p. 8, citations omitted.

[45]Y Xie et al., ‘Association of Treatment With Nirmatrelvir and the Risk of Post–COVID-19 Condition’, doi:10.1001/jamainternmed.2023.0743, viewed 13 April 2023.

[46]Dr Anthony Kelleher, Director, Kirby Institute, Committee Hansard, Malvern, 20 February 2023, p. 39.

[47]Department of Health and Aged Care, Pharmaceutical Benefits Advisory Committee (PBASC) Membership, www.pbs.gov.au/pbs/industry/listing/participants/pbac, viewed 22 March 2023.

[48]Department of Health and Aged Care, Pharmaceutical Benefits Advisory Committee (PBASC) Membership, www.pbs.gov.au/pbs/industry/listing/participants/pbac, viewed 22 March 2023.

[49]Department of Health and Aged Care, Submission 196, p. 20.

[50]Department of Health and Aged Care, Submission 196, p. 20.

[51]MSD Australia, Submission 452, p. 4.

[52]Pfizer Australia, Submission 225.1, p. 5.

[53]Department of Health and Aged Care, Oral treatments for COVID-19, www.health.gov.au/health-alerts/covid-19/treatments/oral, viewed 7 March 2023.

[54]The Hon Mark Butler MP, Minister for Health and Aged Care, ‘Expanded access to subsidised oral antiviral Paxlovid and other COVID-19 supports’, Media Release, 30 March 2023.

[55]NPS MedicineWise, Changes to COVID-19 oral antiviral PBS eligibility criteria – July 2022, www.nps.org.au/radar/articles/changes-to-covid-19-oral-antiviral-pbs-eligibility-criteria, viewed 17 March 2023.

[56]NPS MedicineWise, Changes to COVID-19 oral antiviral PBS eligibility criteria – July 2022, www.nps.org.au/radar/articles/changes-to-covid-19-oral-antiviral-pbs-eligibility-criteria, viewed 17 March 2023.

[57]Department of Health and Aged Care, Pharmaceutical Benefits Scheme - A-Z medicine listing – Viewing by Drug, www.pbs.gov.au/browse/medicine-listing, viewed 14 March 2023.

[58]Department of Health and Aged Care, COVID-19 oral treatments, 1 January 2023, p. 6.

[59]The Pharmacy Guild of Australia, Submission 337, p. 4.

[60]The Pharmacy Guild of Australia, Submission 337, pages 2–3.

[61]Name withheld, Submission 233, p. 4.

[62]See, for example: Name withheld, Submission 12, p. 8; Name withheld, Submission 13, p. 1; Name withheld, Submission 75, p. 4; Name withheld, Submission 83, p. 6; Name withheld, Submission 162, p. 9; Namewithheld, Submission 189, p. 2; Name withheld, Submission 229, p.3; RuthNewport, Submission 231, p. 7; Name withheld, Submission233, p. 5; Name withheld, Submission 234, p. 10; J.T. Smith, Submission 281, p.3; OzSAGE, Submission 299, p. 10; Name withheld, Submission 303, p. 1; Australia Long Covid Community Facebook Group, Submission 309, p. 3; Name withheld, Submission 326, p. 1; Name withheld, Submission 347, p. 1; MrJonathan Munro, Submission 360, p. 1; Name withheld, Submission375, p. 1; Michelle Yang, Submission 395, p. 1; Name withheld, Submission 505, p. 3; Name withheld, Submission533, p. 3; Associate Professor Nada Hamad, private capacity, Committee Hansard, Canberra, 17 February 2023, p. 22.

[63]Name withheld, Submission 221, p. 4. See also, Name withheld, Submission 298, p. 1; Name withheld, Submission 488, p. 4.

[64]OzSAGE, Submission 299, p. 10.

[65]Bethany and Matthew Wormald, Submission 11, p. 2.

[66]Name withheld, Submission 147, p. 4.

[67]Name withheld, Submission 3, p. 8.

[68]Royal Australian College of General Practitioners, ‘A welcome step’ WHO acknowledges aerosol spread of COVID-19, www1.racgp.org.au/newsgp/clinical/a-welcome-step-who-acknowledges-aerosol-spread-of, viewed 22March2023.

[69]NSW Department of Planning and Environment, National Construction Code, www.planning.nsw.gov.au/policy-and-legislation/buildings/national-construction-code, viewed 23 March 2023.

[70]See: National Construction Code, 2019, Volume Two Amendment 1, ncc.abcb.gov.au/editions/2019-a1/ncc-2019-volume-two-amendment-1/part-38-health-and-amenity/part-385-ventilation, viewed 22 March 2023.

[71]See, for example: ACT Government, COVID-19 guidance on ventilation, www.covid19.act.gov.au/stay-safe-and-healthy/covid-19-guidance-on-ventilation, viewed 2 March 2023; Department for Education South Australia, Statement on ventilation in schools, www.education.sa.gov.au/department/media-centre/our-news/statement-ventilation-schools, viewed 2 March 2023; Department of Health (Tasmania), Best Practice COVID-19 Workplace Safety: Ventilation fact sheet, www.health.tas.gov.au/publications/best-practice-covid-19-workplace-safety-ventilation-fact-sheet, viewed 3 March 2023; Department of Health (Western Australia), Information on COVID-19 and building ventilation, www.health.wa.gov.au/~/media/Corp/Documents/Health-for/Infectious-disease/COVID19/COVID-19-ventilation-in-buildings.pdf, viewed 2 March 2023; New South Wales Government, COVID-19 guidance on ventilation, www.nsw.gov.au/covid-19/business/guidance/ventilation, viewed 2 March 2023; Queensland Department of Education, Managing air quality, www.education.qld.gov.au/initiatives-and-strategies/health-and-wellbeing/workplaces/safety/managing-air-quality, viewed 2 March 2023; WorkSafe Queensland, Improving ventilation in indoor workplaces,www.worksafe.qld.gov.au/news-and-events/newsletters/esafe-newsletters/esafe-editions/esafe/april-2021/improving-ventilation-in-indoor-workplaces, viewed 2 March 2023; Victorian Government, Ventilation, www.coronavirus.vic.gov.au/ventilation, viewed 2 March 2023.

[72]Professor Brendan Crabb AC, Director and Chief Executive, Burnet Institute, Committee Hansard, Malvern, 20February 2023, p. 5.

[73]Professor Brendan Crabb AC, Director and Chief Executive, Burnet Institute, Committee Hansard, Malvern, 20 February 2023, p. 5.

[74]See, for example: Name withheld, Submission 1, pages 4–5; Name withheld, Submission 13, p. 1; Namewithheld, Submission 17, p. 1; Name withheld, Submission 25, p. 1; Name withheld, Submission 28, p.4; Caroline Molloy, Submission 43, p. 2; Name withheld, Submission 46, p. 3; Name withheld, Submission51, p. 1; Name withheld, Submission 71, p. 1; Name withheld, Submission 77, p. 1; Namewithheld, Submission104, p.2; Ms Amelia Kerr, Submission 139, pages 4–5; Name withheld, Submission 141, p.2; Burnet Institute, Submission 149, p. 2; Name withheld, Submission 162, pages14–15; Name withheld, Submission 171, p.4; Name withheld, Submission 174, p.3; Name withheld, Submission185, p.8; Mr Colin Kinner, Submission 186, p.7; Name withheld, Submission 194, p.9; Namewithheld, Submission 204, p. 3; Name withheld, Submission 207, p. 3; Name withheld, Submission 217, p. 2; Name withheld, Submission 218, p. 2; Brian Jackson, Submission 223, p. 1; Name withheld, Submission 228, p. 6; Ruth Newport, Submission 231, p. 7; Dr Anita White, Submission 238, pages 6–9; John Curtin Research Centre, Submission 243, pages2, 9; Australian Council of Trade Unions, Submission251, p. 8; Associate Professor Robyn Schofield, Submission, 254, pages 1–11; ProfessorJeremy Howard, Submission 263, pages 1–8; Professor Geoffrey Hanmer (Director at OzSAGE and Adjunct Professor within the School of Architecture at the University of Adelaide), Submission 274, pages 1–18; Australian Education Union Federal Office, Submission 276, pages 3–4; Name withheld, Submission282, p.6; Peri Coleman, Submission296, p. 2; OzSAGE, Submission 299, pages 2–7, 19; Distinguished Professor Lidia Morawska, Submission 304, pages 1–3.

[75]Professor Geoffrey Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, pages 22–26; Distinguished Professor Lidia Morawska, School of Earth and Atmospheric Sciences, Queensland University of Technology, Committee Hansard, Malvern, 20 February 2023, pages 26–30; Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20February 2023, pages 18–21.

[76]Associate Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 18.

[77]Distinguished Professor Lidia Morawska, School of Earth and Atmospheric Sciences, Queensland University of Technology, Committee Hansard, Malvern, 20 February 2023, p. 26.

[78]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, p. 22.

[79]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, p. 22.

[80]Associate Professor Robyn Schofield, Submission 254, p. 2. See also, Department of Climate Change, Energy, the Environment and Water, Indoor air, www.dcceew.gov.au/environment/protection/air-quality/indoor-air, viewed 22 March 2023.

[81]Associate Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 19. See also, Department of Climate Change, Energy, the Environment and Water, Indoor air, www.dcceew.gov.au/environment/protection/air-quality/indoor-air, viewed 22 March 2023.

[82]Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 20.

[83]Adjunct Professor Giorgio Buonanno, Submission 130, p. 1.

[84]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, p. 27.

[85]COVID Safe Schools Inc, Submission 306, p. 21, citations omitted.

[86]Ms Karen Armstrong, Acting President, Covid Safe Schools Inc, Committee Hansard, Malvern, 20 February 2023, pages 38–39.

[87]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, p. 22.

[88]See, for example: Name withheld, Submission 1, p. 5; Name withheld, Submission 17, p. 1; Name withheld, Submission 25, p. 1; Name withheld, Submission 46, p. 3.

[89]Distinguished Professor Lidia Morawska, Submission 304.2, pages 41–43.

[90]Distinguished Professor Lidia Morawska, School of Earth and Atmospheric Sciences, Queensland University of Technology, Committee Hansard, Malvern, 20 February 2023, p. 28.

[91]Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 18.

[92]Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 18.

[93]The National Construction Code is a performance-based code that sets minimum required levels for ‘safety, health, amenity, accessibility and sustainability of certain buildings.’ See: Australian Building Codes Board, National Construction Code, ncc.abcb.gov.au/, viewed 22 March 2023.

[94]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, pages 22–23.

[95]Name withheld, Submission 46, p. 3.

[96]Professor Robyn Schofield, Associate Professor of Atmospheric Chemistry, University of Melbourne, Committee Hansard, Malvern, 20 February 2023, p. 21.

[97]Professor Geoff Hanmer, Director, OzSAGE (and Adjunct Professor within the School of Architecture at the University of Adelaide), Committee Hansard, Malvern, 20 February 2023, p. 23.

[98]See, for example: Lisa Kava, Submission 157, p. 4; Donna Cicca, Submission 192, p. 1; Barbara Romeril and Marg Hutton, Submission 201, p. 5; Professor Quentin Grafton, Submission 208, pages 2, 15; Namewithheld, Submission 227, p. 2; John Curtin Research Centre, Submission 243, p. 2; John Curtin Research Centre, Submission 243.1, p. 1; Professor Geoff Hanmer (Director at OzSAGE and Adjunct Professor within the School of Architecture at the University of Adelaide), Submission 274, p. 4; Name withheld, Submission282, p. 6; OzSAGE, Submission 299, p. 3; Name withheld, Submission 365, p. 3; Name withheld, Submission 445, p. 1; Namewithheld, Submission 463, p. 4; Dr BenjaminVeness, Submission 492, p. 4; MrChristopher Jones, Submission 498, p. 3; Name withheld, Submission 503, p. 9; Name withheld, Submission 542, p.8; Ms Karen Armstrong, Acting President, Covid Safe Schools Inc, Committee Hansard, Malvern, 20 February 2023, p. 38.

[99]OzSAGE, Submission 299, p. 3.

[100]Name withheld, Submission 228, p. 8, citations omitted.

[101]See: Department of Health and Aged Care, COVID-19 and vaccines campaign advertisements, www.health.gov.au/our-work/covid-19-vaccines/campaign/covid-19-and-vaccines-campaign-videos/covid-19-and-vaccines-campaign-advertisements, viewed 12 April 2023.

[102]See: Therapeutic Goods Administration, Reporting suspected side effects associated with a COVID-19 vaccine, www.tga.gov.au/products/covid-19/covid-19-vaccines/covid-19-vaccine-safety-monitoring-and-reporting/reporting-suspected-side-effects-associated-covid-19-vaccine, viewed 8 March 2023.

[103]See, for example: Y Xie et al., ‘Association of Treatment With Nirmatrelvir and the Risk of Post–COVID-19 Condition’, doi:10.1001/jamainternmed.2023.0743, viewed 13 April 2023.