COSSI Webinar: Mandatory Covid-19 vaccination YT Video Transcript https://www.youtube.com/watch?v=nDZ8wTcmlgQ 1,600 views Jul 27, 2021 This webinar was recorded on Monday 26 July 2021. Vaccination against COVID-19 is the main tool for bringing the world out of the COVID-19 pandemic. Mandatory vaccination has been debated as a strategy to get high vaccination coverage and protect individuals in certain settings. This webinar considered the policy, behavioural, ethical and epidemiological aspects of mandating COVID-19 vaccination. In this webinar: find out what vaccination mandates are, who they may be used for and how they could be delivered hear about the governance and political aspects of vaccination mandates - hear about epidemiological, behavioural and social considerations of mandates including effectiveness hear about ethical considerations of vaccine mandates for adults Speakers: Dr Katie Attwell Associate Professor James Wood Professor Julie Leask Dr Jane Williams Moderators: Associate Professor Margie Danchin (Chair of COSSI) Associate Professor Holly Seale (Deputy Chair of COSSI) Start of Autogenerated TubeYou Transcript With Timestamps 0:00 Start Prof MD: ..you to join but oh. uh I'd like to welcome everyone today to the COSSI webinar exploring mandated Covid-19 vaccinations. I'm Dr Margie Danchin. I'm a pediatrician and immunization researcher at the Murdoch Children's Research Institute and I'm the current chair of COSSI and I warmly welcome you today. But before we get started I would like.. 0:27 ..to acknowledge the traditional owners of the lands on which we are all meeting today. Which for me is the Wurundji people of the Kulin nation and to pay my respects to their elders past, present and emerging. So we have a really exciting webinar uh.. 0:45 ..for you all today on Covid uh mandatory vaccination. And of course mandates for Covid vaccines including vaccine passports after vaccination or with presumed immunity and incentives are currently under consideration or already implemented in several public and private settings both in Australia and globally. And mandatory vaccination continues to be debated.. 1:10 ..hotly as a strategy to get high vaccination coverage and to protect individuals in the community. So these are some of the themes that we're going to be covering today; including the social, ethical and epidemiological implications and considerations. So just to give you a broad outline of the webinar today... 1:33 ..the whole session will run for about 90 minutes so we aim to finish at around 3:30 not 4pm as originally indicated. And in the first hour we're going to have uh, four separate speakers and then uh, in the 30 minutes at the end we're going to have a moderated question and answer session by myself and uh the Deputy Chair of COSSI - Associate Professor Holly Seale who is familiar.. 1:59 ..to many of you. She's a leading Infectious Diseases Social scientist at UNSW and she will also do a wrap up for us at the end of the session. 2:10 So without further ado i would like to introduce our first speaker Dr (inaudible) and while I'm introducing Katie she can share her slides. So Katie is an Australian Research Council discovery early career research ah award fellow and one of the world's leading experts on mandatory childhood vaccination which is actually the topic of her ARC funded fellowship. Katie's also leading.. 2:36 ..the interdisciplinary project Coronavax in WA which is looking at preparing the community and government for Covid-19 vaccines and she's also conducted research on community attitudes regarding Covid-19 vaccine mandates as well. Katie's going to talk to us about the governance and political aspects of mandates so over to you Katie and a warm welcome. Dr KA: Thank you Margie I just like to confirm that you can all see a proper slideshow not just an ugly kind of Powerpoint file? Is that right? 3:09 Prof MD: thats perfect Katie Dr KA: Okay, a world of win. Let's go. All right. So I've entitled my presentation Covid-19 Vaccine Mandates: Who, What and How. Um I'd also like to start by acknowledging that I'm on Noongar land today um and pay my respect to elders past and present and encourage all of you to think about the land that you're on and the traditional owners of that land as well.. 3:33 ..okay. So. Mandatory vaccination slash vaccine mandates: what exactly are we talking about? The first thing I wanted to convey to you is that this idea has actually really only started to cohere in the last few years. Um, there's been a lot of talk.. 3:52 ..about vaccine mandates in particular contexts where people then generally regard their country's version to be sort of self-evident. But to kind of do the global consent, comparative and conceptual work has only become something that's happened much more recently. Um and certainly mandates are poorly.. 4:10 ..understood by the general public. And that's very true for recent work that my Coronavax team in Western Australia has done with regard to Covid-19 mandates; where people throw around words like mandates or incentives or compulsory without really um having a lot of clarity about what they mean or indeed having a lot of overlap um in what we would regard those concepts to be... 4:34 ..and this is a quote from Harry which really, really summarizes that 'it shouldn't be mandatory but they could encourage people by like blocking their tax refund or blocking their Centrelink.' So what Harry regards to be an encouragement or an incentive um and many of our participants use those words um.. 4:51 ..I would actually regard to be a vaccine mandate. So if we unpack vaccine mandates a little bit more and kind of try and work with um getting a concept and a definition going. A mandate is a policy intervention that imposes consequences for non-vaccination. So something happens to you if you don't comply with the government requirement for you to vaccinate or indeed as we will discuss.. 5:17 ..it perhaps a private requirement. And mandates aren't new for vaccination. Um governments have historically imposed them in various settings in our own Australia, uhm at a federal and state level we've got the no jab policies applying to childhood vaccination limiting access to family financial entitlements and child care subsidies. For adults and indeed for anybody traveling to certain areas um, yellow fever vaccine requirements are in.. 5:47 ..place for some governments. And we would be familiar as well that if you work for a health employer, you might have to have certain vaccines before you start in the job or demonstrate immunity and you might be required to have the flu vaccine annually. 6:04 And this is one of the things that's a bit complex or tricky when talking about vaccine mandates. It may include a consequence that um, that the person interpreting it might think of as an incentive like I talked about in that quote that i shared. 6:18 Um, in Australia we had the maternity immunization allowance um for many years for childhood vaccination which strictly was an incentive, um but if this was to be removed from somebody who chose not to vaccinate it would likely feel like a punishment if it was a form of money that everybody else was getting and you weren't. 6:37 So although some would say we should be very clear about the distinction between an incentive and a mandate, I think we also need to carefully consider that certain incentives might feel like a punishment if everybody doesn't get them. Or indeed if the thing you're in being incentivized to do and there you then.. 6:53 ..you miss out on is something like travelling interstate or internationally. Um, certainly in the context of Covid, what I want to suggest to you today is that mandates may also include something that I refer to as a collective requirement. Which I'll come back to but is the idea that um perhaps a mandate may not apply to me personally so Katie Atwell.. 7:16 ..if you're not vaccinated you can't get on that plane or you can't go and visit somebody in that nursing home. But rather West Australians where I am, collectively if you as a population don't get 70% of you covered by a Covid-19 vaccine, you as a group may not be allowed to come and go freely and travel in Bali which is all West Australians ever seem to do. So it might be that governments use.. 7:43 ..collective requirements to motivate individual behavior but based on the idea that collectively we will be allowed or not allowed to do certain things. 7:54 Finally a mandate with exemptions or opt-outs is still a mandate, but it may be less salient. And I'll explain what I mean by that in a moment. I just first I want to touch on this question of why are we mandating. And to get us thinking about who are the target population of vaccine mandates. So at a population level we can think about there being two under vaccinated groups; those who have.. 8:22 ..access barriers that mean that the system is not reaching them appropriately or it's not easy enough for them to overcome complacency or busy lives or complex factors making life difficult to go and get vaccinated. And then of course the one that gets all the headlines which is acceptance barriers. So this includes vaccine hesitancy and refusal. So these two different groups of people who may be under vaccinated can both be.. 8:47 ..reached and affected by vaccine mandates. But we would want to think about which group is perhaps being targeted by them. Within the acceptance subgroup sorry within the acceptance group there are two further subgroups. There are those who are very determined that they're not going to vaccinate and there are those who are hesitant. And the idea of a mandate for these people is you might manage to change their behaviour even if they don't really want you to. Um you might be able to push some of.. 9:16 ..these people over the line using a mandate. And finally to note that when thinking about this access and acceptance distinction, we want to think about the lever of the mandate and ask ourselves 'is it being aimed at basic social compliance?' kind of getting everybody over the line. Or is this actually about saying 'no if you refuse, something bad is going to happen to you' because you don't deserve to have good things happen.. 9:42 ..if you choose not to participate in this vaccination program. So I did some conceptual work a few years ago with an American scholar called Mark Navin and it uses this idea of The Five S's. I'm going to briefly talk you through that now in the context of Covid-19 kind of updating some of these ideas. So The 5s's refer to; scope, sanctions and their severity and selectivity which I'll briefly unpack now. So the scope is which vaccines are mandated. Now obviously in this context, derrrr it's Covid-19 vaccines. But still which ones? 10:18 Right? You know which specific vaccine? Um and obviously internally we know that right now if, if we were to have mandates they would apply to the vaccines that we currently have approved and available in our population. But if we're thinking about mandates applying to people coming into the country for example, we might have to think about the vaccines we haven't.. 10:36 ..approved. And what do we think about those as uh, as being included or not included in the status of being vaccinated? The other crucial point here is which populations. Are we talking about mandates for the general public or are we talking about mandates for aged care workers; for a subset, for a specific population group. Sanctions: this is seemingly one of the most crucial questions at the moment when mandates are talked about. What happens to people who don't vaccinate? What is the consequence associated with the mandate and relatedly how severe is that? Because for example if the consequence.. 11:12 ..was a fine. Is it $50 or is it $50,000? Selectivity is the question of how to enforce or exempt people from Sanctions. So there will always be people who don't have to follow the vaccine mandate - but who? and how? 11:28 And if you put those things together into the cauldron what you come up with is Salience. Which when we're talking about a specific vaccine mandate, how do all of these factors come together to determine how burdensome it is if I don't vaccinate. Like how much is that actually going to impact my behavior? And in this I would really note that the local context matters. So.. 11:50 ..what this looks like in one place will be different from what it looks like in another. And what's novel in the context of Covid-19 is that we have new private sector actors and agents applying or potentially applying mandates like this - arguably for the first time. 12:09 So Sanction design I mentioned is really perhaps one of the key focuses at the moment one of the most important things. And what I'm going to just run through is a theoretical kind of view of what some of the sanctions could be. The ones up this end I think we're very unlikely to see in this country. But you know forced vaccination is on the books in some places it's on the books in some American states. 12:32 It's generally left in the box but it's something that States do have at their disposal. Certainly in Australia it's not something that could form part of a routine vaccination program, uh and it's not something governments could do in a policy sense. Criminalize non-vaccination - the idea of fines and imprisonment - is something that's historically been used for childhood vaccination in other settings. Again it's not something we're associating here in Australia with our policy history. What we do have instead is the idea of.. 13:02 ..losing financial entitlements if you don't fully vaccinate your kids. And also this idea that you might be excluded from public spaces where the collective gathers. And again in the childhood space, our state governments have done this for child care, American states do it for schools. Um, other countries do it for schools but for the first time we're seeing that businesses might say this to their clients now which again would be a very novel thing to do. Restrictions on travel is obviously.. 13:31 ..another hugely important area where mandates may apply. Within a state, between states and between Australia and overseas. People also being unable to do certain types of work and this is obviously um government may say, oh you know if you work in um a particular industry, whether it's working for us the government or working for somebody else you have to be vaccinated. Um it may be.. 13:56 ..an employer doing it um, with what's within the law and within um, the agreements that um govern the way that we work. Ah but Queensland um, for a short time did a very weird version where they said 'okay businesses will empower you to exclude um, you know unvaccinated people if you want to' um, which Queensland has some form for doing in the childhood setting as well.. 14:18 ..um and anyway they rolled it back and replaced it with something more conventional. Um now, I've put incentives in here and I want to be very clear that these are not mandates and certainly the way we're seeing incentives operate at the moment - ideas of lotteries or the famous joints for jabs in Washington - these are not mandates. However if we were to look at something like a cash incentive that was $500 for everybody that goes and gets.. 14:44 ..vaccinated, you could very quickly see people developing a narrative whereby that would start to feel like a mandate for those for example who are reliant on money from the state and who are impoverished. So I'm wanting us to think carefully about incentives but I do want to be clear that in general incentives are not classed as mandates. 15:04 I've already mentioned collective requirements so that's something else to throw in the mix. What might government say to a group of us? Perhaps a state or a country? About collectively what we might need to get to in order for our freedom to change in order to things, do things like travel. Now exemptions are.. 15:23 ..a key aspect of mandates and so here I just want to talk through a few of the key features of them. Um, it's pretty much a given that medical exemptions will apply. Um, but the big questions here is who designs them and who governs them and I and other experts would argue that it's best if it's a government thing, So even if we're talking about my local Chinese restaurant introducing a mandate and saying 'if you're not vaccinated you're not coming in for a dinner,' um it would be better if they're not actually then having to decide who would be medically exempt from that. It's governments who have that technical.. 15:59 ..capacity and they should be deciding um, what you know, following the advice of technical experts, what medical contraindications should exist and should apply. And again experts would be arguing that we actually need a bit of scope, a bit of wiggle room for special exemptions to allow discretion in certain scenarios. 16:19 Much more controversial perhaps is what we should do with people who don't want to vaccinate in the event of mandates being applied. And what's been done um, formerly in Israel and now is being introduced in France and Italy is this idea that you have to be vaccinated. You have to demonstrate proof of vaccination in order to participate and enter in certain public spaces. But you can actually also get into those spaces if you can show that you have antibodies to Covid- 19 or a negative recent test. Now it's noteworthy that when Israeli officials brought this policy in, they explicitly constructed this as the.. 16:56 ..opt-out for vaccination and they were mindful of the fact of designing it in a way that was burdensome, and in fact more burdensome than the alternative of getting vaccinated. And for those of us who are involved in behavioral science and vaccination - we would know that that's actually the kind of optimum way to design a mandate. 17:15 You want to have its exemption available but you want it more difficult than the default setting you're seeking. And of course it will be a political issue and question for people as to whether they're willing to tolerate those um, opt-outs but certainly governments can draw strength from them. And certainly we found this in our study here in WA.. 17:34 ..that people link this to the kind of restrictions they're already used to. They're used to being not allowed in public space because they might spread disease so they would see not being allowed in public space without being vaccinated as an extension of that. But I note that the UK is saying that won't be enough for nightclubbing, you.. 17:53 ..will actually have to have been vaccinated. So you know watch this space. Um, also in terms of travel mandates, um some of us in Australia have discussed the idea that perhaps if you don't want to be vaccinated and you still want to travel, then at your destination you may have to fund your own mandatory quarantine if you're not fully vaccinated against Covid-19. Um.. 18:16 ..in a, in again again in that risk mitigation perspective, so that you're not actually spreading the disease, um if you're choosing not to be vaccinated when you travel. So this has been a whistle-stop tour by me of some of the policy and governance implications of mandates and i very much now look forward to handing over to my esteemed colleagues who are presenting today around the other aspects of mandates and returning to all of you in the question time. So that's me signing off for now. Thanks for your attention. 18:48 Dr MD: Thanks so much Katie. That was really excellent. Um, certainly a lot of food for thought there. Ah I forgot to say at the start please put any questions or comments for Katie into the q and a session. I think a couple of people are already doing that which is fantastic and obviously we'll get to all of those at the end of the four talks. 19:06 So I'm going to introduce our next speaker now, uh who is uh, Dr James Wood. And James while I'm introducing you please go ahead and share your slides. So James is an associate professor in the School of Population Health at UNSW in Sydney and he has specific expertise in Epidemiology and Modeling, for vaccine preventable diseases. And he's a current member.. 19:31 ..of uh the first ATAGI working group on vaccine prioritization and uh f, for population. So James is going to talk to us now about some of the critical epidemiological considerations for Covid mandates. Thanks James and over to you. Dr JW: Maggie, can I just check is.. 19:49 Dr JW: ..are my slides showing properly? Prof MD : you pop them into presenter view? That's perfect. Dr JW: Okay perfect. All right thanks. Um, Hi everyone. Um, so I'm going to just try and talk through some of the epidemiological considerations for, for Covid-19 mandates.. 20:06 ..um, and I guess I, I'm speaking this, as a capacity as a sort of eh, infectious epidemiologist and modeler, uh who's involved also in, um vaccination work quite heavily. So just while I get my, sorry. 20:22 So just the basic considerations, I've got quite a bit of text on my slides but I'm just going to step through this quite simply, and you can read as you go along. Um, So when we're thinking about reasons why you might want to impose a mandate, or you know, enhance coverage, uh firstly I guess we think about the burden of disease and.. 20:41 ..I think we know that Covid is a severe infection. Um, I guess the other thing is we expect it to be extremely common if we relax restrictions, and so that eventually maybe everyone will become exposed to Covid. A third point which i just will comment on a little bit more on the next slide is just that also there's quite varied outcomes for Covid. So you've got specific groups which are a high risk of.. 21:01 .. um severe events but also other groups that might be more important in terms of transmitting Covid and this also potentially bears on questions about um, things like mandates. Um, Secondly, what do vaccines do? Do they uh, stop you getting sick or do they also um, prevent.. 21:19 ..transmission? And we have evidence from the the randomized clinical trials that uh, the Covid vaccines are very effective against uh, symptomatic disease. And since then from observational studies in countries.. 21:31 ..that have had you know, very large population coverage, we know that there's very high protection against hospitalization and death. But also good protection against infection itself. And if you do.. 21:43 ..become infected as a vaccinated person, that you're less likely to transmit to others. Okay so there's good evidence of what we call indirect protection: the ability for, for the Covid vaccines to interrupt transmission. Um, I should note that the Delta variant is a sort of a new feature here. Um, it ehh, sort of somewhat reduces the.. 22:02 ..ability of the vaccines to protect against infection. But it they still interrupt transmission against the Delta variant so these, these sort of points still apply for for Delta. Um, finally, I guess that and the key point.. 22:15 ..is that the reduction in transmission due to vaccines is proportional to vaccination coverage in the population. So the more coverage you have, the more you interrupt transmission. And therefore there is err, a kind of a.. 22:28 ..um, this weighs on the, the question about whether you should be aiming for particular coverage targets or whether you should be taking steps to trying to ensure higher coverage. So I'm going to focus on the overall um, population level where most of the data is. But um, you can think about uh, I think Katie.. 22:45 ..touched on this area such as workplaces where um, you might have close tong, contact with vulnerable individuals as workers. Or you might be thinking um, how you, you know workplaces where, the loss of work time might be very costly and so there might be economic reasons to think about.. 23:02 ..and have attaining high coverage in workplaces. So just to kind of um, talk about this balance between um, transmission and um, disease. I've just pulled some data from the Netherlands here. As of about February this year and sorry there's a bit of Dutch on these slides um. But at the left I've just shown.. 23:21 ..evidence from their blood surveys about who gets infected in different age groups. And so, in the sort of this 18 to um, 24, 34 sort of age group, you have the highest rates of infection. 23:33 Okay. And it declines into older age. So about half as high in people of sort of 50 or 60 and a bit lower again in, in older people. Um, and of course this was in the context of some restrictions but not nearly as much as we've had here. Um, and then on the right here I've shown, I'm showing, um, what, what's hap what.. 23:51 ..happened with mortality. Okay. And you see that that's all concentrated in people over 50. Of course they did have deaths in people under 50. But ,you know the, the severe burden is very much in that older age group. So you've got.. 24:03 ..two different groups; one which you really want to protect through direct protection, and the other who might be responsible for uh, you know, exposing people to, to Covid. And so both these, these, these issues are sort of relevant in terms of thinking about... why we need potentially high crub.. 24:20 ..coverage and, and why it might be for different reasons in different groups. 24:25 Okay, so I, I wanted to talk through very briefly, um some of the evidence a little bit more detail about, um disease burden and sort of (inaudible) how the, how well vaccines work. Um, so just firstly I want to sort of note that the Delta strain has changed quite a bit of thinking about the level of vaccine coverage that's needed to open up. Um, it's, it's much more transmissible than the strains that we had last year. Um and, as you know, I'm in Sydney and I think probably a number of our audience are. Uh.. 24:58 ..we're struggling to contain this, even with a lock-down and very good contact tracing here. So this notion of maintaining Fortress Australia um, has sort of cracked a bit. So anyway there's all I'm saying is, is there's urgency around this. Uh, secondly um... you know, we know that vaccines, they provide very good protection against disease but they're not sterilizing. They don't.. 25:22 ..completely stop you getting infected. Um and like other respiratory viruses, we do expect that in the longer term, um we're going to be exposed and re-exposed to SARS-COV-2. We don't think it's going to go away, but the longer term is unclear. Is it going to be a benign infection like other human corona-viruses? Or is it going.. 25:43 ..to be something we're a bit more worried about, like flu? where you have seasonal peaks and so on that's unclear at the moment but we do.. 25:50 ..expect this to be a long-term um, you know, infection in our populations. So getting on to the um, the the evidence around um, vaccine efficacy there's this nice summary table that the UK puts out in its weekly uh, vaccine surveillance reports. Um, and I just sort of highlighted these lines around severe disease and infection. Uh, prevention of infection.. 26:15 ..and transmission here. Um, this largely reflects the Alpha variant so that was the, the one which caused the big wave um, over winter in, in the UK. So that there is emerging data around Delta but it's not contained in this table. 26:27 But just to show that um, you know f, for hospitalization and mortality the, the efficacy is really up around these sort of 95 percent or maybe even better. It's a little bit uncertain for the Astrazeneca um ,vaccine in this in this table but the more recent data for Delta suggests that the values are similar. So we're talking about being about, around.. 26:45 ..about 95 effective or better against hospitalization and death for the two vaccines we're using in Australia. 26:52 The effect, effect on infection is less, okay. So um, there's not a huge amount of data for second dose vaccines, particularly around uh, breakthrough infection. This was around sort of 50 to 70 percent uh, um, earlier on But now we're seeing with uh, the Delta strain, it's a little bit lower against protection against infection. 27:13 But when you look at the combined effect of reducing your chance of being infected and then uh, your chance of you know, if you get breakthrough infection, having a less severe course and being less likely to transmit to others, We still think that the, the vaccines are going to be about 85 to 95 effective at reducing transmission on a per person basis. I guess you know there's a lot of numbers there. What does that sort of mean? So I'm going.. 27:38 ..to get on to, uh some of that over the next few slides, including some examples of what we think different levels of coverage might mean in Australia. So um, but before I get to that I just want to bring up um, safety considerations. Because, you know, if you're thinking about rolling out vaccines um, to large numbers of people and.. 27:56 ..potentially if you're saying that they have to take, have, have to have the vaccines then safety is a of course a consideration. And we're all aware of some of the safety issues that have arisen with the vaccines that we're using in Australia. 28:08 So I'm not going to talk about minor side effects and, and anaphylaxis. Which of course is you know, is, is a serious concern but one we manage extremely well in Australia. Um, but with the Astrazeneca vaccine of course um, uh this issue of blood clots with low platelets. So TTS, um emerged, you know in Europe earlier this year and is one that ha, has been reacted to by Australian advisory groups in terms of the age, the preferential recommendations for different ages. Um, in terms of the data that we're seeing in Australia. So I think a lot of the focus has been on, um the, the incidents, and, and deaths.. 28:48 ..um and you don't see a huge change in incidents from younger people to older people. But it certainly declines. Uh, we don't have much data in people under 40 because we, we, we changed our recommendation quite early for that, for those groups. But the, the aspect which perhaps has been less well publicized is the change.. 29:05 ..in severity with age. So in, uh people under 50, um almost all the cases have been what we call this tier one classification which is where the, the clot occurs at an unusual location; whether it be in the brain or in the abdomen. At the sort of the key points and those tend to be quite severe. 29:23 Um, as you get into older people um, this rate really reduces. So by the time you're in the 60 plus group it's less than 30%. And so these two kind of things together are kind of what have governed, the sort of uh, recommendations around, uh age-specific use of this vaccine. Now all of this can't be taken in isolation if you're at high risk of being exposed to COVID.. 29:46 ..then in almost all age groups the, the, the benefits the vaccines still outweigh um, the uh, you know, the risks associated because of prevention of COVID. But just to point out that, you know, this, this does certainly makes it a.. 30:00 ..circumstantial kind of, something that where policy needs to be adapted to circumstance. And, and potentially offers some challenges in terms of mandated use of the Astrazeneca vaccine in for example workplace settings. Um.. 30:14 ..uh for the Pfizer vaccine um, there is some emerging evidence for the link between the Pfizer vaccine and Mycocarditis and Pericarditis. 30:22 Um, and this is sort of particularly after dose two in, in younger men. So ah, I, I believe under the age of 25 is sort of particularly the concerning area. Now this is still emerging and so it's not considered to be a proven link at present but has led to initial caution in the UK and other European countries in terms of recommending, uh vaccination of healthy children. Okay, so that's, that's sort of, some of.. 30:47 ..the safety considerations. At present, I should say at the moment we're a long way from um, having enough vaccine to be able to vaccinate children and the evidence around these uh, different uh, safety considerations we look stronger by the time we are. Um, So I want to get on to some examples of.. 31:03 ..how coverage influences restrictions. Um, and just to sort of make a couple of brief points ,we think that every person who's infect, on average each person infected with Delta, is uh infects about five others, with a lot of.. 31:17 ..variation between individuals. Um, and to get to herd immunity we would need four out of every five people to be immune. Um, we think the vaccines are pretty good at, at preventing onward transmission but um, only say 85 to 95 percent effective. So if we assume they were 90 effective, um yeah, we would need eight out of every nine people to be vaccinated. So 90% coverage. Um, I think this is optimistic. 31:44 So, um there are some questions about whether specific groups, you know, you don't need that across the whole population and you certainly wouldn't need that in children. But um, I, I guess the point I'm trying to er, get across here is that even if you don't get that high, um you know there are big differences between different levels of coverage. 32:03 So I'm going to go through some of that on the next slide. Um, so I've got three rough examples here which are based on some simplistic calculations that I, eh (inaudible), sort of behind the scenes. I, I should note that there are multiple groups in Australia producing modeling, uh you know, detailed modeling... 32:19 ..studies around this. Um, but also that, th, the outcomes are really quite sensitive to certain assumptions. So the first example is just thinking about, um if we got to 60% two dose coverage, ah, er ,of people over the age of 16. And in terms of high risk groups, so I'm thinking people who are.. 32:37 ..at most risk of, of severe illness getting to about 85% coverage. And I guess this is similar to what the USA has achieved thus far. Um, what we would find is that the um, transmission of the virus, it would fall below the sorts of levels we saw last year with the older strains. 32:56 But not that much below them. Okay? Just with this little level of vaccination. So, we would have a few different options.. 33:03 ..um, none of which uhh, are perfect. You know, so we continue to um, you know, maintain our low rates of.. 33:10 ..travel and eliminate the virus with, um, contact tracing and so on. We could do that. 33:16 Um, the other extreme would be to say, 'well, you know, this is as good as we're going to get. So let's just allow virus to spread. And the overall impact would be something of the order of three to five times as bad as a bad flu season, okay. In, in, in 2022. 33:32 After that it's really unknown as to what the future will be. I, I tend to think that this will be a sort of a more flu-like infection going into the future but that's that's really just speculation at present. So my second example is well what if we did a bit better? So what have we got to 70% two dose population coverage? And, and that's sort of, um you know, not far off what's been achieved in uh, in the UK at present. And also 90% coverage of those at high risk. So this would, um bring our uh, the transmission a fair bit below what we saw with um, the strains last year without vaccination. And it's likely that um, we, you know, we could, we could allow infection in our population and potentially have brief periods where we needed to impose some, ka, some controls in order to potentially protect the health system from having too many hospitalizations. 34:28 Um, if you didn't worry about doing that but use some public health measures maybe just at at sort of the peak of infections, the impact might be, you know, a bit worse than a, than a bad flu season but not terrible. Okay, so at that level of coverage does the potential to um, uh greatly change uh, how we approach um, COVID I suppose. Um, and then I've picked a sort of more optimistic example where we get as high as 80 percent and I don't know that um, any large country has, has achieved that as, as yet. Um, and 95 percent courage of those at high risk. 35:03 Um, and, um I realize I'm running out of time but I'm gonna, just gonna try and speed up a little bit. Um in that sort of situation you start to be in a uh, er situations like flu but ah uh, a milder season, okay? And so if you wanted to, uh stop transmission relatively mild restrictions will do it, you would only really consider border control if er, a problematic new variant emerged. And um, you know if you allowed the epidemic to spread um, your sort of impact would be more like a fff, a typical flu season. 35:35 So just a few implications of, of this that I, I'm going to try and get through quickly. Um, you know there, there are large differences to um, the potential burden, ah or, or the restrictions or freedoms, how if you want to look at it. Um.. 35:50 ..between good and excellent coverage. Um, and so it does argue for consideration of effective approaches to achieve high coverage and and mandates could be one of those potential, uh considerations. Um, a few caveats I've basically ignored the situation with children here. Who, who don't ah get infected as much or transmit as much. 36:10 Um, er, it is likely that younger adults are more important in transmission but then that's a challenge of how do you get high coverage in that group. Um, I'm not worrying too much here about waning of immunity because um, in play and new variants and also booster doses next year so there's a few things in the next 12 months that are important. Um, finally just to kind of make this point again... 36:35 ..Um, if you look at three different modeling studies they'll all have different coverage levels that they'll say you should get to. Um, and different consequences. And it all comes down to your assumptions really around how well a vaccine works against transmission and how well it works against hospitalization and death. Um and we just don't have really precise numbers on that so this allows this sort of variation between the different groups. So I'm going to stop there. Um, sorry for.. 36:58 ..going a little over time.. And er, I'll pass back to you Margie. Thanks. Dr MD: Thanks so much James. Gosh, you certainly make 80 coverage sound appealing. So back on to ah, ha ha, the argument for mandates. So I'm going to ah, um introduce our third speaker who is Professor Julie Leesk. Julie, go ahead and uh, share your slides. So Julie will be familiar to many if not.. 37:22 ..all of you. Uh, she's a social scientist who specializes in immunization and she's a professor at the Susan Wakil school of nursing and midwifery at the University of Sydney. Aah, and as many of you will be aware her research focuses on the social and behavioral aspects of vaccination uptake programs and policy. And she's going to talk to us about behavioral and social aspects of mandates. So over to you Julie. Prof Julie Leesk: Thanks Margie. The slide's showing properly? Prof MD: Yep, beautiful. Prof Julie Leesk: Great. Thank you. And um, Hi everyone. Um, great to have you join us, we've got 410 people now so that's fantastic 38:01 And I'd like to acknowledge um, the country I'm on which is Darrek (sp?) country and pay my respects to the elders; past , present and future. Tradigish, the traditional owners and any Aboriginal or Torres strait islander people uh, joining us today. So I'm going to.. 38:20 ..look at the behavioral considerations of mandatory vaccination but centriss on the fact that what we want from vaccination is thriving healthy societies, health for all, global health. We want families to be able to reunite like the, the family on the bottom right there, um, able to reunite with their young son recently. And we want to be able to get together with each other. I