 My view is that the essential problem with COVID or a lot of other things it's an infection control prevention and management problem. I mean there's all these other issues that are important obviously are very important like vaccination and and other things but that's where my interest is how you decrease the spread and minimize the impact of this and I might say this is all shades of gray people try and make it black and white but it's shades of gray and it changes as time goes on the situation now is different to two years ago including how the virus I think behaves as well all the variants we've got now. So I'll try and put this will end up being controversial I guess because I think we don't always have the answers and people are dogmatic about it but I'll try and I think only speak for about 40 minutes so we have a good 20 minutes for questions and I think it's really valuable if people ask questions disagree however you want to put it because that actually is how you go forward in this and you know how do we do better in the future I mean this pandemic is bad this is a virus it's not good but to put in perspective 1918 Spanish flu was much worse than this when you look at the figures and we need to take that into account too and there's a balance between what you do to prevent infections and the collateral damage be it on education economies which then do cause their own lots of problems including death so that's all got to be taken into account and to some degree I think a lot of that has not necessarily but anyway we'll go on. I put this up because literally two days ago in one of the Lancet associated article things a group of us ask what could we have done better in Australia what we did well what we could have done better so if you like a whole lot of my lecture if anybody wants to read it is in this Lancet article that came out a couple of days ago with a number of I think very I thought impressive colleagues including Tanya Surrell Catherine Bennett Bart Currie you know there's quite a lot of I respect their opinion we don't always have the same views I might say and so when you do these joint papers there's necessarily compromises in words but I wouldn't have put my name on it if I didn't agree with the overall principles so I thought that was very important and it really summarizes I think a lot of things I was going to say now basically I still think this is essentially an infection prevention and control problem and that's what's paramount and my overall view during this epidemic is not all the right experts were given the advice at the highest levels and there was a lot of anaesthetists and intensive care people that got a lot of advice and their contribution to infection control in my view over the last decades has been pretty minimal so you know there's been a lot of people who I think had you know appropriate you know giving you know input but you know I think the people in hospitals who know more about infection control and prevention are infection control prevention practitioners who mainly nurses and even in the hospital they weren't the highest level of advice yet alone in the in broader things so I think a lot of times the people who've got the practical knowledge didn't percolate up to the area as they should and that was both for the hospital in the community and I think to a large degree fear and politics overcame necessarily the most appropriate decisions or clouded it and you could see the arguments about how New South Wales was doing it versus Victoria New Zealand for instance now I'd argue New South Wales did as well if not better than Victoria with less stringent restrictions and had a better end result but we'll look at the data to see whether that's true or not later and I think there is still poor data on basic infection control issues how much difference does wearing a mask really make is there any difference between a respirator in 95 mask and a surgical mask for instance they're basic questions that and you know that are still unanswered and there's also things about new drugs the vaccines because we are still not doing in my view the science properly because people think oh it's unethical but if you don't do some basic research particularly in lower risk groups like you know people in their 20s you can never answer the fundamental questions that have got a lot of issues and a lot of costs for what we do in the future COVID's not going to go away it's going to be here well at least for decades so every winter in my view we're going to have a problem but how do we learn to minimize the risk with the if you like the maximum benefit for the least amount of collateral damage I put this up is there's a lot of perception that governments control all this you know and the government's got to have rules from my perception when you look at the first epidemic curve in Australia where we had lockdowns over all states numbers were coming down before any restrictions were put in place the curve had already changed a bit and you've got to remember any restriction you put in place takes seven days to have an effect now this is data that you know I found in a paper from the US and apparently Ohio has almost no restrictions and Illinois has a lot and what this actually showed it's people's behavior that changes that makes the difference rather than government regulations I mean my own view is government rules don't work unless 90 percent of the population believe they're a good idea and I think that's an issue for the currently to and why there's been a big change that this actually shows irrespective of the government regulations you had people complying and doing things that decreased the rate of transmission okay it said that that's all that says another controversial thing I'll get on to another subject is where did this virus come from well it came from bats okay and how did it get to bats of people I think the short answer is we don't know the common theory at the moment is it came from bats to people probably at the Wuhan seafood market that also sold animals however there were cases before that market there was no doubt that was a super spreading event and I don't think we can discount the fact that it came out of the lab because they were collecting huge numbers of viruses and what really worried me was they were culturing them in human and monkey cells now with any animal virus if you want it to get into people and spread you've got to adapt it for a new host well in my mind where you can put in animals that are you know been genetically engineered to be more human like but if you're growing a virus in a cell line that's human well that strikes me as a good way of suddenly allowing a virus to get to people and spread to people now you know I don't think we'll ever probably know the answer but I think there's a bit of a conflict of interest in all the people say I know couldn't possibly come from the lab their procedures are so good well first of all smallpox probably h1n1 came out of a russian lab smallpox is you know leaked out of the lab in in the UK there's been lots of leaks from high security labs including SARS from labs in Taiwan so I don't think anybody can dogmatically say it didn't come equally you can't say it did and but my own view is that because grants and everything are so dependent for these labs there is a lot of conflict of interest with people if you like wanting grants to continue for in my mind where is the evidence that it's actually improved vaccines or improved drugs for all what I think is a risky procedure now that's controversial okay but I think it is an issue so and this is an issue in the future about what else we do in in these things so there are a lot of things that were done I might say with funding from the US government because they weren't allowed to do it in the US so the NIH funded a group that then did the research in the in Wuhan because they were worried about influenza and there was some gain of functions done and there was a moratorium put over a number of presidents in the US so they couldn't do this research in the US so indirectly they funded the research to be done in China that doesn't mean that was a cause I might say but it is interesting how internationally it goes so you know what animals we put viruses into you know if you modify mice to be suddenly human you know adapted it strikes me that the fundamental problem I find with any of these viruses because most bad virus was had including measles measles probably came from cattle when we first started herding cattle and then humans adapt and HIV is another example just about every virus you can think of originally was in animals then became human adapted and spread from human to human so I think we got to be careful we don't give these viruses an extra start that they wouldn't have had if you're like in the natural environment you know that's the cell lines what levels of protection do you have for staff you know the wet markets are an issue I think because you have a lot of animals stressed in close contact with people and the whole human and animal interface if you look at Lyme disease in the US and elsewhere it's because a lot of changes in vegetation so deers with tick were closer to people and therefore you get the bacteria thing so there's lots of these factors that increase our risk plus just increasing human population now one of the really controversial about COVID was children now having quite a number of grandchildren myself I can tell you if you want to get any infection just have grandchildren they're really good at doing it and for most respiratory viruses children would have four or five times more infection than do adults but I actually think the evidence for children is that they're not the super spreaders yes they can get it they can spread it but not the same as influenza or you know adenovirus a whole lot of others but because of that we had quite prolonged school closures in some places like the Philippine schools have been closed for two years you know at the the poorer the country the longer the schools were closed in in Australia and Victoria but even there was a lot of school closures here the whole mask for young people the masks you know how much difference does masking young children have and in fact there's a danger in children under the age of five for instance wearing masks with choking and stuff so they in my view were not super spreaders their parents had a bigger risk of spreading it than children and the teachers and most of the school outbreaks were in fact in staff schoolrooms or functions for adults now that doesn't mean children don't spread it they do but they do it less than their parents um vaccine policies again um I'll bring this up the worst age to be is probably in our age group you know over the age of 70 we definitely get worse outcomes if we get infected the ones with the lowest risk are actually children so they are actually at the lowest risk but often had most of the you know impositions put on them they and young adults and there's a lot of collateral damage from restrictions economically schooling you know some people some children have lost two years of schooling and you can't see how that's going to be fixed up and the worst you are off socioeconomically the worst you did I mean I've heard of examples in northern New South Wales well I'll give you my example um one of my daughters has four children they lived in Brisbane and they had home schooling they had enough money to buy a computer for every one of those children and they had good internet and it was still a big thing other people I've heard in northern New South Wales they just didn't do anything for six months so this is very socioeconomic dependent of the poor outcomes from restrictions and and even if you look at the Australian Bureau of Statistics statistics if you came from a poorer English second language you had five times the death rate of COVID than if you were you know basically more like I presume most of the people are in this room so there is a real difference in socioeconomic outcome where the people who have the least downside in forms of effectively restrictions but also pay and loss of income are the people who are at lower risk of having a bad outcome you know if you're a family of six in a two-bedroom apartment well you can't go out in the backyard very often and do all those things so there's a lot of social issues to do with what we've done as well this is in Australia and I think this data is from a few months ago I can't remember but this basically shows you the group of diagnosed COVID case and now you can make a lot of the arguments our children had and we never know it but there were serological studies particularly UK did a lot of good studies and essentially what this shows is essentially what most countries show whichever way they look at it the peak group for infections were 20 to 40 year olds males and it varied a bit actually I think males had worse outcomes at females had slightly more infections and children had lower rates of infection than their appearance now this is and you can see the older age groups had much lower rates of infection and that's because they were taking more precautions quite appropriately because they were more at risk okay and what's happened more in the last six months is the infection for the first time has got to a lot a lot of the people in more our age group and that's why you know we're seeing increased deaths as well but this is the death rate in Australia so down below the age of 40 very few deaths even though that's where most infections are occurring it's really those over the age of 80 that have the highest death rate and if you look at this is another way this is from about two years ago and it's important data because it's before vaccines were available basically if you're a 30 year old and got COVID you're unvaccinated your chance of dying was about one in 10,000 now I might say people say well what do you worry about that well if you've got a million people that's suddenly a hundred deaths I might say so in people that wouldn't have otherwise died but if you're an 80 year old you had at least a 10% chance of dying or higher so a huge differential and if you look at this the Spanish flu from 1918 the biggest group that died then were 20 to 30 year olds and they had about a 2% a case fatality rate so that on a society point of view had a much bigger impact because the overall mortality rate was higher and it was in a group of people who you know basically were out there working and a lot of people dependent on them so you know that there is a huge effect on age on your mortality chance now this is a paper from a bunch of economists I think the reason I looked at it because they have a different way of looking at this and this talks about again the mortality rate but it talks about the inter-generational trade-off and I think this is an issue the people who get the most benefits from restrictions are people over the age of 60 because we have the biggest chance of dying but we don't necessarily pay the biggest economic cost and social cost it's the younger people who are much less of a risk and you can't see all the fine print here but basically the richer you are as a country the more you probably saw your mortality rate go down with lockdowns in other words if you're high off as a country you probably saw a reduction on their modelling of the number of people you saw but if you go into but interesting the top I'm not sure if I can does that show up there that the top left hand corner here is poorer countries and they see much less benefit from the lockdowns and particularly if you start looking at this based on age in some places you actually increase deaths in children by having lockdowns because they had a very low risk of dying of COVID because their risk was so low but they can't get basic facilities delivered to them immunisation etc has gone down markedly around the world not for COVID but for all the other diseases so all of those catch up or your water supply is not as good so if you're in a low socioeconomic country you seem to have a lot more downsides to children in particular than the benefits you got from decreasing their risk of COVID death which was pretty low and that even takes into account if their parents may or may not have died because the parents are often younger and had a low risk this is just another again there's numerous places you can say and and I I think I've been trying to look at all the data objectively rather than cherry picking but UNICEF and other people have come down as a huge loss of learning to children that will never be made up from COVID restrictions and lockdowns and school closures now you and to some degree that's this intergenerational trade-off the biggest losers were often children who had the lowest individual risk now that may be worthwhile keeping their parents alive or their grandparents alive but you know we need to be a bit more I think conscious of the fact that that has occurred now how did Australia do I think Australia did very well as much as a lot of people are saying we didn't I think we've done very well for a number of reasons and one of them was that we closed our borders to a lot of people coming in I personally think the bushfires were an advantage too because you might remember in January there was all this argument that you know Australia looked like it was on fire because we did have a lot of fires I might say so I think we had a lot less tourists coming in which meant the virus was already circulating at least in December in France and obviously in China and in January I think it was widely circulating in the US and Europe it was not recognised yet so we had a lot of people if you like less people coming than normal but equally we put restrictions in place for at least the high prevalence places initially and then we had all restrictions and quarantine now I actually think that made a difference to the number of people coming in and spreading it so I do believe that was a good policy move and it was good to do it early quarantine hotel quarantine people say oh that was appalling but you might actually think there was a number that went out particularly in Victoria and that caused a big problem in 2020 but again I actually think it was an infection control issue they the people who were manning those hotels were not given any infection control training whatsoever in Victoria as far as I can see you know you know in retrospect I think that was a big mistake New South Wales I was part of a federal government review looking at the quarantine arrangements in 2020 and I went to a number of these places New South Wales in my view was doing it very well they had very good surgical mask eye protection which I think is really neglected anything that can go into your nose it drops into your eye it goes straight to your nose so eye protection I think we've still really underappreciated but they actually looked after in their quarantine hotels in 2020 700 return travellers who were positive because they put them all under under central health area they did not have one transmission to any staff member so I think they were doing it very well and you can say well New South Wales was the cause of the Delta outbreak well that probably well you can say who you can blame I think it would have happened eventually anyway but that was a return cargo air crew it wasn't a quarantine hotel and a driver and a car cars are dangerous places for recirculating air I might say so you know I think hotel quarantine decreased the risk by about 99% it wasn't a zero risk but that's the order it decreased the risk than if you didn't do it okay I think it was that order so it wasn't zero risk but it markedly decreased the risk and so I think a lot of things we did do we did do very well and I think a lot of the contact tracing and testing was very good one of the things that we don't still do as well as we should is sewage testing if you really want to know what's going on society test the sewage because whether people front up or not I've got symptoms or not or want to hide it they still go to the toilet and it comes out the other end where you can measure it and you can see what new variants and also it tends to predate by about four or five days before your clinical cases and about 10 days before your hospital admissions and New South Wales has stopped doing it as far I actually think that's the one public health monitoring that's going to be more useful than anything else mind you I have a bit of conflict of interest because I did do a study with NCF on this and we showed you could pick up one person in a hundred thousand with the virus by looking at at feces so it was very sensitive as well it's also very good for antimicrobial resistance monitoring for anybody who's interested so what about vaccines well vaccines are the life saviours of all of this as far as I'm concerned there's a lot of controversy you might remember in 2020 the federal government was backing a Queensland University vaccine that was very good except for some reason they used the HIV protein to you know stabilize it or something and all these people had HIV antibodies which is a problem you know for the rest of your life and then we ended up having the AstraZeneca vaccine mainly because of the deal CSL did with you know AstraZeneca and at that stage and still now I might say we have no ability still to make messenger RNA vaccines and they were pretty new and there were a number of others the Novavax one which was a more traditional one but was still by genetically engineered moth cells I think it came out of so some of the vaccines all most of the ones we use in Australia gave you a template be it DNA or RNA where you made the spike protein in your own lymph node or your muscle while the more traditional vaccines like Novavax and the Queen was presenting you an already made spike protein which coats the virus now at the end of the day all those vaccines were very good at illicit and immune response and they became available at the end you know December 2020 actually but to some degree but they were all very good and to put it in perspective they all decreased your risk of death by over 90 percent now an influenza vaccine gives you about a 50 percent reduction so these were good vaccines but they had side effects like every drug and every vaccine we have I mean there was this expectation you would have zero risk well that was never realistic and the AstraZeneca vaccine got trashed because of this clotting thing now that was a real risk and it was a more of a risk if you're younger in particular if you're a woman but your overall risk on a population basis of dying from that complication was one in a million versus if you're a 70 year old okay one in 20 one in 50 of dying if you got COVID yeah there was a risk but the benefits so far outweighed it the real problem was when you were successful in controlling it everybody said oh wait a minute you know we we're never going to have spread here so we don't need it so in my view it list in in 2021 when it became available we had a lot of extra deaths particularly in victoria because a lot of my colleagues were bad mousing the AstraZeneca vaccine so people didn't take it up I know my own mother-in-law who was in the 90s she was given pressure from you know one of her sibling or one of her children I'll wait to wait for Pfizer it's so much better you know god you know eventually I talked her into getting it but it was you know that was a real effort and it markedly decreased your risk of dying so I think a lot of my colleagues and was Pfizer a better vaccine well it did seem at the stage it decreased transmission a bit more but at the end of a day they're about the same for their efficacy of decreasing death and hospitalization so you know we had a lot of people I think a few hundred people died in Australia needlessly because of that adverse media publicity that basically underrated that vaccine and the other advantage I might say that vaccine you could store at four degrees the Pfizer one had to be at minus 70 and the Moderna at minus 20 now they've fixed that but that's not practical for most of the world plus it was instead of four dollars a dose it was 25 or 50 dollars a dose you know money and practicalities are important and having a zero risk mentality didn't help us in my view and didn't help the world particularly since probably 80 percent of poorer people are still not vaccinated you might say well they missed the boat because most of them been natural infection now but you know there was a lot of controversy about vaccines that was needless wanting a perfect product with no side effects which is an impossibility for any medical drug vaccine and I think the benefits so outweighed the downsides that it was problematic the other thing is we did do it in my view in Australia appropriately in that we had a sequence of people who could get the vaccine I was one of the first people to get the vaccine because I worked at the hospital I guess but we prioritized people in nursing homes and then people over the age of 70 that was entirely appropriate and if you want to see what happens when you don't do that properly look at Hong Kong they had zero COVID just like we did then it got in and they had huge numbers of people dying mainly the elderly because they had not enough of them vaccinated and probably not with a vaccine but there was a large proportion of their elderly unvaccinated so they went from having one of the lowest deaths rates in the world to one of the you know middle of the road where they shouldn't have got there um I'm not sure I you know this is just the current fatality rates in Australia and basically you can see if you look at the bottom here most of the deaths occur in people over the age of 60 particularly over the age and the vaccines really do markedly drop your um your um you know your um case fatality rate you know if you look at here one point four percent to point three percent now so you know I I expect to be tenfold in fact these figures don't look as good as I expect because all the studies you see still talk about a 90 percent decrease in death even you know six months 12 months after you've been vaccinated providing if you're older you get at least one booster so um vaccines do make a difference in my view this is from the economist and what I think this shows nicely again is basically this was your mortality rate which goes up at age you know I would have thought it's slightly higher than this but doesn't matter but if you get vaccinated as an 80 year old you drop your mortality rate to here which makes you the equivalent of 50 year old who's unvaccinated so there's this expectation that we get vaccinated you'll have no deaths that's unrealistic what it does it makes you 30 years younger but it doesn't make you into a five year old or 10 year old okay so um and I don't think we actually have this appreciation of benefit versus risks you know we're into black and white I'll have absolute protection and this is all relative risk um reduction which I might say vaccines do very well and this is another slide from the economist which I think is also useful when this first started people some people were saying oh it's just like flu it was never just like flu because it had at least a 20 times higher mortality than influenza but with variations in the variants and vaccination its mortality rate now is about the same as influenza the only difference is we only have one influenza wave a year and in Australia we've had at least four waves in the last eight months and that's why we've got 10,000 people dying instead of 3,000 people dying because we've had four or five waves but my expectation is and and I'll put this in print and think in the Australian financial review is that we'll end up with just one big wave a year mainly in winter but and you'll have you know the rest of the time you'll have cases but at a much lower level what about lockdowns well lockdowns or restrictions work to decrease infections and you need restrictions until you have your population vaccinated particularly your elderly but preferably everybody so they do have a benefit you know we actually had little spread in Australia because of restrictions um how severe your lockdowns need to be is a separate argument and I guess they were never part of any pandemic plan lockdowns like China used it in Wuhan and it appeared to be effective and that actually influenced policy changes the only country that probably kept to a pandemic plan was actually well Sweden gets a reputation but in fact Japan and South Korea probably never locked down either they had partial restrictions but so not every country in the world had lockdowns but China did and then New Zealand was probably the main western country that adopted that policy and it was quickly adopted by Victoria and that was a lot of politics you might remember you know New South Wales isn't locking down soon enough look you know do what they're doing in Victoria New Zealand well at the end it hasn't made a lot of difference for the number of excess deaths and cumulative deaths in fact Victoria has had more deaths per population than New South Wales on a age adjusted thing there's not a lot in it I might say but I think that is one of the views that it's a problem and once it became more infectious these restrictions were less effective for probably two reasons because it was easier to transmit the virus but also people tire of it you can have these restrictions maybe for a year um but to do it for two three and what some people want ongoing I just don't think that's realistic that you'll get the cooperation to to achieve that as well that's not to say people shouldn't take individual protection themselves I still if I go to a restaurant eat outside rather than inside okay so I think there's a lot of things you can do to decrease your own risk but you can't make your risk zero and that and that's this trade-off we have to worry about um China is still trying to get zero COVID um I can't actually see how they're going to succeed over this upcoming winter I you know the politics might change as well but I can't see how they're not going to actually have spread within their their community and there one of the problems is there I think they've dropped the ball and vaccination of their elderly okay the Hong Kong is just an example and I suspect that'll be similar and and even Taiwan was a bit of an example of that that was another very well controlled place that actually when it got in disproportionately some elderly were died more often than they should because people assume I'll look I'm safe it'll you know won't be a problem and they don't get vaccinated when they should have um so um now how effective were restrictions well again it depends how you look at this um Sweden was compared to other countries Sweden has got the same mortality rate as Germany despite never having lockdowns or but they have got a higher mortality rate than Finland and Denmark okay so it depends who you compare them to um Denmark recently has been a prior because it's taken away all restrictions and in fact is not recommending vaccine boosters for those under the age of 40 because of the myocarditis side effect and I think this is a real issue is what is good for 70 year olds may not be good for 20 year olds and we tend to be too black and white about it um so that's England Scotland had much more severe restrictions in England but as far as I can see hasn't overall done better in fact it's got slightly more cases currently uh Australia and New Zealand New Zealand was put up as the example of how to do it and Australia was bad well at the end it's been very similar as far as I can see China well I'm not sure how good the data coming out of China is to I don't think they've got widespread um spread but North Korea said hey we're pretty good until they had four million cases or 20 million cases I can't remember a lot and for a virus they couldn't identify because they didn't have testing and they had no vaccination but interestingly despite having about 20 million infections they only had 70 deaths which is you know we should give them credit for that or how they manipulate the figures I suspect but here Singapore has done well it's been very similar to Australia they actually had a lower case fatality rate than us but that's because it was mainly in young workers in their hostels that were getting it and because they were 20 and 30 year olds they didn't have a high mortality rate so Singapore and Australia have done similar um Singapore probably has a more compliant population I presume than Australia but I was there a few months ago and I was surprised on how people weren't you know doing a lot to you know restrict themselves so and Japan has done looks like it's done very well um with lower excess deaths than most other countries and COVID deaths well sorry COVID deaths but they do about a tenth of a testing that Australia did and if you look at their excess mortality which I think is really important to look at they've got a much higher excess mortality than Australia so I think there were a lot of deaths there from COVID that weren't recognised as COVID so I don't actually people are putting up Japan's the way to go well I'm not sure I believe the data from there either now this is um what I took yesterday I think the data from I actually think the two important parameters at the end that are going to be important is what is your total cumulative death per population from COVID but you've got to look at that with excess deaths to make sure people aren't shonking the numbers or having done those tests now basically Australia is down here and in some ways I think very similar to all these other countries South Korea Japan and South Korea and Japan never had country-wide lockdowns I might say they were you know they had restrictions and but um Singapore uh we're all down here um Hong Kong was down here until the virus got in and spread and then because they hadn't vaccinated enough elderly they jumped up um I don't think Australia will ever get to the level of the US while we've got a lot more deaths now in the last six months at least it was when your population was quite highly vaccinated because that's the protection so you will get deaths but you'll just never get to the level of deaths that those countries had because they had it spreading in an unvaccinated population so you know a lot of Europe is up here Sweden and Germany are here Denmark is down here Canada seems to have done in a Canadian data you tend to believe so you know the world has actually separated itself into these outcomes and excess deaths are not that dissimilar from countries where you can believe the data but this has got a lot of relevance in what restrictions do you put in place if this happens again because this is to me the ultimate result you want you want to have the minimum number of people dying from this um and you're going to measure that and hospitalization obviously is an issue too it's become more complicated because of are you there with COVID or off COVID so um but so deaths if providing you the data is accurate I think is right this is another one of um these studies that looked at and this is some economists again so there's probably people in the audience more experienced with this than me but I thought it was interesting they looked at how um intensive your restrictions were and what was your outcome based on death and essentially in Europe they found no correlation but in the US they found a little bit of a correlation in other words if you had more severe restrictions you tended to have less deaths but you know it's not it's you can see it's a bit of a scattergram but that what their statistics showed and interestingly they then looked at all the individual things you can do this SIPO stands for stay in place you know in other words lockdown stay at everything it actually seemed to have some benefit that was you know 95 percent confidence limits but the biggest one had business closures which does make sense to me if you close pubs and clubs and places where a lot of people are intermingling you can see that I don't find it hard to believe that that has a beneficial effect how long you can do that for is a separate issue but um you know there's a lot of controversy and trying to dissect this out there's so many confounders it's very difficult you know and that's why it's all shades of gray but my own view is we need to minimize the amount of deaths but you've got to take into account the collateral damage and you got to look at what different places have done and try and dissect out well what gives you the same benefit but for less economic and social costs how does COVID spread you think this wouldn't be controversial but it is um basically it spreads through the air from person to person and the closer you are and the more confined just base the bigger your risk um but I actually think and I've written a few papers about this your eyes you I might say this is an original um back in 1920s somebody was writing about this with Spanish flu as well your eyes are in direct communication with your nose and the virus replicates in your upper respiratory tract so if you deposit the virus in your nose you'll get replication and then usually it then goes down your airways to your lung uh if you if you do badly so I even spectacles in a reasonable UK study it decreased your risk taking into account um you know other variables by 15% and interestingly contact lenses don't they didn't decrease your risk so it is something about stopping things getting in your eyes and I've done a study with face shields um well where we looked at all the data that decreased your risk by 50% or more in in medical situations so I do think protecting your eyes from direct um you know particles containing virus getting in there has an has an effect um there is much less um going via your hands and what I thought you can actually find viable virus and I'm sure you can inoculate yourself but most of the spread is people in close contact for prolonged periods of time with people who are infected um and feces it's in feces as well I've already managed to do age testing but again doesn't seem to be a big factor in spread now I'll get into a non-controversial area like aerosols and droplets why is this important well basically when you cough or sneeze you produce a lot of particles of various sizes now this whole aerosol debate which I might say I've copped a fair bit of flak about is and different groups have different definitions of this like um air conditioning people talk about aerosols as being anything less than a hundred microns well in medicine we tend to think about five microns because that's the particle size that can get directly into your lung and also surgical masks don't work as well against them so you know you'd then need a thing now the long and short of this is that if you look at all of this my I actually believe it's mainly not all spread you can get this via aerosols or small particles the theory of small particles aerosols they stay in the air for hours and they can travel 20 or 30 meters now my view is if this is mainly spread by aerosols we're all screwed there's no way you're going to avoid this because you you know one person here has got it we're all going to get it you know if this was 2020 that doesn't mean you can't get it that way but I just think predominantly it's through close contacts with larger particles and the reason I guess I want to believe that is because we can do something about that it means face shields work it means eye protection works it means surgical masks give you reasonable protection they probably only give you a 15% reduction but that's still worth having while if it's aerosols I you think well how can you ever let people on public transport again how can you ever have a building reopen with people all there how can you even go to a supermarket so you know I think there's huge practical implications if the aerosol theory is correct for the majority of spread but I don't think the available evidence actually shows that not that it can never happen that way even the hotels that said people said oh look you know these people in this room and those people got it it's because both doors were opened at the same time and they were less than two meters apart and the other thing is droplets don't all drop to the air within 30 seconds if you've got the right airflow behind you they can go four or five meters but they tend to go in a straight line rather than this dispersion so I think there is a lot with ventilation and stuff we got to do better but I and I seem to be in a minority now I might say but I don't think aerosols as defined in traditional medicine is a big factor in the spread it is a factor but not a big factor and these are just some articles I've been involved in looking at evidence for eye transmission and mask mandates well I think masks are useful okay I don't think mandates are useful anymore because I don't think there's evidence that they work that doesn't mean you should not tell people to wear them but that's different for finding people for not wearing them and look you know there's no good studies to really answer this question but you see studies like this when one area has a mandate and another doesn't and you know and the same in Germany they've got some above area had N95 respirators and the rest of the country had ordinary surgical masks or mostly and when you look at the epidemic curves on a population basis you can't see a marked difference now as far as I can see nobody's shown me this data has been manipulated wrong but all the figures I've seen where you look at this you're hard pressed to show that mandates make a difference I still believe masks are worth wearing okay but I think that's different for mandating and believing it has a huge effect on a population curve at this stage ventilation well this has got a lot to do with aerosols and I might say I've received a bit of flak for co-writing this article there's a guy in England called Hobday who talks about open air factors and I he got in contact with me by email I've never met him but we've co-written a paper and what I thought was interesting is all the research that's been done Florence Nightingale wanted big ceilings and open air rooms because it made a lot of difference even back 150 years ago for the amount of infections you saw and interestingly in World War one and the Spanish flu people who were nursed outside intense did better than people who were nursed in in buildings the staff hated it because it was cold but the patients didn't find and even for wounds actually you did better being outside now a lot of that I think is dilution effects you know there's so much I think but there are factors in outside air that kill viruses and bacteria and the British in their germ warfare branch in the 60s and 70s showed that they were worried about anthrax and various things various bacteria they were gonna they found that if you exposed a lot not spores anthrax actually doesn't get killed by outside air but a lot of bacterium viruses die very rapidly if exposed to air more so day during night but even night time air and whether it's ozone or hydrogen peroxide a whole lot of even pollutants it's not clear it's probably a mixture but there's no doubt that outside air is protective compared to stale inside air that's not ventilated so I think ventilation is important but for a different reason than is being proposed at the moment and that has an issue about HEPA filters I think HEPA filters are probably a good idea to get pollens out of the air of nothing else how much difference it makes for infection I don't know but the other sort of studies you need to do if you're going to spend billions of dollars on retrofitting buildings I think we need some basic data to show how much benefit you get from it and we don't have that socioeconomic I've sort of touched on this basically the poorer you are the worse you do not a surprise but a lot of the impositions we have put in place have much more detrimental effect on those who are less well off on a country basis as well as internal in society so I'm speaking too long this is what I think is going to happen for COVID I think we've had our the highest mortality is when it spreads through your community the first time so in the US and Europe it was actually 2020 and 2021 is where they got their highest mortality in Australia it was earlier this year because that's when we had probably 80 percent of the population last eight months have been infected but a much lower mortality rate because we've been immunised but you'll get it you can't that's why I think China is going to have a problem you know when it's it spreads you're going to get a problem that's what happened in Hong Kong but interestingly there was only one or two years that Spanish flu was really bad and then it went back down but you might notice it didn't go to basal levels there was still increased deaths for the next four or five winters it was just markedly less than those big peaks and I think that's what we're going to see as well so that doesn't mean we can say hey this isn't a problem anymore it is but it's a different approach because the risk profile is different and what's the future look like well I think in Asia Pacific we've done very well for lots of reasons next winter I still think will probably be a problem at least we'll know what happens in winter in North America, Canada and Europe will tell us what to maybe expect here and what preparation we need to do particularly in March or April with everything from who needs boosters do they need boosters what drugs do we need have available and low and middle income countries well they've got the raw end of this all along and I think we've got to work out particularly how do you get vaccines to those places more efficiently and better in the future because that's as well as learning from ventilation being outside more etc so at that stage I'll stop because I've gone longer than I thought I would anyway and I'll take questions