Bubble trouble: what will the pathway out of restrictions for the fully vaccinated look like?

As the rate of vaccinations climbs, Australians – particularly those in lockdown states – are waiting to hear what freedoms, if any, will be afforded to those who are fully jabbed.

NSW Premier Gladys Berejiklian’s recent recent announcement that restrictions will be eased for the fully vaccinated after the state manages to vaccinate 70% of its population have kick-started conversations about the feasibility and safety of her approach placed other state premiers under increased pressure to outline their own roadmaps out of lockdown.

As of 22 September, 48.5% of all Australians aged 16 and older are fully vaccinated. The rapid increase in vaccinations has some asking: why can’t restrictions be eased for those who are already fully vaccinated? Is it possible for states to introduce so-called “double vaccination bubbles”, and what would that entail?

Despite much of Europe and the US already being open, experts say data about interaction between fully vaccinated people is non-existent: no country has quite managed to implement such a policy, or been able to collect data that clearly distinguishes between the risks of vaccinated people associating with other vaccinated people versus a mixture of fully vaccinated, half vaccinated and unvaccinated.

So where does this leave Australia?

What would a fully vaccinated bubble look like?

“There’s no simple answer,” says Dr Driss Ait Ouakrim, an epidemiologist at the Centre for Epidemiology and Biostatistics at the University of Melbourne.

“There’s no comparable data out there. Even if you look at US data, you can’t compare because we are not experiencing the same pandemic. Their numbers are extremely high, in the region of 130,000 cases a day, and vaccinated people are hanging out with non-vaccinated people, and as a result there are a lot of breakthrough infections.”

Australia and New Zealand are in a unique situation, as “we’ve had very few cases and deaths compared to other jurisdictions like ours”, Ait Ouakrim points out.

In the Australian context, Ait Ouakrim says the risk of allowing vaccinated people to be around each other would be very low because we don’t have much virus circulating in the community.

“As we’re not aiming for COVID-zero anymore, it is sensible to let vaccinated people do things to reduce the burden on the economy and other parts of life.”

– Professor Emma McBryde

“While the risk of transmission with Delta will be slightly higher than with previous COVID variants – depending on which studies you look at, early data shows the vaccine’s effectiveness against Delta has dropped to somewhere between 65% and 80% – if you’re fully vaccinated and only being around other vaccinated people in the current environment, you will be fine,” he says.

Professor Emma McBryde, an epidemiologist and COVID-19 modeller at the Australian Institute of Tropical Health and Medicine, believes that fully vaccinated people should be allowed the type of freedoms we saw before the Melbourne lockdown – provided we continue to socially distance and that masks are still worn indoors.

“As we are not aiming for COVID-zero anymore, it is sensible to let vaccinated people do things to reduce the burden on the economy and other parts of life,” she says.

“Among fully vaccinated people, the reproduction rate (R₀) will drop to 1, as opposed to 5 in the unvaccinated population. Sensible public health actions should take that into account and allow fully vaccinated people to meet anyone outside who is also vaccinated without a mask and with some physical distancing.”

McBryde says that retail, restaurants and some small events – “let’s not have massive concerts quite yet” – should also open to the vaccinated.  

“The vaccine has four modes of action: it reduces your chances of getting the virus in the first place; if you do get it, you’re less likely to be symptomatic which means less infectious; if you do end up with symptoms, you’re less likely to transmit them; and finally, it reduces the risk of getting severe disease,” she says.

By these measures, NSW’s plan to allow vaccinated people freedoms such as five visitors to the home, 20 people to gather outdoors, access to hospitality venues, retail stores, hairdressers, gyms and sporting facilities with a one person per four-square-metre rule, outdoor events, weddings, funerals and domestic travel seems reasonable.

“The negatives here are not public health negatives; they would be public resentment negatives,” McBryde says.

The ethics of opening up to only vaccinated people

As recent events at Sydney beaches showed, fairness considerations are not inconsequential, and policymakers should bear them in mind when planning any easing of restrictions for only parts of the population.

“If you believe in the importance of solidarity, then although you might be lucky enough to be offered ‘early release’ from lockdown, you may still choose to keep in place the tougher rules – not because it’s strictly necessary, but to ensure that no one feels treated as a second-class citizen,” says the Ethics Centre’s executive director Dr Simon Longstaff.

Ethicist Dr David Hunter, from the University of Adelaide, agrees: while our ethical obligations to those who have chosen not to get vaccinated are weaker, he says that until everyone has had a chance to be vaccinated, it could be construed as being unjust to let some people out and not others.

“One of the reasons I’m reluctant to open up significantly at 70% is that it imposes risk or disadvantage on those who want a vaccine, but haven’t had the opportunity to have one yet,” he says.

“As we can see, socio-economic status – which is also more likely to lead to underlying health conditions – and rurality are morally arbitrary factors that impact on people’s opportunities at no fault of their own, and only serve to compound disadvantage.”

Where it gets a little murkier is the matter of choice. While it’s frustrating to hear about people who are refusing to be vaccinated while having had the chance, both Longstaff and Hunter warn against spreading blanket resentment and punishment.

“It can depend on the reasons why people choose not to get it; there are populations that have suffered historic injustices such as medical abuses, and others who may be declining due to misinformation about the vaccine,” says Hunter.

“One of the reasons I’m reluctant to open up significantly at 70% is that it imposes risk or disadvantage on those who want a vaccine, but haven’t had the opportunity to have one yet.”

– Dr David Hunter

Others may also object for legitimate ethical reasons, adds Longstaff.

“In general, we should begin with the principle of respect for autonomy and freedom of conscience,” he says. “Yet, there may be times when it’s perfectly justifiable for people to protect themselves from the implications of another person’s conscientious objection, and it’s never been reasonable to expect that conscience can be exercised without consequences.

“I worry about stigmatisation and anger being directed at those who choose not to vaccinate. There can be ‘principled disagreement’ – where mutual respect is the best response.”

Our ongoing preference for sweeping lockdowns also poses a different set of risks – not least to mental health and to the livelihoods of individuals, families and communities. Opening up to vaccinated people might not only be good for those who enjoy immediate benefits; it may also be for the longer-term benefit of those who continue to be living under restrictions.

“It’s possible that improvements in the circumstances of one group can actually be of benefit to others,” Longstaff says.

“It may be the case that by keeping people closed in for longer than is strictly necessary, you end up damaging the very people you’re trying to help.”

What about the healthcare system?

What seems unavoidable is the impact a surge of cases has on the health system.

With an already burnt-out workforce standing guard, Ait Ouakrim says existing problems – such as delayed interventions for other conditions due to the preeminence of COVID cases – will continue, as staff are re-allocated to look after people who “cannot breathe”.

“Even vaccinated, some people will still end up in ICU beds, which require at least one full-time staff 24/7. When you have a surge of people who need this kind of treatment, you can’t just find post-grad nurses and doctors from nowhere,” he says.

McBryde says health systems are generally not designed for health disasters, and that next year will be tough – unless we continue to vaccinate widely.

“At the moment, about 300,000 people over the age of 70 are unvaccinated and don’t seem to want to get vaccinated,” she says. “There’s a good chance many of them will be exposed to COVID in the next 18 months. One in 20 will die, and about three times that many [45,000] will end up in hospital.

“On top of that, a few vaccinated people will die, a few younger unvaccinated will die; that’s the burden we have to anticipate.”

“If you want the police involved, you need to have made it clear that people who are unvaccinated are committing an offence by being in a public space, which, from a civil liberty status, I would be very worried about.”

– Dr Katie Attwell

To prepare for that, we need to get as many people over 70 vaccinated as possible, capture the AstraZeneca holdouts and continue to vaccinate the young to slow down the spread of transmission.

“And with new generations of vaccines and those under age 12 potentially getting vaccinated, we may even be in a position where we can aim for herd immunity next year,” McBryde says.

How enforceable is a vaccine bubble?

As positive as this may sound from a public-health perspective, enforcing vaccinated bubbles is another matter.

The University of Western Australia’s Dr Katie Attwell says that enforcing vaccination-only bubbles is near impossible, especially in a liberal society such as Australia.

Attwell, who specialises in mandatory vaccination policy across Australia, Europe and the US, says that asking people to prove their vaccination status, even when picnicking outdoors, is not appropriate.

“If you want the police involved, you need to have made it clear that people who are unvaccinated are committing an offence by being in a public space, which, from a civil liberty status, I would be very worried about,” she says.

Despite questions of civil liberty, at least being outdoors in public spaces would still make it somewhat feasible to police vaccination bubbles – something that would be impossible if the vaccinated were allowed to congregate indoors.

“So if you’re vaccinated and can go to your vaccinated friends’ houses and your unvaccinated friends can’t, how could you enforce that as a government?” Attwell asks. “Who would be the responsible agent here – you, the visitor, or the homeowner? It becomes very murky.

“At the end of the day, fully vaccinated bubbles have to take place in spaces that the government can regulate; this means that you probably can’t be hanging out at your mate’s place until we can reopen everything.”