S2E01: What happened in the lab last summer?

In the first episode of season 2, Dr Michael Dray reflects on his 'pandemic presidency' with Dr Lawrie Bott and the six things that overwhelmed the system.

Copyright © 2022 The Royal College of Pathologists of Australasia. All rights reserved.

Transcript

[Voiceover] Welcome to the Pathologists Cut podcast. This RCPA podcast explores the broad medical specialty of pathology and the critical role pathologists play in medicine and health care.

[[Dr Lawrie Bott]]

Hi, everyone. I'm Lawrie Bott, president of the College. It's nice to have the opportunity to talk with you on this podcast. I took over this role from Michael Dray, who, due to the pandemic, had an interesting two years as president. Michael unexpectedly became the COVID-19 president. This created logistical problems for him, plus the need for many critical decisions as head of a medical college at the heart of the pandemic response.

[Dr Lawrie Bott]

I caught up with Michael to reflect on his two years as president.

[Dr Michael Dray]

That's three months now since I relinquished the presidency to your capable hands and a lot has changed over that time. I've reclaimed a lot more free time. But also, I've lost track of things a little bit. You know, when you're president, you sort of feel like you're in the midst of everything happening all around you. And now that I'm not, it's quiet.

[Dr Michael Dray]

It's taking a little bit of getting used to.

Dr Lawrie Bott]

Well, you had a very, very busy presidency and a very unusual presidency. You are the COVID-19 president of the college it appears. How do you reflect back on that?

[Dr Michael Dray]

You're right. It was certainly not what I expected when I first started. It was all about forest fires. That was the national crisis. And then in February, things started taking hold with COVID. It was very busy, but it was also really focused. You know, you had a goal. You had something in mind that you were working on. And a lot of sort of other less relevant things were able to just pull by the by.

[Dr Michael Dray]

I think in comparison with my predecessor I spent far less time travelling, far less time in a plane. And so that physical demands on being president with the travelling and jet lag. I didn't have to cope with. I think the previous presidents, that's been quite an onerous burden. So I didn't have that to deal with. But certainly there were plenty of late teleconferences and video conferences, often daily and preparing and thinking for that, as well as doing my normal day to day job.

[Dr Michael Dray]

Certainly, your plate is very full.

[Dr Lawrie Bott]

What were your immediate reflections when this virus coming out of Wuhan was mentioned?

[Dr Michael Dray]

I don't think I believed that it was going to be such a big deal. You know, we've had those previous experiences of coronavirus, the MERs and the SARs in Hong Kong and there was a bit of alarm, but it was always somewhere else and it wasn't going to affect us. So I think in the early stages I was thinking it was just going to just blow over.

[Dr Michael Dray]

And then life would continue as normal. But that soon became apparent with some of the images and stories coming out of some of the other countries in the Middle East and in Europe that things were getting a little bit out of hand. One of my very first podcasts that I hosted was talking to Mike Catton, who was running the Virology Research Institute down in Melbourne, and just hearing him tell the story of isolating the COVID-19, the first virus in Melbourne, Australia on Australia Day a couple of years ago.

[Dr Michael Dray]

That was a really exciting story, that he was able to tell and it really to me put the laboratories right in the forefront of the COVID epidemic, and we've stayed there, I think all the way through. It's been a good test of our laboratory service, of our standards, that we keep our adherence to quality so that our results are reliable, but also the downstream ability to genotype the virus and track it that way.

[Dr Michael Dray]

Yeah, it's just been a huge, huge effort.

[Dr Lawrie Bott]

It's true. I totally agree. It's remarkable and that we needed to scale up early on, too. And I think when the supply companies were able to keep us supplied luckily with equipment and reagents, and we have that dependency on overseas supplies for these things that we're able to keep us supplied. And we scaled up to an extraordinary level at the same time as we had to do the routine work that we always do. A remarkable achievement, the scale we hit with the testing, the numbers in both countries.

[Dr Michael Dray]

And that increase in scale was an in orders of magnitude, you know, thousand-fold increase, which is just a phenomenal increase.

[Dr Lawrie Bott]

Yes, it is absolutely amazing Michael. And I think both countries have been extraordinary. I did a back of the envelope calculation myself a little while ago, and this time they're testing PCR, testing was done at the level of about one in a thousand. So 1 in 1000 people every day would have these top testing for different reasons. But at the height of our testing of that with the Omicron outbreak, we were testing one in a hundred of the citizens of Australia, at least during that outbreak.

[Dr Lawrie Bott]

It's a tenfold increase in the productivity of that test, which is remarkable.

[Dr Michael Dray]

And your laboratories are not ten times bigger. You don't have ten times as much staff. It's a huge efficiencies in the laboratory systems.

[Dr Lawrie Bott]

Huge efficiencies. And of course we had to collect all the samples too. So we're having to set up systems and the safest system, which was in any innovation originally in this country, I think we actually observed that they were doing drive through collection centres in Korea. But very quickly, we got the idea from those countries and we set up large scale drive thru collections which allowed the collecting to be done safely and on a scale.

[Dr Lawrie Bott]

And then as you pointed out before, we scaled up the laboratories to unprecedented levels and people cope, they worked hard, they put in long hours, we train new staff and by hook or by crook, we were are able to provide extraordinary numbers of tests. The situation Michael in Australia over Christmas with just extraordinary. For the first time ever in Australia I would say pathology tests were not able to be returned in a meaningful timeframe.

[Dr Lawrie Bott]

That was amazing. So I guess it was the greatest demand ever for pathology and it went beyond capacity sadly. My calculation is that six things happened at once. The first thing was there was an increase in the number of cases due to the Omicron outbreak and it hit virtually when Christmas was on. The positivity rate increased of all of the testing we were doing.

[Dr Lawrie Bott]

So we suddenly weren't able to do pooling which is sufficient way to do testing. So we lost capacity because of that. A number of states also had in place border requirements that needed PCR testing. On top of that, we had staff that were off work due to COVID infections themselves or were off during because it was Christmas and it was the holiday period.

[Dr Lawrie Bott]

And in my thoughts on top of that, we had a population of people who up to this point had been advised to go and have a PCR test if there were minor symptoms or even no symptoms at all. So people turned up in all those settings in large numbers when the outbreak hit and it just overwhelmed the system. And we were able to do, in Australia at that time, 250,000 PCR tests per day, which is an extraordinary number.

[Dr Lawrie Bott]

But it went beyond that and it all fell over in that period.

[Dr Michael Dray]

250,000 PCRs in a day. That's a mind boggling number. And that wasn't enough.

[Dr Lawrie Bott]

And that wasn't enough. That in Australia that's one in a hundred Australians around that time were getting tested. I guess as a guide to when you're going to hit your capacity in a country, it must be somewhere near doing one in 100 of your citizens every day. I don't think any system would have coped.

[Dr Michael Dray]

So RAT testing is beginning to increase here in New Zealand. And so we're testing both symptomatic and asymptomatic people. It's been used now to sort of aid decisions as to when to go back to work or when to go into isolation. How did RATs work and the sort of the decision making process over the last couple of months in Australia.

[Dr Lawrie Bott]

With the use of RATs was limited in Australia up to recently and with good reason. So RAT testing in a low prevalence population has problems with sensitivity inherently and specificity. In other words, you have your missing cases, false negatives or you're calling things positive when they're not positives. As the prevalence got higher they became more useful than when PCR hit its capacity.

[Dr Lawrie Bott]

Well, they just had to be used in that setting. There's widespread use now. They still have the problems with false negatives. In fact, if it's in a people with no symptoms or mild symptoms, the sensitivity could be as low as 60%. In other words, you're only picking up six out of ten cases who actually do have COVID. Is there a use?

[Dr Lawrie Bott]

Certainly, I think he in certain settings, if repeatedly used for schools and perhaps other settings, they are useful despite those limitations. Personally, I think that you've always got to back them up with a PCR test, an accurate test, particularly people with symptoms. You just want to know if that person has COVID or not. Or if it's a critical situation where you want to know if that person has recovered or not.

[Dr Lawrie Bott]

PCR is the gold standard.

[Dr Michael Dray]

The laboratory capacity is maxing out for PCR in New Zealand, and so people have been handed out RAT tests to perform either in their car or at home. And then make decisions on that.

[Dr Lawrie Bott]

I mean, I think the key to it and to good public health measures is if you have symptoms you should isolate. Testing, in many of these situations, is secondary to that. And if you hit the capacity in your country of your PCR, testing, well, you only have RATs to go to. It's my belief in Australia and New Zealand, whilst you've got the capacity to use your PCR testing that's still a superior test. So how do you think we went? We've got the opportunity now to reflect back over two years.

[Dr Lawrie Bott]

How do you think we went as a college and what influence do you think we both in Australia and New Zealand?

[Dr Michael Dray]

I like to think we made a difference. I like to think that we were the voice of moderation, the voice of reason with all the various other interest groups and individuals. I like to think we were able to provide sound sensible advice to those that need it and to the decision makers so that they were able to make the right choices. In New Zealand,

[Dr Michael Dray]

I don't think the college has quite such an impact in the broader health sector. We were able to support our fellows, but the courage per say wasn't. There's not a natural conduit from the politicians and the Ministry of Health to college for advice, and it was difficult to sort of try and make those relationships because they weren't there earlier.

[Dr Michael Dray]

So I felt that, as a college, we had less impact here in New Zealand.

[Dr Lawrie Bott]

I've noted through the media that there's been some criticism in all areas, not only health care, other areas of being better prepared. You know, we should have anticipated things and should have made quicker or different decisions. Do you think the college could have made any different decisions or pathology should have made different decisions?

[Dr Michael Dray]

That's an interesting question. I think better preparation would have allowed us to cope with that huge surge that peaked earlier in the year in Australia. And it's clear that a lot of those sorts of preparatory things really relied on people who had the levers to release resources and put resources in the right place. The college doesn't have direct ability to spend money where it needs to be spent.

[Dr Michael Dray]

The college can give advice and I think it was important that the college didn't give advice that sort of soured the relationship that we had with those that we were giving advice to, and it wasn't necessarily always accepted. Could we have done things differently? I don't know. I don't know. I don't think. It was all such an unknown.

[Dr Michael Dray]

We were feeling our way. We were just trying to just make sure we didn't trip up badly. And I don't think we did. I don't know if we could do anything different again. I'm sure we could. Perhaps you could probably have some ideas on that because you're involved that you are an interested observer, perhaps a little bit more.

[Dr Michael Dray]

And I don't know. Laurie, what do you think?

[Dr Lawrie Bott]

Look, it's a very good question. Look, I think we were very thoughtful as things appeared and things came. I think we have a lot of experts in the college and epidemiology or microbiology, and they were prepared and so they did have a lot of the answers. We watched things as they appeared and we changed advice. If we had new information, I think one of the things that struck me is because we had the ability to offer very accurate testing with PCR testing, and we were able to scale up very quickly and offer it in both countries at the required level.

[Dr Lawrie Bott]

And that allowed us to protect the vulnerable quickly to tell where the infections were. And both countries went pretty hard in terms of public health measures, I guess isolation of people where required. And I think we were able to support that. And I think that the world over the countries that tested early and tested in high numbers, we were able to really support the public health authorities in my thoughts that we did it well and we're still doing well.

[Dr Michael Dray]

Yeah. And I think you're right that we did change our mind at times, and we did it at our policies and our advice, and we did that in response to the altered situation and more information. And I am not for comfortable saying, look, this has changed, things have moved on, and we need to alter our advice as appropriate.

[Dr Michael Dray]

But also coming back to that ability to really test and scale it up. We have gained huge benefits from that. It's given us two years to allow time for vaccinations to become developed and then rolled out and then repeated. And so that now we have a different population that's not a naive population to COVID that's a population that has a huge resistance now to the infection so that we can then basically, hopefully look forward to getting back to the new normal, where hopefully COVID risk becomes another influenza virus every year that we immunise against.

[Dr Michael Dray]

And life continues That's my hope.

[Dr Lawrie Bott]

No, I think you're right. I mean, I think it's I think both countries have done incredibly well, we've had among the lowest death rates in the world. We've been able to, as you say, protect people to the point where we largely had vaccine protection. I think that's no mean achievement. And the people the people of both countries have gone along with it and supported it.

[Dr Lawrie Bott]

So I think it's a great achievement. And I'm proud of the role that we've played in pathology to allow this to happen. So when do you think you'll be able to visit us in Australia?

[Dr Michael Dray]

Sooner rather than later? I hope, but I suspect it will be towards the end of the year. As you know, I've got a couple of kids over there and we hope to be able to meet up with and have some family time together.

[Dr Lawrie Bott]

Well, it was great talking with you, Michael. I really appreciate you expressing your views on the past and present events.

[Dr Michael Dray]

Well, thank you, Laurie. Likewise. It's been really great to chat with you. I hope to be able to visit in the flesh in the next year or so when this all blows over. I wish you all the best for the next to the next 18 months or so and hope we weather the storm together.

[Dr Lawrie Bott]

Thank you. And thank you for your mentorship of me when I was vice president. I look forward to seeing you in the flesh.

[Dr Michael Dray]

Again, thank you.

[Voiceover]

You have been listening to the Pathologists Cut podcast with our RCPA president, Dr. Lawrie Bott. To learn more about pathology, check us out on Facebook, Instagram and Twitter.