The next phase in Aotearoa New Zealand's COVID-19 response: a tight suppression strategy may be the best option
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editorial
The next phase in
Aotearoa New Zealand’s
COVID-19 response: a tight
suppression strategy may
be the best option
Michael G Baker, Amanda Kvalsvig, Sue Crengle,
Matire Harwood, Collin Tukuitonga,
Bryan Betty, John Bonning, Nick Wilson
I
n this editorial, we consider the implica- (Figure 2). Elimination included much
tions of the New Zealand Government’s stronger border management (quarantine
shift away from a national COVID-19 and testing) to prevent importation of cases;
elimination strategy. This is a critical stage testing and contact tracing, so cases could
in managing the pandemic, with major be isolated and contacts quarantined; and
uncertainties and difficult trade-offs. We an alert level system to guide measures to
argue that the response should continue eliminate community transmission.2,3 The
to be shaped by key principles: notably, initial, national COVID-19 wave was success-
science-informed strategic leadership; a fully eliminated by May 2020.4,5 Subsequent
Tiriti and equity focus; use of the precau- outbreaks in Auckland were managed
tionary principle; and the need to create in a similar way, sometimes using rapid,
legacy benefits for our healthcare and public intense circuit-breaker lockdowns to regain
health systems. These principles support elimination.
critical actions to get Aotearoa New Zealand Accumulating evidence suggests that
through the next phase of the pandemic in elimination is probably the optimal initial
the best possible shape from a combined response to an emerging pandemic disease
health, equity, wellbeing and economic per- of moderate or greater severity, at least
spective. These actions include applying a until vaccines and disease-modifying agents
“tight suppression” strategy; rapidly closing are available.6 The elimination strategy
the remaining immunity gaps; strengthening has performed exceptionally well for New
public health and social measures, including Zealand, giving us the lowest COVID-19
contact tracing, border management and mortality in the OECD, a significant increase
mask use; and adapting the primary care in life expectancy,7 a relatively high
and hospital system to safely manage large degree of personal freedom for much of
numbers of people presenting with illness the pandemic period and relatively good
from COVID-19. economic performance.8
The first major upgrade of the elimi-
The elimination phase
nation strategy was the Reconnecting
The first COVID-19 case was identified
New Zealanders to the World strategy
in New Zealand in late February 2020, and
released on 12 August 2021,9 which
case numbers rose rapidly in the following
proposed a carefully managed increase
month (Figure 1). New Zealand initially
in inbound travel to New Zealand while
followed the mitigation strategy that was
continuing with elimination. It implied
core to its influenza pandemic plan.1 A
a more comprehensive revision of the
major departure was rapidly switching to
pandemic strategy in early 2022.
an elimination strategy in late March 2020
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editorial
Figure 1: Epidemic curve for diagnosed COVID-19 cases in New Zealand, distinguishing cases infected overseas (blue = history of recent overseas travel) from locally acquired cases (red).
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Zealand also introduced a range of vaccine
The apparent shift to a suppression mandates for occupational groups and
strategy will soon introduce a mandate preventing
On 4 October 2021, the Prime Minister unvaccinated people from entering a wide
for the first time indicated New Zealand range of indoor social settings, such as gyms,
would transition away from the elimi- restaurants and hairdressers (the COVID-19
nation strategy. The new approach was not Protection Framework, or “traffic light
formally announced or defined but could be system”).12
classified as a suppression strategy (Figure
At the time of writing, New Zealand
2). This change was precipitated by a Delta-
is typically experiencing around 150 to
variant outbreak first detected on 17 August
200 new COVID-19 cases a day, mainly
2021 in Auckland (Figure 1). This outbreak
in Auckland. Spread from Auckland to
proved too difficult to stamp out using the
other regions has been occurring but at a
methods that effectively eliminated previous
low level. Consequently, some of us have
outbreaks arising from border control
argued for continuing with suppression in
failures.10
Auckland while maintaining an elimination
It appears the goal of the new policy strategy for the rest New Zealand, which
settings is to control rather than eliminate would require maintaining strong boundary
SARS-CoV-2 (Figure 2). A positive feature of controls around Auckland.13
these settings is that they suggest a “tight
suppression” approach, as opposed to loose Principles to guide the ongoing
suppression or mitigation policies used pandemic response
by countries like the United Kingdom and There is a series of key principles that
Sweden. Another positive feature is the can help inform Aotearoa New Zealand’s
continuation of many public health and pandemic response, some of which have
social measures, including restrictions on been articulated in government plans.14
New Zealand’s external borders and active
contact tracing to keep case numbers low. Science-informed strategic
However, there has been little promotion of leadership
masks and improvements to indoor venti- One of the strongest lessons from the
lation in public spaces, despite the strong pandemic response comes from the demon-
evidence base for these measures.11 New strated benefits of combining effective
Figure 2: Major strategic choices for managing a pandemic (albeit not including the exclusion strategy
successfully used by some Pacific Island nations).
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political and scientific leadership. This have significant impacts,22 such as when
success was shown when New Zealand infectious diseases like COVID-19 emerge.
switched its response from the established It is important to recognise and be explicit
pandemic mitigation approach to an elim- about these unknowns. We do not know
ination strategy. Given the ongoing need the impact of endemic SARS-CoV-2 infection
to meet new challenges in the pandemic on morbidity and mortality, even in a
response, it would be timely to institu- highly vaccinated population. An under-
tionalise an improved set of processes for lying assumption by some appears to be
decision-making that foster use of evidence, that SARS-CoV-2 infection will inevitably
innovation, consensus decision-making, become endemic, and that this infection
continuous quality improvement and trans- will be relatively benign once population
parency.15,16 These processes could include: immunity is widespread, as was eventually
convening a cross-party parliamentary seen following the 1918 H1N1 influenza
group along the lines of the Epidemic pandemic.23 There is evidence that this
Response Committee;17 forming a high-level assumption may be overly optimistic. The
science strategy rōpū (council) to provide post-acute effects of SARS-CoV-2 infection (so
the multidisciplinary expertise needed called “long-COVID”) appear to be far more
for complex emergencies; and developing common and severe than for influenza.24
a well-resourced COVID-19 research and For example, there is the possibility of
development strategy. life-course impacts in the child population
through effects on the developing brain.25
Having a Tiriti and equity focus If that is found to be the case, then this
A major lesson from the pandemic
pathogen may belong in the same category
response is the overwhelming importance
as measles and polio, which create such a
of health equity. There is a long history
burden of illness that they justify efforts for
of infectious diseases18 and pandemics19
progressive elimination.26 27
being patterned by inequalities in Aotearoa
New Zealand. COVID-19 is unfortunately One of the biggest unknowns is about the
no exception. Most COVID-19 cases are in future evolution of SARS-CoV-2 “variants
Māori and Pacific peoples (71% in the Delta- of concern,” which may be more vaccine
variant outbreak at the time of writing).20 The resistant, more infectious and even more
markedly lower rates of vaccination in Māori lethal.28 The best way to stem SARS-CoV-2
illustrate what happens when Māori input is evolution is to rapidly suppress trans-
not adequately sought or ignored, and how mission of this virus to very low levels
long-standing inequities in social determi- across the globe, which is technically
nants drive health outcomes. The lack of feasible but difficult to implement given
engagement with the appropriate people, inequities with vaccine supply, public
especially in Auckland, ultimately derailed health infrastructure and coordination.
control efforts and contributed to the On the positive side, improved vaccines
current outbreak not being eliminated.21 Key (and vaccine schedules) and disease-mod-
responses need to align with the principles ifying treatments are providing tools to
of equity, tino rangatiratanga, partnership reduce both the frequency and conse-
and active protection. More fundamentally, quence of infection. They may even provide
there is a need to identify opportunities to the ability to entirely interrupt trans-
strengthen and resource Māori and Pacific mission or make this a trivial infection, or
leadership of the pandemic response. both.
Creation of the Māori Health Authority will Given this changing landscape, it will
provide a pathway to institutionalise this be essential to periodically review our
goal—but this is in the longer term. strategic direction and policy settings to
ensure our response is optimal. It would be
Application of the precautionary
unwise to take any option off the table. For
principle
example, there may be circumstances in
The precautionary principle expresses the
the future where a nationwide return to the
need to take a cautious approach in situa-
elimination strategy, and even global eradi-
tions of high uncertainty where decisions
cation, might become optimal.29
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strategy. Tight suppression could extend
Creating legacy benefits from
to elimination outside of Auckland until at
investment in the response least the end of January 2022. This mixed
It is imperative that we gain as many
regional approach would increase the time
legacy benefits as we can from our huge
available for the next key action: closing
investment in the pandemic response. We
the remaining immunity gaps. A critical
are now almost two years into the pandemic,
decision that will also increase the time
and it is time to move beyond the crisis
available to raise vaccine coverage is careful
phase and establish more mature systems
management of the regional border around
that can undertake robust risk assessment
Auckland when it "opens" on 15 December,
and react swiftly to emerging population
allowing Aucklanders to travel widely
health threats. One test is whether the deci-
across New Zealand. The currently proposed
sion-making processes and infrastructure
controls will miss many infected people, as
we have developed for this response are
they only require vaccination or testing.35 By
sufficiently versatile for future threats,
comparison, even the reduced requirements
including evolution of the current pandemic
for travel into New Zealand from overseas
and multiple emerging infectious disease
that will start in January 2022 still require
threats that require a similarly vigorous
far more controls (vaccination, pre-travel
response.30,31 The proposed measures in the
test, test on arrival, one-week self-isolation,
COVID-19 Protection Framework are not
post-isolation test) for a traveller who
flexible enough to protect New Zealanders
may have a similar or lower level of risk
against outbreaks of non-COVID infectious
compared with a traveller from Auckland.36
diseases (eg, influenza or meningococcal
To maintain even some consistency in risk
disease) that are likely to occur once border
management, the government needs to set
restrictions are loosened and may have
the requirement for travel out of Auckland
atypical epidemiology and severity.31 The
at a much higher level (a minimum would
time to begin planning and rehearsing for
be full vaccination for those who are eligible
the next pandemic is now.32
plus fully tested for all, including children
The reforms proposed by the new Pae Ora down to two years of age).
(Healthy Futures) Bill provide an overdue
opportunity to create a national public Rapidly close remaining immunity
health service that is fit for purpose. Estab- gaps
lishing a dedicated national public health Disease modelling and international
agency could consolidate New Zealand’s experience indicate that creating and main-
capacity to deliver a consistently high- taining uniformly high COVID-19 immunity
quality and sustainable pandemic response, is the most important requirement for
along with other disease prevention and minimising the population health impact of
control services across the country and for COVID-19 with a suppression strategy. New
all its citizens. Such an agency would have Zealand has extremely low rates of “natural
an additional valuable role in supporting immunity” compared with other countries,
the pandemic response in the Pacific region. so we are very reliant on vaccine-induced
Finally, in the ongoing resource-constrained immunity. Firstly, we need to achieve high
environment, there has never been a better vaccine coverage—that is, as close to 100%
time to Choose Wisely33 for rational and as possible for the total population. This
equitable34 healthcare resource stewardship. is because the dominant Delta variant is
highly infectious and, as with previous coro-
Key actions that need to be taken navirus vaccines, the currently available
now COVID-19 vaccines are not able to create
Applying these principles supports a “sterilising immunity” (where people are
number of immediate actions as part of highly protected from becoming infected
the pandemic response, all of which are and infecting others, as is the case with
underway to varying degrees. measles vaccine). Secondly, this coverage
needs to be high across all population
Adopt a tight suppression strategy groups, and protecting those who have a
We argue that the uncertain public higher risk of infection or adverse outcomes
health impacts of the pandemic necessitate must be a focus. This is not presently the
a relatively cautious, tight suppression case in New Zealand, where coverage is
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around 20% lower for Māori (albeit this gap a new national testing strategy to provide
is declining).37 Thirdly, we need to extend better protection for high-risk groups as
coverage to young children. Currently in New Zealand transitions to the COVID-19
New Zealand, vaccination is limited to Protection Framework. This strategy will
children 12 years of age and older, but include a new telehealth case investigation
several international jurisdictions, including service, increased PCR testing capacity and
the United States, Canada and Israel, are wider use of rapid antigen testing and sali-
now vaccinating the 5–11-year age group, va-based PCR testing.43
with over three million first doses admin-
istered. Finally, we need to address waning
Retain border entry controls
Border management is less critical with a
vaccine immunity over time by providing
suppression strategy in comparison to elim-
“booster” doses six months after the first
ination, and re-designing border controls
two doses (which may in fact be just part of
is now necessary to free-up rooms in MIQ
the primary vaccine course38), and also in
facilities for isolating cases who can’t isolate
future years. These COVID-19 booster doses
at home. Nevertheless, border controls will
could potentially be combined with seasonal
still help reduce the overall case load, espe-
influenza vaccination.
cially in regions outside of Auckland. Even
Strengthen public health and social the reduced requirements for travel into
measures New Zealand from overseas that will start
Although vaccination will certainly in January 2022 still require a minimum of
reduce case numbers and severity of illness, full vaccination, multiple tests and one-week
it is insufficient to prevent all COVID-19 self-isolation.36 Tight border management
illness. To limit SARS-CoV-2 transmission, may also need to be reinstated in the future
we need to continue upgrading our public to prevent importation of more virulent
health and social measures. Many of these SARS-CoV-2 variants.
measures are familiar from the elimination
Strengthen primary healthcare
strategy. However, activation of lockdowns
(stay-at-home orders) is less likely with
services and support for cases in the
a suppression strategy, where there is a community
greater tolerance for transmission than The primary healthcare system and
there is with elimination. We may need community support services need to
to retain localised lockdowns for situa- increase their capacity to manage large
tions where cases threaten to overwhelm numbers of people with mild to moderate
healthcare services, or if new, more-vir- COVID-19 infection safely in the community.
ulent variants emerge. Effective prevention Strengthen hospital services
of transmission in schools requires high The need to assess and manage more
uptake of masks and optimising indoor seriously ill COVID-19 patients in hospital
ventilation to prevent spread by inha- emergency departments, wards and
lation.39–41 It would be useful to develop a ICUs will increase. This is a concern, as
nationwide mask strategy to ensure high use the healthcare system had limited surge
of appropriate masks in all settings where capacity prior to the pandemic, due to
this would reduce the risk of SARS-CoV-2 heavy demands, resource and work-
transmission.41 It will also be useful to inte- force constraints. Ultimately, the current
grate the use of rapid antigen testing into healthcare system reform, as outlined in the
supporting infection-control actions.42 new Pae Ora (Healthy Futures) Bill, aims to
Strengthen and adapt contact tracing strengthen the capacity and performance of
Testing, contact tracing, case isolation the healthcare system in total.
and quarantine of contacts are all essential Ensure effective public
components of COVID-19 suppression. These communication
measures need to be strengthened so they The highly effective communication
can manage the potentially large numbers of the elimination strategy was critical
of cases that may arise following the switch to its successful implementation. Since
from elimination to suppression. The the transition away from elimination
government has recently announcement was announced on 4 October, and the
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proposal of the “steps system” and the wellbeing and economic outcomes through
following “traffic light system,” there has the initial phase of the pandemic. The
been less clarity and consistency around transition away from elimination will be
the pandemic strategy and how it will be challenging. Outcomes are likely to be
achieved. It would be useful to consider optimised by taking a tight suppression
ways to ensure clear communication about approach, minimising immunity gaps and
the current aims of the pandemic strategy using public health and social measures
and their rationale. Such communication to protect populations that are more
is particularly important for communities vulnerable to infection and adverse
where English is a second language, notably outcomes of infection. All investments in
some Pacific peoples. the response should be assessed according
to their legacy benefit as well as their
Conclusion immediate value. In this new phase of the
New Zealand’s COVID-19 elimination response, science-informed strategic lead-
strategy was highly successful, having ership and a commitment to equity are more
maintained positive public health, equity, important than ever.
Competing interests:
Nil.
Acknowledgements:
This work was based in the Covid-19 Research Group (CoSearch) at the University of
Otago, Wellington which receives funding support from the Health Research Council of
NZ (20/1066). The epidemic curve was produced by Andy Anglemyer, Senior Research
Fellow, Department of Preventive and Social Medicine, University of Otago, Dunedin.
Author information:
Michael Baker: Professor of Public Health, Director of CoSearch,
Department of Public Health, University of Otago, Wellington.
Amanda Kvalsvig: Senior Research Fellow, Co-Director of CoSearch,
Department of Public Health, University of Otago Wellington.
Sue Crengle: Professor in Māori Health, Department of Preventive and Social Medicine,
University of Otago, Dunedin; Specialist General Practitioner, Invercargill
Matire Harwood: Associate Professor, Department of General
Practice and Primary Care, University of Auckland; Specialist General
Practitioner, Papakura Marae Health Clinic, Auckland
Collin Tukuitonga: Associate Dean (Pacific) and Associate Professor of Public
Health, Faculty of Medical and Health Sciences, University of Auckland
Bryan Betty: Medical Director of the Royal New Zealand College of General
Practitioners; Specialist General Practitioner, Cannons Creek , East Porirua
John Bonning: FACEM, Emergency Physician Waikato Hospital; Chair of the
Council of Medical Colleges of Aotearoa NZ; Immediate Past president ACEM.
Nick Wilson: Professor of Public Health, BODE3 Programme,
Department of Public Health, University of Otago, Wellington
Corresponding author:
Professor Michael Baker, Department of Public Health, University of
Otago, Box 7343, Wellington 6242, New Zealand; 0064 (0)21 355 056
michael.baker@otago.ac.nz
URL:
www.nzma.org.nz/journal-articles/the-next-phase-in-aotearoa-
new-zealands-covid-19-response-tight-suppression-may-be-optimal-
for-health-equity-and-wellbeing-in-the-months-ahead
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