Prof Michael Baker, Prof Sue Crengle, Assoc Prof Collin Tukuitonga, Sarah Helm, Dr Amanda Kvalsvig, Prof Nick Wilson*
Regardless of whether Auckland returns to Covid-19 elimination or transitions to a suppression approach, there are critical actions that can be taken to strengthen pandemic control measures, including: (1) Enhancing Covid-19 control in groups who experience deprivation and marginalisation; this is key and requires a dedicated strategy, leadership by trusted members of those communities, an expanded role for Māori and Pacific providers, and models of care that are equity focussed and culturally safe across all providers; (2) Enhancing surveillance and screening to detect infectious people and areas; (3) Expanding vaccine access and mandates to protect key groups and slow transmission; (4) Upgrading the Alert Level system to provide more nuanced options for controlling Covid-19; (5) Strengthening regional boundaries to limit national spread of Covid-19.
The Government’s current Covid-19 strategy was released at a Reconnecting New Zealanders to the World forum on 12 August. It was based on continuing the elimination strategy (which has performed well) for at least the short-term; achieving high vaccine coverage; and increasing connections with the world to allow larger numbers of New Zealanders to safely enter Aotearoa NZ.
This strategy was reasonably sound but is now threatened by the Delta variant outbreak which began on 17 August and has now continued for more than 6 weeks in Auckland. Application of Alert Level 4 restrictions stopped widespread transmission within 2-3 weeks. However, there has been a persistent tail of transmission and the decision to step down to Alert Level 3 will have generated increased opportunities for transmission. The regular detection of unexpected cases in settings such as hospitals (notably Middlemore and Waitākere) and on screening people being taken into custody (prisons, police stations), suggests ongoing transmission in the community.
Covid-19 infection appears to be established in groups who experience deprivation and marginalisation, notably people living in emergency and transitional housing (many of whom have substance use dependencies and mental distress). Controls operating at Alert Level 4 were not able to extinguish such transmission, suggesting that we need a fresh approach. Multiple factors are likely to be contributing to this situation, including insufficient engagement with affected people, families, and groups; lack of trust in officials; and the multiple effects of long-term poverty, deprivation and crowded and precarious housing.
Auckland and NZ generally remain under-prepared for widespread transmission of Covid-19. Vaccine coverage remains relatively low, particularly in Māori (30% fully vaccinated) and Pasifika (41% fully vaccinated). Hospital resources for treating seriously ill patients are limited.
Recent modelling by Te Pūnaha Matatini suggests large numbers of hospitalisations and deaths if Covid-19 circulates widely at the present time (though there are very high levels of uncertainty around these estimates).
This situation suggests that an upgraded strategy is needed. Here we describe 5 critical measures to suppress and contain transmission of Covid-19 to buy additional time to achieve the levels of vaccine coverage needed to limit the health and social harm caused by the current pandemic. Several of these measures are already underway to varying degree. We also acknowledge the huge amount of dedicated work already underway across Auckland to manage the pandemic.
Image by Luke Pilkinton-Ching, University of Otago Wellington
- Enhancing Covid-19 control in groups who experience deprivation and marginalisation
As noted above, there is evidence that Covid-19 transmission is continuing in Auckland with infection established in groups who experience deprivation and marginalisation. Māori (19% of cases) and Pasifika people (64% of cases) are most affected by the current outbreak. Such transmission is likely to continue, and we would expect it to accelerate as we see the impact of the less restrictive Alert Level 3 (which came into full effect on Wednesday 22 September). We suggest the current Covid-19 strategy is reviewed and enhanced in the following ways:
- Convening an urgent meeting to review Covid-19 containment measures and how they can be further enhanced in Auckland. This meeting could include key Auckland leaders (Māori and Pasifika community representatives of all age groups including rangatahi, Māori and Pacific public health leaders, church leaders, gang leaders), key agencies (Auckland Regional Public Health, Ministry of Health, Ministry of Business, Innovation and Employment [MBIE], NZ Police, Department of Corrections, Ministry of Social Development [MSD], emergency and social housing providers, Alcohol and Drug Services, Auckland City Mission, Auckland City Council), and public health experts. Specific actions that should be considered include:
- Leadership of Covid-19 control programmes by members of those communities
- Wider engagement with local community leaders (of all ages) that people trust
- A new dedicated Covid-19 strategy for Pasifika and for Māori
- Development of models of care that are culturally safe whilst achieving Covid-19 control measures
- An expanded role and resourcing for Māori and Pacific providers in local areas and
- Evaluation of processes and monitoring of the so-called ‘mainstream’ providers to ensure that they deliver equitable care to these communities.
- Review of the support and Covid-19 control service model for people who have drug and alcohol dependency who may be particularly vulnerable to Covid-19 infection. This review could aim to identify options for the All-of-Government groups (Health, MSD, Police, Corrections, Alcohol and Drugs Services) to apply a ‘harm minimisation’ approach and enable people who use drugs to stay safe and contribute to the goal of controlling Covid-19. These measures could extend to an Auckland-wide moratorium on prosecuting people for drug possession and use until the pandemic threat has diminished to reduce barriers to them engaging with Government agencies (in line with police discretion provisions in the Misuse of Drugs Act, which allows police not to prosecute).
- Review of the Covid-19 control service model (for testing, surveillance, quarantine of close contacts of positive cases) to ensure that it is fit for purpose to ensure that people who experience deprivation and marginalisation are able to meet expectations for surveillance, testing and isolation. Providing social support, access to food, and access to health services will be key components of the model.
- Review of support measures for the most affected groups. As shown by research conducted under previous lockdowns, such support needs to include housing, food security, income for essential needs, and healthcare. Urgent financial transfers from government may be needed – especially in the deprived suburbs where cases are still occurring, and which could be subject to specific suburb-level restrictions if the rest of Auckland does shift down Alert Levels (see below regarding Alert Level 3 minus).
- Enhancing surveillance and screening to detect infected people and areas
There are multiple useful systems for Covid-19 surveillance and screening operating in Auckland. All can be reviewed and enhanced in various ways to make them more effective.
- Consider enhancements of wastewater testing to improve its ability to detect suburbs where there is Covid-19 transmission. One way of reducing false positives with wastewater testing would be to trial the feasibility and acceptability of providing Portaloos for all recently discharged patients so they are not adding residual viral fragments into the wastewater system (although this approach would not be sustainable if case numbers rose dramatically).
- Introduce or enhance routine Covid-19 screening for key population groups, including:
- Those travelling out of Auckland (currently require a PCR test within 72 hours, to which could be added a rapid antigen test at the crossing-point)
- Those attending hospitals and residential care facilities as patients or visitors
- Those detained by police and corrections
- Those identified as part of enhanced contact tracing
- Populations that experience marginalisation (eg, those in transitional housing) potentially through mobile and door to door outreach services
- People living in suburbs where there is evidence of Covid-19 transmission (including evidence from wastewater testing).
- Potentially, all essential and permitted workers at Alert Level 3
- As part of improving the speed and acceptability of testing, continue with moves to phase in saliva collection (for PCR testing) and the use of Rapid Antigen Testing (RAT) where suitable.
- Expanding vaccine access and mandates to protect key groups and slow transmission
The outbreak in Auckland could rapidly transition to become widespread as thousands of workers have returned to work at Alert Level 3, and especially if there is an upcoming shift to Alert Level 2. Many of these workers are in industries that employ large numbers of young people, including some who are part-time and casual employees. The resulting mobility and mixing between households can greatly amplify transmission of Covid-19.
It is important to empower and resource Māori and Pasifika communities to lead, deliver, and mobilise their communities. Dedicated community-led vaccination drives for Māori and Pasifika and by Māori and Pasifika providers continue to be highly effective.
There are two broad types of vaccine mandates: (1) those for specific occupational groups (eg, border and health care workers), and (2) those for specific settings (such as travel, indoor public places such as restaurants, and attending events such as festivals). Mandates for specific settings will require a valid and portable vaccine certificate or passport so will need to wait until this is available in NZ (work underway at present).
However, Covid-19 vaccine mandates for occupational groups are already used for border workers and could be rapidly expanded:
- Immediately introduce a vaccine mandate for key occupational groups:
- Essential and permitted workers in Auckland who travel across the Auckland border or are managing this border, notably police
- Public facing workers in Auckland, including retail, food and beverage workers, and those who work in police, corrections, armed forces, and other security-based occupations
- All healthcare and aged care workers across NZ (but especially Auckland)
- Consider extending this mandate to other essential and permitted occupational groups working at Alert Levels 3 and 4 in Auckland
- Indicate that vaccine mandates will be required for a wide range of settings as soon as a valid certificate system can be implemented, notably indoor public places (eg, cafés, restaurants, theatres, music venues, nightclubs, gyms, faith-based meetings), air travel, and organised events (eg, music festivals).
- Upgrading the Alert Level system to provide more nuanced options for suppressing Covid-19
The Alert Level system performed well when first established in 2020 but needs to be rapidly enhanced. It is currently weighted towards ‘lockdowns’ with two stay at home levels (Alert Level 4 and Alert Level 3). As we have previously proposed, it needs more gradations in the suppression range (currently Alert Level 2). We have suggested that Alert Level 2 be stratified into three levels to support a more nuanced approach:
- Alert Level 2 plus – Adds regional boundary and includes universal masking indoors outside the home (notably all schools, school buses, and workplaces)
- Alert Level 2 – Standard measures, including universal masking indoors
- Alert Level 2 minus – Allows larger event sizes
Without these changes, school-age children will be particularly exposed if there is community transmission occurring at Alert Level 2 because they are still largely unvaccinated and are congregating each day in school buildings where ventilation is poor and mask-wearing is not adequately socialised.
To give an even more nuanced option, we could also define an Alert Level 3 minus – for potential suburb level application in parts of Auckland where the outbreak is persisting (albeit not restricting travel to work in other parts of Auckland and combined with additional economic support from the government).
Regardless of Alert Level system upgrades, it would be premature to move Auckland out of Alert Level 3 (from a Covid-19 control perspective) until the effects of this level of control on virus transmission are established. It will take at least 2-3 weeks for these effects to be apparent. Alert level shifts in Auckland could be made provisional on a sustained period without unexpected cases or achieving a suitably high level of vaccine coverage across all ethnic groups. But we recognise that the Government needs to balance Covid-19 control with the wider adverse social and economic impacts of maintaining Alert Level 3 restrictions in Auckland.
- Strengthening regional borders to limit national spread of Covid-19
The current outbreak could easily transition to become widespread in Auckland as thousands of workers have returned to work under Alert Level 3 – with even more if there is a further downward shift. This situation will increase the risk of Covid-19 spread from Auckland to other parts of NZ. It will also create pressure to maintain Alert Level 3 conditions in Auckland to suppress transmission while maintaining lowered Alert Levels in other parts of the North Island and South Island (eg, Alert Level 2 minus).
This situation means that it may be necessary to tighten the border around Auckland for several weeks to prevent dissemination of the pandemic across the country (though the duration would be strongly dependent on how the outbreak evolves in Auckland). Government has already confirmed that a border around Auckland will continue in the short-term. Options for tightening this border include requiring vaccination for crossing the border and a rapid antigen test at the time of crossing. The importance of careful management of this border is shown by such cases as a truck driver found to test positive after travelling to other parts of the North Island.
Planning should also commence for establishing a border (like the border around Auckland) between the North and South Islands in case there is spread outside Auckland into other parts of the North Island.
Other measures to improve NZ’s Covid-19 response
There are multiple other improvements that NZ could make to enhance its Covid-19 response that are beyond the scope of this blog, including the following:
- Develop an Aotearoa NZ mask strategy to ensure high coverage with effective masks in all settings where this approach will reduce the risk of Covid-19 transmission.
- Prepare for immediate rollout of vaccines to children aged 5-11 years in Auckland after scrutiny of trials that indicate satisfactory vaccine safety and efficacy in this age group (noting that so far there have been 235 confirmed cases of children aged 0-9 years in the Auckland Delta outbreak).
- Continue work to identify improved risk-based approaches to managing NZ’s external borders.
- Identify ways to strengthen health system capacity in hospital and primary care to manage more widespread Covid-19 transmission.
- Develop a Covid-19 research and development (R&D) strategy, supported with a fast-start research fund, to support research on these key issues. Rapidly investing millions on R&D is highly cost-effective compared with the billions spent on efforts to manage Covid-19 transmission and the associated health and economic cost of both the pandemic and response.
- Repeat and refine disease modelling of Covid-19 scenarios by commissioning additional modelling by independent groups.
- Review the optimal medium to long term strategy for managing Covid-19 in Aotearoa NZ based on considerations of emerging evidence in areas such as the impact of long Covid, likely virus evolution, and improved vaccine and antiviral interventions.
Successful control of Covid-19 in NZ now depends on successful control in Auckland. Slowing, or ideally eliminating, Covid-19 transmission benefits the entire country and buys time to achieve high and equitable vaccination. As always, this approach relies on good evidence-informed strategies and highly effective delivery.
We need an urgent review of our Covid-19 control measures in Auckland and an upgraded strategy. This enhancement needs to include leaders of the Māori and Pasifika communities who are most affected by the pandemic and can establish and sustain models of care that are equity focused and culturally safe across all providers. There also needs to be specialised support for people who have drug and alcohol dependency and may be particularly vulnerable to Covid-19 infection.
The pattern of continuing Covid-19 transmission in Auckland in groups who experience deprivation and marginalisation is a vivid example of why achieving equity is key to advancing public health. With infectious diseases and pandemics, we are all in it together.
*Author details: Prof Michael Baker, Prof Nick Wilson, and Dr Amanda Kvalsvig are with the Department of Public Health, University of Otago, Wellington. Prof Sue Crengle is with the Department of Preventive and Social Medicine, University of Otago, Dunedin. Assoc Prof Collin Tukuitonga is Associate Dean (Pacific) in the Faculty of Medical and Health Sciences, The University of Auckland. Sarah Helm is Executive Director of the NZ Drug Foundation. We acknowledge helpful comments from Prof Philip Hill from the University of Otago, Dunedin.