Dr Rawiri Taonui: The Covid-19 risk for New Zealand and Maori in 2021
|13 Jan 2021 15:52 PM|
Dr Rawiri Taonui: The first six months of the New Year will decide the success of New Zealand’s defence against the Covid-19 Pandemic. New Zealand has the lowest case numbers, cases per capita millions, total deaths, and deaths per capita millions of all European OECD countries. New Zealand’s path through 2021 will be interwoven with runaway numbers bordering on collapse in other countries, the emergence of new more virulent and dominant strains of Covid-19 and the promise of contagion ending vaccines.
THE WORLD SITUATION
The world is witnessing unprecedented Covid-19 cases and deaths. In the developing world, the upward surge is driven by poverty, inequality, and weak health infrastructure. In the West, countries with the richest economies and strongest health systems are caught between protecting public welfare and maintaining rich economies.
More fundamentally, regional cooperation and coordination have been absent between adjacent countries like the Europe Union, and between states and counties in federal jurisdictions like the United States (US). Different authorities apply different regimes at separate times. When one restricts travel, another is opening travel; one is closing borders, another is opening a travel bubble. The outcome, when Covid-19 was declining in one country it was rising in another. Incrementally, the peaks became higher and the troughs shallower, allowing Covid-19 to build sufficient impetus to accelerate beyond standard controls.
On 10 January, the world passed 90 million cases and 1.9 million deaths. New records are set every few days. A record 15,200 deaths were reported on 30 December. Ten million cases every 16 days have been added to the world total three times in succession.
On 6 January, new daily cases eclipsed 800,000 for the first time, then followed by two more 800,000-plus days and a 730,000-plus on 9 January and the world had accrued 3.2 million new cases in four days equalling the total of all cases in the first 148 days of the pandemic.
Unchecked, Covid-19 is heading toward 105 million cases and 2.2 million deaths by the end of this month and a first 1 million cases per day by mid-February.
2. The New B117 Strain
The emergence of new highly infectious strains is exacerbating a borderline out-of-control pandemic. Like other viruses, Covid-19 mutates. Mutations can enhance or inhibit how a virus behaves. Most change nothing. There are thousands of Covid-19 variants comprising one to two inconsequential changes.
First seen 20 September, Britain reported a new B117 variant to WHO (also called VUI 202012/01, 501Y.V1, or the S-Gene) in December. The B117 variant has 23 changes a level of change in one variation unprecedented in the global genomic data for Covid-19. Scientists believe this is due to the virus having infected a yet unidentified patient in England whose weak immune system allowed Covid-19 to evolve multiple times over weeks before emerging as B117.
Seventeen of the changes, three deletions and 14 mutations, affect how the virus behaves. Several have been seen before, but never in combination.
The N501Y alteration is a change to the protein spike of the virus. Another, the P681H mutation occurs at the point of cell penetration. Together, they facilitate easier penetration of human cells.
An H69/V70 deletion reduces the ability of antibodies to detect and attack the pathogen.
Together these changes make B117 50% to 70% more infectious and more dominant than previous versions of Covid-19. Evidence for this was seen as early as mid-December with B117 comprising 60% of all new cases in large parts of England.
Another change on the ORF8 protein is associated with more frequent mutation and milder clinical infection and less post-infection inflammation. While the latter is encouraging, the risk remains that B117 will generate higher deaths through sheer volume of cases.
3. The 501Y.V2 Strain
Another variant 501Y.V2 emerged in South Africa. Like B117, 501Y.V2 is more infectious than other strains of Covid-19. The 501Y.V2 virus carries a spike protein mutation called E484K that reduces antibody recognition. The profile is greater contagion and milder sickness.
On 9 January, Brazil reported the first case of reinfection by 501Y.V2. Reinfections have been seen before, but this is the first from the new strains. The case was first infected in May 2020, recovered, and tested positive for 501Y.V2 on 20 October. The symptoms are reported as more severe which raises the spectre that the hyper-contagious strains are more aggressive in reinfections.
4. The B11248 Strain
Last weekend, Japan reported a new B11248 strain found in travellers from Brazil. The strain has 12 changes to the spike protein. The infectivity and lethality of B11248 are not determined. The high number spike mutations are cause for concern.
5. New Strains and Vaccines
The preliminary evidence is that the Pfizer-BioNTech will protect against viruses carrying at least one of the key mutations found in B117 and 501Y.V2.
The new highly virulent strains render an already dire situation worse. Though clinically milder, they could cause higher deaths through sheer numbers. The consensus among experts is that outbreaks of the new strains will require level three or four lockdowns. A new deadly wave of Covid-19 variants would echo the second more deadly wave of the 1918 Spanish Flu. Strengthened border controls, the early introduction of vaccines and community preparedness are imperative.
THE NEW ZEALAND SITUATION
7. International Travel Negative Test Requirement
On 3 January, the government announced that travellers from Britain and the US will need to provide proof of a negative Covid-19 test before departure to New Zealand. After widespread criticism, the government extended the requirement to travellers from all countries except Australia, some Pacific nations and Antarctica. A start date will be decided next week.
The government has avoided a huge blunder. Requiring a negative test from Britain and the US alone was only appropriate to the extent that they are the largest sources of cases in New Zealand (at 10 January, Britain 278 and the US 182). Positive cases have come into New Zealand from 83 other countries as well.
Moreover, between October and December, flights from Britain to foreign destinations had a total capacity of 8 million passengers. Some were not at full capacity, others were cancelled. Nevertheless, because destination countries had not imposed restrictions on Britain until well into December, B117 had already left the country. By 8 January, 45 countries have identified the variant; 13 of which have recorded community transmission. On 11 January, Mexico, Japan and Russia reported finding B117. On 12 January, Malaysia reported the strain. More than 50 countries. New Zealand was targeting two.
The new decision is the right one albeit late. Fifty-three other countries had banned or imposed restrictions on travel with Britain by 25 December. Beginning this week, Australia requires all travellers from all overseas points of departure to take a rapid antigen COVID test or otherwise prove they have returned a negative result, a decision framed in the context that 80% of Australians living overseas reside in countries that have reported the strain, not just Britain.
Recommendation International Travel Negative Test Requirement: Recognising that historically positive cases have entered New Zealand from 85 different countries, that internationally world cases numbers are spiralling upwards and that B117 and 501Y.V2 are already in more than 50 countries, New Zealand applies the pre-departure negative test requirement to all travellers intending to enter the country as soon as possible.
8. The Vaccine Rollout
On 17 December, Prime Minister Jacinda Ardern announced that New Zealand had purchased 15 million vaccine courses and would begin vaccinating frontline workers (border staff, frontline healthcare workers, managed isolation and quarantine employees and their household contacts) in the second quarter of 2021 (between April and June), and at-risk groups (Māori, Pacific, the aged and those with disabilities) and the general public in the third quarter (July to August).
The government has not changed the timetable. At best this is unwise, at worst, negligent. Other countries have responded to the challenge of proliferating numbers and virulent strains by bringing vaccination programmes forward. Mexico, Chile, and Costa kick-started their vaccination programmes on 24 December.
The European Union (EU) followed in all 27 EU countries on 27 December. Britain has boosted its inoculation schedule aiming for 15 million people vaccinated by the end of February.
Australia initially had the same timetable as New Zealand. On 6 January, their rollout was brought forward to the beginning of March. Two days later, Prime Minister Scott Morrison announced Australia would begin vaccinating in early February and aim to have 6 million or 25% of all citizens vaccinated by the beginning of March.
Recommendation Vaccine Rollout: New Zealand has 19 cases of B117, the first arrived on 13 December, and one case of 501Y.V2, which arrived on 26 December. Given the rapid rise of Covid-19 cases across the world, the emergence of hyper-virulent strains, and the decisions by other governments to bring their vaccination programmes forward, New Zealand must bring the vaccine roll-out forward for implementation as soon as possible. The only reason the government would not do so is that they did not order vaccines early enough in 2020.
9. Capping Arrivals and Reducing Active Case Numbers in MIQ
Every arrival at an airport and every active case in MIQ creates risk with every interaction they have with aircrew, border staff, customs, transport and MIQ staff. To combat the widening overseas crisis and the new strains, Australia has capped numbers entering its borders. Arrivals are halved into New South Wales (now 1500 arrivals per week), Queensland (500) and Western Australia (500). Caps for South Australia (600), Victoria (1,120) stay in place.
New Zealand allows more international arrivals per capita than Australia. Queensland has the same population as New Zealand, but its current fortnightly entries will be 18% of the 5,553 projected entries into New Zealand over the next two weeks, and weekly cap just 19% of the 2,600 average weekly border entries into New Zealand since June.
New Zealand has never employed a reduction strategy when events in MIQ or breaches into the community occur. As the graphics above shows, there have been 10 breaches of our borders and six significant risk events in MIQ since June last year.
Putting aside the first two beaches, the British duo who were released from MIQ without being tested and the short escape from Stamford Plaza both of which happened because of lax security now significantly tightened, the graphic below shows that entries were at a high of 4,000 per week (shown by red line) when the infections leading to the Auckland OutBreak occurred.
When other risk events (shown in blue) and breaches (shown in red) occurred entries were in the range of 2,800 to 3,200 per week (shown in black lines). A safe level of entries would be a maximum of 300 entries per day or 2,100 per week (see the green line).
The number of active cases in MIQ has also steadily increased (see below). Again, apart from the British duo and the Stamford escape, nearly all breaches and risk events occurred when active cases in MIQ exceeded 20 (shown in red).
MIQ was significantly strengthened during 2020 making an upper limit of 30 active cases in MIQ feasibly safe. However, with global new cases trending past 800,000 per day, no sign of a decrease, and the threat from new strains, both the current number of arrivals into New Zealand and the number of active cases in MIQ are no longer sustainable.
The introduction of the negative test requirement for entry should decrease active cases and to a lesser extent the number of entries. If entries and active cases continue at present levels, then it is likely New Zealand will see a further breach into the community in the next three months and almost certainly within the next six months.
Recommendation Capping Arrivals and Reducing Active Case Numbers in MIQ: With the number of world cases trending past 800,000 per day and no sign of slowing down, and the threat from new strains; at current levels, both the number of arrivals into New Zealand, which are over five times higher than those for Queensland which has a similar population and the number of active cases in MIQ are no longer sustainable. The government needs to consider capping arrivals at 300 per day or 2,100 per week, and, when the number of active cases in MIQ reaches 20 to 30 cases, cap the number of entries to a lower level.
10. Vaccination Strategy for Māori
The Ministry of Health Vaccination Strategy ostensibly regards Māori as a priority group and aims to
The vaccination strategy is subject to change according to three scenarios. Māori are only a priority when there is a severe outbreak under Scenario 3. This is contradictory to the epidemic-pandemic history of Aotearoa New Zealand which shows that Māori as indigenous peoples are the most vulnerable people in the country. Kaumātua, koroua and kuia and other Māori aged over 50 who are at particular risk of Covid-19 are not included as at-risk in any scenario. This too falls short of Te Tiriti.
Recommendation Vaccination Strategy for Māori: The government enter discussions with Māori to bring the Vaccination Strategy into line with Te Tiriti o Waitangi.
The current New Zealand Vaccination Strategy falls short of Ngā Tikanga o te Tiriti o Waitangi on protection, partnership, and equality. It is contradictory to the epidemic-pandemic history of Aotearoa New Zealand which shows that Māori as indigenous peoples are the most vulnerable people in the country. Kaumātua, koroua and kuia and other Māori aged over 50 who are at particular risk of Covid-19 are not specifically included as at-risk.
11. MIQ vs Airport Testing
On 31 December, in addition to existing day three and 12 tests, the government introduced an extra required day-zero/day-one test for all travellers arriving from Britain and the US. On 12 January, this was extended to travellers from all countries except Australia, some Pacific nations and Antarctica.
Day-zero/day-one test provide immediacy in detecting arriving positive cases, narrow margins of error in MIQ testing and reduce the previous risk of transmission while arrivals waited for day three tests.
Another option is to test travellers in airports immediately upon arrival. This will reduce the opportunity for transmission by sending confirmed positive cases directly into quarantine. Some countries use cost-effective rapid antigen tests which produce results in 15 minutes. Antigen tests have higher error rates; however, this can be backed up by repeat tests on-site and existing scheduled tests in isolation facilities.
Recommendation MIQ vs Airport Testing: The government explore the efficacy of testing travellers to New Zealand immediately upon arrival in airports as they disembark.
12. Travel Bubbles, Holiday Bubbles, Sporting and Cultural Groups, International Workers and Students
On 27 November, the government announced an agreement to allow 2,000 horticultural workers from the Pacific to enter New Zealand between January and March of this year. New Zealand has also allowed two groups of Russian mariners into New Zealand, one in October last year and another this month. Both resulted in pockets of cases in MIQ, and the first, two cases among quarantine staff.
Sports and cultural teams have been allowed into New Zealand, including the Wallabies, the Americas Cup, and the Pakistan cricket team. The latter led to a significant cluster in MIQ.
On 12 December, New Zealand and Rarotonga agreed to open a quarantine-free travel bubble by end of March 2021. On 14 December, New Zealand announced plans to introduce a trans-Tasman quarantine-free travel bubble with Australia in the first quarter of 2021. Since last October, Australian states had opened their borders to New Zealand without requiring them to do 14 days isolation.
Late last year, the National Party called for a wide easing of entry restrictions for seasonal workers, international students, tourists and people from Covid-19 free countries and allowing companies to manage private MIQ facilities.
Recommendation Travel Bubbles, Holiday Bubbles, Sporting and Cultural Groups, International Workers and Students: In the current situation, quarantine-free travel bubbles, holiday bubbles, bringing in seasonal workers, foreign students, sports teams and cultural groups and others presents a significant risk of a further outbreak, including by one of the new highly virulent strains of Covid-19. The government must halt all plans to establish new international quarantine-free bubbles and immediately review and risk-assess existing and planned group entry arrangements.
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