Because we don’t have widespread community transmission of Covid-19 in New Zealand, our response managing our border and responding to any outbreaks will also help the rest of the world understand more about Covid-19. Let me explain how, and what I think a robust Covid-19 response looks like at least in the short term.
Controls at the border are all about minimising the risk of further spread of Covid-19 from someone coming into the country with the virus. The current model of using a network of hotels overseen by the state is a good one, as is having an entirely separate facility for people who test positive for the virus and are more of a risk for transmission and needing medical attention.
The isolation hotel network
It may be useful to have the managed isolation facilities operate on a similar risk level, with some hotels dedicated to housing travellers returning from countries with widespread community transmission or coming via a route that may be more of a risk for transmission. Others could house less “risky” travellers. On the other hand, we’ve all seen how quickly a country’s situation can change so this may just lead people isolating and working in such a “low risk’ facility into a false sense of security. Mandatory mask wearing by all returning travellers when they are outside of their rooms would also help reduce the chance of transmission and there should never be any mingling between travellers especially if they have arrived on different days.
At the moment, travellers are put into managed isolation for 14 days. This is pretty standard around the world and is based on the fact that most people incubate the virus for two to 10 days before showing symptoms. There are reports though, of people incubating the virus for longer. I don’t think it’s practical for people to stay in managed isolation any longer than 14 days. But I think it would be wise for people to have follow-up testing done perhaps one and two weeks after they’ve left managed isolation to be sure. And obviously, if they develop any symptoms in the couple of weeks after leaving, they shouldn’t discount Covid-19 just because they’ve done their managed isolation.
Having the day three and day 12 tests has been an important addition that could prove really useful from an understanding the virus perspective. Following up people to see whether those who test positive ever develop symptoms will really help us understand more about people who are truly asymptomatic. Many of these people would never be detected in countries with widespread outbreaks as they aren’t likely to be tested. Following all people who test positive and capturing information on all their symptoms will also be important for understanding the potential long-term health consequences for people who catch the virus.
Testing of everyone working at the border and managed isolation and quarantine should also be standard but how often? This is a tricky question to answer. A test gives you an answer of what was happening at a particular point in time so the more often the better. But regular testing is a logistical nightmare and who wants to regularly have a swab stuck up their nose? The solution is to use a less invasive way of getting a sample, like using saliva instead. Pooling samples from workers with particular roles and individual facilities together may also help get more tests done more quickly.
The latest outbreak in Auckland and the case of the Rydges maintenance worker have shown just how useful genomic sequencing is so this should become standard now. That would also contribute to the global understanding of how the virus is changing as it moves around the world. Not all positive test samples have had enough good genetic material from the virus to be sequenced so it should also be standard to ask people for a follow up swab if needed.
Beyond the border
Moving on from the border, it’s really clear that even with the best processes in place, there is no magical forcefield guaranteed to keep Covid-19 out. As someone said to me recently, even a low-risk gamble will sting if you repeat it often enough. That means we need to be doing everything we can to be on the lookout for cases of Covid-19 outside of the border and our managed isolation and quarantine facilities.
So, what should that look like? First off, it means rapid access to testing for people with any symptoms of Covid-19. I agree with National’s health spokesperson, Shane Reti, that people shouldn’t have to wait for hours to get a test, although I definitely disagree with the idea that people should be able to pop out during their lunch hour to get a test. If they need a test they shouldn’t be at work! Which brings me to a big change we do need: better sick leave and working conditions so people aren’t incentivised to work when unwell.
Speaking of testing, another thing that would be really useful would be if people leaving New Zealand got tested before they went. That would help calm some of the nerves if people test positive for Covid-19 once they arrive at their destination. We’ve had a couple of examples of this recently, where people were infected on the way to their destination and that led to a mad scramble of contact tracing back here in New Zealand.
Testing the water
Another way to monitor whether Covid-19 may have made it back into the community is testing wastewater for the virus. In the interests of full transparency, I’m involved in a large collaboration led by ESR which was just funded by MBIE to look into the feasibility of doing this. It is being carried out in other countries though there are still some things that need to be sorted out around limits of detection. By that I mean how many people need to be infected in the community before a sample of wastewater tests positive?
Ironically, some collaborators and I have been trying to get funding for the last couple of years to do something like this to monitor antibiotic resistance. It’s sad to think that if we had been funded back then we would have had everything in place to start testing wastewater samples as soon as the pandemic started.
With all of these measures in place we should be good to quickly identify community transmission so we can quickly stamp it out. Contact tracing and isolation is clearly an important part of our response and it’s been incredible to see how quickly these have ramped up to meet the demands of the current outbreak in Auckland. It’s also been fantastic to see better uptake of the government’s Covid Tracer app. But should we be relying on such technologies? Interestingly, a review just published found that the effectiveness of digital solutions hasn’t been shown in real world situations, mainly because so few studies have been done. Modelling studies have shown, however, that while digital contact tracing will reduce the number of cases in an outbreak, it’s not as effective as manual contract tracing. It will be interesting to see what happens with the trial of the Bluetooth CovidCard.
One thing the government has newly added to help try to stop transmission in the current outbreak is moving people who test positive and their households into the managed quarantine facility. This is a good idea as the studies show that the majority of Covid-19 transmission happens within households.
But – and this is a big but – this solution won’t work for everyone. Many communities have had and continue to have terrible experiences with the health system and government departments. Our Covid response needs to be mindful of this and work with the families and communities to figure out solutions that may not involve managed quarantine.
The border agency proposal
The National Party on Thursday announced its plans to control Covid-19 at the border. They included a new border protection agency, a requirement that people only be allowed entry to the country if they have proof of a negative test, and a limited rolling out of the Bluetooth Covid Card to help with contact tracing.
Let’s start with the idea for a new Border Protection Agency. After Judith Collins announced the pledge set up a new agency dedicated to defending New Zealand from Covid-19 and other pandemic threats, her deputy leader, Gerry Brownlee, added it would be established within National’s first 100 days in government.
I’ll get to the idea for an agency in a minute, but first let me address the 100 days bit. To be honest, I can think of few worse uses of time and resources right now than trying to establish a new agency while everyone is focused on actually dealing with the pandemic. I can completely understand the desire to put more robust systems in place, but to think this can be done by distracting everyone from the crucial task at hand seems misguided to me.
The UK is currently undertaking a similar exercise, not with their border controls but with their public health agency. Yes, you read that right. During a global pandemic they’ve announced they are scrapping Public Health England and merging it into a new National Institute for Health Protection alongside the Joint Biosecurity Centre. Also in the new institute is the disastrous private initiative misleadingly called NHS Test and Trace which took over contact tracing for Covid-19 from Public Health England. Don’t even get me started over who they have put in charge of the new institute.
Sir Jeremy Farrar is a former professor of tropical medicine at the University of Oxford. He’s currently the director of the Wellcome Trust, a massive medical research charity, and a member of the UK government’s Scientific Advisory Group on Emergencies (Sage). Farrar is firmly against the new institute and on Twitter said this: “kneejerk, reactive, short-term reforms that fail to listen or learn lessons from past, present crisis and future trends will be wasted opportunity for needed reform, public health, social services and medical care.”
Knee jerk,reactive,shortterm reforms that fail to listen or learn lessons from past, present crisis & future trends will be wasted opportunity for needed reform public health,social services & medical care.Learning lessons & commitment to real investment needed is the opportunity
— Jeremy Farrar (@JeremyFarrar) August 19, 2020
The point that is relevant to National’s Border Protection Agency. While an agency dedicated to defending us from pandemic threats sounds like a very good idea, to suggest we can do this by focusing solely on our border seems naïve and short-sighted to me. If we are to have a new agency, it should have a much broader remit that also addresses what makes us vulnerable to pandemics. Any future government also has to address the decades of underfunding our public services have been subjected to. Proposing more cuts will only make us more vulnerable to any future pandemic.
As for requiring a negative test before people can board a plane to New Zealand, I can see why this is an attractive option. It will certainly stop some people who may be infectious from being able to travel. But given how far some New Zealanders have to travel to get home, it won’t stop people getting infected on the way. Instead it’ll just discriminate against those who can’t afford to or aren’t able to access testing – the availability of testing is very different in other parts of the world. And what about the fact that there are huge numbers of different test kits, some of which are better than others. Will that be standardised? Will it be possible for people to fake it? And what happens to those people who still test positive weeks after they are no longer infectious? Will they be exempted? It seems to me this policy runs the very real risk of stranding New Zealanders overseas while doing nothing to actually increase the security of our border.
Infectious diseases research
I’ll end with one final thought. Infectious diseases as a research area has not been well funded in Aotearoa New Zealand. Human infectious diseases are specifically excluded from the National Science Challenges, a 10-year $680 million initiative established by the National Party in 2014 to “tackle the biggest science-based issues and opportunities facing New Zealand”. To put that in context, 2014 was the year the WHO reported that antimicrobial resistance – the ability of infectious microbes to overcome the drugs we use to kill them and treat infected and vulnerable patients – was making routine surgeries and treatments like chemotherapy more and more risky.
Now with this pandemic, everyone can see just how important infectious diseases are. We should be taking this opportunity to develop, support, and coordinate our country’s activities in infectious diseases nationally. That means bringing together everyone – from our clinicians, epidemiologists, and microbiologists, to our geneticists and molecular biologists, bioinformaticians, modellers, and social scientists – to deliver the research and evidence needed to inform policy and develop best practices that work for all our communities. This is critical if we want to respond better as a nation to the threats we face from infectious disease. That includes fast-moving threats like the Covid-19 pandemic and the slow-moving one likes antimicrobial resistance.
This post was originally published on The Spinoff.