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Covid-19: Is New Zealand’s switch in policy a step forward or a retreat?

BMJ 2021; 375 doi: (Published 11 October 2021) Cite this as: BMJ 2021;375:n2476

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“For this outbreak, it’s clear that long periods of heavy restrictions have not got us to zero cases,” said New Zealand’s prime minister, Jacinda Ardern, announcing on 4 October that the country was shifting from a policy of elimination to a mitigation approach more in line with policies in other developed countries. “But that is okay. Elimination was important because we didn’t have vaccines. Now we do, so we can begin to change the way we do things.”

Changes on the ground are minimal, for now. In Auckland, the only region under lockdown, groups of up to 10 are now permitted to assemble outside, and early childhood education has resumed. But it is the first time that New Zealand has relaxed restrictions without first suppressing new cases.

Further lifting of restrictions are planned, at unspecified dates, which will increase the size of gatherings and reopen businesses and services. The government is also changing its vaccine recommendations to suggest only a three week gap between first and second doses of the Pfizer vaccine. Next week the cabinet will vote on making vaccination compulsory for teachers.

The shift was one “we were always going to make over time,” Ardern said. But, she acknowledged, the delta variant had “accelerated” this transition.

Two of the country’s leading experts—Rod Jackson, a professor of epidemiology at the University of Auckland, and Michael Baker, an epidemiologist at the University of Otago and one of the authors of New Zealand’s elimination strategy—spoke to The BMJ about the situation.

Is this really an admission that authorities think they can’t get case numbers down?

MB: “The government’s covid-19 strategy was mapped out in August in its Reconnecting New Zealanders to the World plan and was one I supported.1 It included continuing with elimination until we had high vaccine coverage and then cautiously opening up to greater inbound travel while keeping case numbers low. This stage was expected to be reached in early 2022.

“This timetable was overtaken by events, with a prolonged delta variant outbreak beginning in Auckland on 17 August. This outbreak was largely eliminated within 2-3 weeks of the lockdown. But we had the bad luck that the virus became established in marginalised populations in south Auckland, including people living in emergency housing and motorcycle gangs. This situation meant the outbreak continued at a low level for a further four weeks, and it now appears to be slowly growing. This, and the associated lockdown, started to erode the government’s social licence for continuing its vigorous response and also created real hardship for some households. That situation appeared to be a major factor in the decision to switch to less intense control measures.”

RJ: “Delta has forced us to move beyond elimination sooner than we wanted to. When delta arrived here, we were only partially immunised. We almost got it under control, from 80 new daily cases or so down to the low tens of cases. But elimination was never an endgame: it was only a strategy until you had a good vaccination. Fortunately, now we do.”

What level of vaccination should New Zealand aim for before opening up?

MB: “The government has signalled that it’s aiming for 90% coverage of the eligible population aged 12 years and over, which I think is achievable. First dose coverage is 80%, and fully vaccinated coverage is at 51% but rising quickly, partly driven by the now real threat of covid-19 infection. That’s something that the population here has not experienced for most of the past 18 months.”

RJ: “I believe we need 95% minimum. In Europe you’ve got 95% immunity, when you combine immunity from vaccination with immunity from previous infection. To get to 95% we need to mandate vaccines for health workers, people in education, the police, and supermarket workers, then give businesses the licence to bring in ‘no jab, no job, no entry’ policies.

“Auckland is closed off to non-essential workers, but this week the government let a senior gang member from outside in through the ring, because he’s pro-vaccine. That’s the kind of thinking that’s needed.”

Why are the Māori and Pasifika populations less vaccinated?

MB: “Māori and Pasifika are far more likely to experience health and social inequalities in NZ. Some of the apparent differences are confounded by their relatively youthful age distribution. Older age groups have been prioritised for vaccination and actually have quite similar coverage levels to those of non-Māori and non-Pacific.”

RJ: “Marginalised parts of society in NZ are like marginalised groups elsewhere: they’re not as receptive to mainstream approaches. Jacinda Ardern is the world’s greatest political communicator, but no politician, no prime minister, reaches that marginalised population. That’s our biggest challenge: getting to that population before the virus does.”

Is NZ still short of vaccines?

MB: “We have enough vaccines for the entire population, including children down to 5 years of age, once this age group is approved. The main reason for our relatively low coverage is that our rollout didn’t start in earnest until the second half of this year, when most of our Pfizer vaccine order was delivered.”

What scenarios do you most fear in the coming weeks?

MB: “The main concern is that the current outbreak will increase and spread beyond Auckland, which it is starting to do. We’re closely following outbreaks in Australia, where case numbers and deaths have risen to relatively high levels. That’s a concern because they have similar vaccination coverage levels to us.

“This situation would be likely to increase ethnic health inequalities because of the multiple forms of disadvantage experienced by Māori and Pasifika, including lower vaccination levels; poor quality, crowded, and precarious housing; and a higher prevalence of comorbidities.”

RJ: “The populations that are hardest to reach with vaccination are often the easiest to reach for the virus. I worry like hell about the 20% of people who have not had their first shot.”

What would a good outcome look like?

RJ: “Looking at the experience of the rest of the world is unhelpful to New Zealand. In many countries a lot of the immune protection has come not from vaccination but from infection. The countries we should be comparing ourselves to are Australia and Singapore.

“Singapore has better than 90% vaccination, the same place we want to end up. Colleagues there are reporting about 3000 to 4000 cases a day, with probably twice that many going under the radar because vaccination is much less protective against infection than against severe disease.

“It looks like delta will work its way through the whole of Singapore’s population, with the infections effectively taking the place of boosters. But they’re still kind of okay, because they’re 90% vaccinated. So they’re seeing about five deaths a day. It’s worth noting that even this low rate would double New Zealand’s pandemic death toll in one week.”

Has elimination been vindicated by New Zealand’s experience?

MB: “The elimination strategy has operated from March 2020 until now and has enjoyed huge support here. It gave New Zealand the lowest covid-19 mortality rate in the OECD, a high level of freedoms, and above-average economic performance. If we had experienced the same mortality as the UK (around 2000 per million) we would have had 10 000 deaths. Instead we had 28 (5 per million).

“Elimination certainly appears to be the optimal initial response to a new pandemic. With the availability of safe and effective vaccines, the optimal strategy is probably now swinging towards suppression, with high vaccination coverage.

“There’s still insufficient information to know the optimal long term strategy for managing covid-19. If we get more effective vaccines and antivirals in the future, elimination may again become the optimal strategy, as it is now for polio and measles. This approach would also be more important if long covid turns out to be as serious and common as some evidence suggests.”

RJ: “Our approach has been the best by far. It bought us time to watch what was happening elsewhere and learn from the failures and successes of others.

“Sometimes delta doesn’t give you a choice. But most of New Zealand is still eliminating while vaccinating.”

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