When the coronavirus pandemic hit Planet Earth in early 2020 it was confronted with two main opposing strategic responses to community transmission. One was elimination which was followed by parts of Asia including China, Vietnam, Thailand, Singapore and Taiwan while the second was mitigation (suppression was a stronger version) which was much of the rest of the world, including Europe and North America.
Deciding which response to adopt wasn’t helped by the lack of pandemic experience compounded by the equivocation and lack of authority of the World Health Organisation. New Zealand initially leaned towards mitigation but, just in time, switched to elimination. Australia started with suppression which then transitioned to elimination although with much variation between its states.
It didn’t take long to appreciate that the elimination response was the most effective in terms of infection and death rates as well as economically. Despite being ill-prepared and our public hospitals lacking capacity to cope if we had adopted mitigation, New Zealand’s response was outstanding. While there were failings in areas such as contact tracing, testing for essential workers, early mask wearing, and border security, unlike most economically developed countries, there was no failure.
But now, since early April, there has been a dramatic surge of infections and deaths in Taiwan (held up by many as the exemplar). There have also been less severe outbreaks in Vietnam, Singapore, Thailand and Fiji which all had successful elimination strategies. This has have led to suggestions that elimination has failed.
Taiwan’s response was outstanding with the lowest death rate in the world and no lockdown required because of its quick response in closing borders after learning of the Wuhan discovery, its early and extensive use of masks, early contact tracing, and other public health measures. But now it has suddenly lurched from occasionally reporting single-digit daily infections to hundreds plus increased deaths. It was the worst outbreak since the pandemic began.
Taiwan highlights the problem of success leading to complacency. Its outbreak has been traced back to relaxed quarantine requirements in airports and for airline employees. These employees were housed in an airport hotel that was also patronised by domestic tourists.
While Taiwan had performed better than New Zealand in 2020, especially given it never had to enter a lockdown, our experiences with community transmission have brought important lessons enabling public health systems to be improved. In contrast, Taiwan experienced fewer outbreaks and consequently didn’t build up its testing and contact tracing capability as much as New Zealand did. This meant less capability to confront much more contagious new variants.
Taiwan has also been much more reluctant, through higher thresholds, than New Zealand to consider lockdowns. Last resort lockdowns have been an important part of New Zealand’s strategic approach, but not so with Taiwan.
New Zealand’s vulnerability
New Zealand is vulnerable to a large Covid-19 outbreak through a combination of more contagious variants of the virus, the travel bubble with Australia, relatively low vaccination rates, and winter. Australia is in a similar situation
Measures that worked well against Covid-19 previously may not work as strongly against the more contagious and deadly variants. Extra interactions are now much riskier. But regular vaccine supply can’t be guaranteed and beyond the Government’s control.
These outbreaks have underscored the importance of robust border defences and the risks of border failures which is a big reminder for New Zealand to keep reviewing its border defences and the assumptions that sit behind them. We need to close any loopholes with sea and air crews.
New Zealand’s vulnerability in the context of much more contagious variants is that with vaccinations now being rolled out is inadvertent creeping complacency. We are already seeing signs of this with declining use of people scanning places of entry.
The United Kingdom with 72% of the adult population receiving at least one vaccine dose provides a serious warning for New Zealand. Its expert virus advisory group, noting that the latest variant originating in India now makes up half of infections sequenced, warned its government that the UK could be on the cusp of yet another wave of cases.
Has elimination been a failure?
But does Taiwan and other outbreaks in countries with elimination responses to community transmission mean that elimination has failed? The data from the research university John Hopkins in Baltimore unequivocally answers no.
Let’s start with a sample of economically developed countries that went for mitigation. The cumulative pandemic death rate per one million population as of 25 May was 1,885.53 in the United Kingdom, 1,785.31 in the United States, 1,047.13 in Germany, and 669.52 in Canada. Sweden’s ‘herd immunity’ had a 1,425.45 death rate.
How does this compare with New Zealand? Our death rate was 5.39 while Australia which evolved from suppression to elimination unevenly was noticeably higher but still only 35.69.
But what about those elimination response countries with recent outbreaks? First, let’s consider those with less severe outbreaks. The death rate per one million in Vietnam was 0.45, 4.46 in Fiji, 5.47 in Singapore, and 11.92 in Thailand. Second, let’s consider the most severe outbreak – Taiwan; its death rate was 1.47. China which also adopted an elimination strategy, but hasn’t reported a recent outbreak, is 3.22.
While there have been severe surges where elimination strategies were adopted they have been on very low death rates and much less severe than earlier (some still ongoing) surges where mitigation was adopted. Further, those facing outbreaks where elimination was adopted have responded quickly.
That doesn’t mean that New Zealand can sit on its laurels. We still have failings in our approach and we are now at risk to variants much more contagious than experienced last year beginning with those originating in Brazil and United Kingdom and now, even more so, from India.
New Zealand is facing an unprecedented pandemic characterised by an inexhaustible continuous supply of learnings. We must continue to learn from them even more effectively than we have to date.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion.