COVID in NZ Part I: Breathe
This is Part I of a three-part piece. You can read Part II here and Part III here.
The first time I was welcomed into the Māori community, I was pulled into my first ever hongi. I stood opposite one of their leaders at the Waitangi treaty grounds, sweaty foreheads pressed together until my nose touched his. He inhaled my air, expelled a friendly chuckle and said “welcome friend” to me and my whanau, a diverse family now unified in community.
With the hongi, the ha (breath of life) is shared as a sign of unity and trust. A potent metaphor on the grounds of the treaty, Te Tiriti, which forms the founding document of this Aotearoa/New Zealand. When several iwi (tribes) announced in mid-March of 2020 that they would place a temporary ban or rahui on the use of the hongi, they helped set the tone of unity for New Zealanders as we approached a Level 4 lockdown, one of the strictest COVID responses. That week COVID-19 proved to be spreading in the community. Placing the priority on integrity, respect, and facing challenges head-on threads through from the past into present Kiwi culture. Islanders depend on each other.
In January 2020, under ominous orange skies due to smoke from Australia’s devastating bushfires, my wife Erin and our three boys were just settling into our sixth Southern Hemisphere summer. I had been watching the news and social media streams about a Chinese ophthalmologist who leaked his concerns about a SARS-like pneumonia outbreak from a wet market in a city of 11 million I had never heard of before, Wuhan. Of course Asia had handled coronavirus outbreaks previously, and our small Emergency Department in Whangarei, where I work as an Emergency Specialist, even had a HEPA filtered negative flow room retrofit to cohort four infected patients for that purpose. No one here seemed too concerned, a Kiwi default mode I erroneously mistook for overconfidence. It has taken a while to see it for what it is: a poker face.
Shortly after I started working in New Zealand in 2014, I had helped organize PPE training and staged a system wide simulation of a woman brought from home by ambulance with a febrile illness. The ambulance did not fail to ask if she had recently travelled from a region endemic for Ebola. We passed our simulation although our “sim” patient sat in the ambulance for 2 hours waiting for the ICU to accept her directly to the only Airborne Infection Isolation Room in the hospital. As any emergency nurse will tell you, waiting kills patients and especially so in a backed up emergency department in an infectious disease outbreak. But Ebola never made it here. It was controlled and the concern faded with case numbers. We stashed boxes of goggles and N95 masks, a few dozen bunny suits and white gumboots in a rolling locked cage stored outside the ICU. We were comfortable in the notion we would always get adequate time and notice. Done and dusted, as you do with emerging infectious disease preparedness.
In late January, I was getting anxious. The mRNA sequence of a novel betacoronavirus was published January 10th and primers for PCR testing were chosen so as to monitor the spread in China and beyond. I knew of other scientists in the United States who were after that sequence too. Previous work on MERS and SARS had targeted neutralizing antibodies to the receptor binding domain of the spike or S-protein. I knew this because I usually lecture on emerging infections. I had prepared a talk for a conference about my run in with Zika Virus, which I had contracted in Fiji in 2015. I walked into our ED a week after exposure with a fever, petechial rash and pounding retro orbital headache. After being reviewed by half the on duty staff, I declined the lumbar puncture and waited at home for the arbovirus panel sent to Sydney to confirm it wasn’t Dengue. This was a year before the seemingly mild mosquito-borne Zika would be linked to microcephaly in unborn children and cause panic at the Olympics in Brazil.
I remember coming across work on a new vaccine platform for Zika, RSV, SARS and MERS and noticed the name of an old friend, Barney Graham. Barney had moved from Vanderbilt, where we did our PhDs on lung mRNA cytokine response to infection, and he was now at the NIH. Back at Vandy, Barney was consumed with understanding the vaccine associated enhancement of respiratory disease seen with the initial attempts at a formalin inactivated respiratory syncytial virus (RSV) vaccine. Back in 1967, this ill-defined and unexpected complication occurred when immunized children during Phase 3 of the trial were infected by wild type RSV. This reaction led to worsened illness and the tragic death of two toddlers who had received the new vaccine. He has made it his life work. Barney would have also known why the act of breathing each other’s air had unsettled me in the time of a new respiratory pandemic and the context of prior ones. Back when we graduated, our department hosted an anthropologist whose research painstakingly calculated the pre-Columbian population of the Americas and the measurable decline due to disease by the time settlers returned after the initial discovery. She calculated a staggering loss of 90% of the indigenous population. When I was reading up on Zika a few years back, I came across Barney’s work on mRNA vaccines now at the Vaccine Research Center of the NIH. I reckoned he would be working on SARS CoV2.
By mid-February, Erin and I thought we’d stock up on canned goods and yes, toilet paper, adding a couple extra on our order each week. I wondered if I had made a mistake moving us here. I warned my family and friends back in the states, but they mostly thought I was overreacting, like when I warned them about West Nile Virus and again with the swine flu.. Then, we had our first imported case in NZ test positive on February 26 and widespread testing began. I was asked to start preparing for our response. When I looked for our pandemic plan, I was handed a dusty 3 ring red binder with generic disaster response protocols and some pandemic influenza recommendations. There had not been a concise plan released from the Ministry Of Health and the CDC in the US was in a tailspin over release of a faulty PCR test. The WHO was struggling over their masking recommendations, a true paradox of the precautionary principle versus utilitarianism. Stories emerged of nurses and doctors being told to not wear masks in the hospital, boxes disappearing due to either theft or to hospitals securing them for when they would truly be needed. Statements came out of the ether of how masks would increase your risk due to touching one’s face with unsanitized hands. Fit testing N95s was suddenly “not validated by evidence” and “unnecessary”, as it became apparent we didn’t have a scalable process. Reassuringly, we were told New Zealand makes its own PPE and boxes of duckbill “NZ N95 FFP2” masks appeared on trolleys. However, they fit less than 50% of people and have since been recalled. New Zealand toy making entrepreneurs sent for charter jets from China filled with PPE, like a Berlin Airlift for single use masks, as we faced our own frontline healthcare Gallipoli.
Looking at CXRs and CTs of COVID-19 patients in the literature I was struck by the similarities to Hantavirus Pulmonary Syndrome (HPS), which I encountered in my Emergency Medicine training. I was convinced early on that respiratory droplets small enough to be airborne were likely the mode of transmission. China and the other Asian nations were bending their curves wrapped completely in the highest level PPE. They were reporting few health care worker (HCW) infections. Airborne pathogens of concern change the game. These are what some nations have tried to weaponize. No virologist would work on airborne pathogens in lab animals unless they were in at least Biosecurity level 3 containment, wearing a personalized air-purifying respirator (PAPR) or N95 respirator, fully covered in PPE with HEPA filter laminated flow hoods and negative pressure rooms. Conventional building ventilation spreads the disease from room to room. N95s were in short supply and everywhere was supposed to make do with surgical masks known to be fit for decreasing the risks from exhalation of a surgeon into an open wound, but not for blocking inhalation of a virus.
Masks on infected patients slow transmission and protect HCWs. Mask wearing crowds casually bob along sidewalks in Tokyo news clips but masked mandates precipitate plans to kidnap politicians in the U.S. This non-pharmacological intervention is embraced by Asian countries since Wu Lien-te, a Malaysian physician, demonstrated efficacy of his cotton surgical mask in the Manchurian pneumonic plague of 1910, effectively embarrassing his European public health detractors. The West has shunned masks, declaring them inferior to pharmaceuticals and vaccines, eschewing them even in the early days of this emerging respiratory pandemic. I was looking for any method to decrease or dilute the dose of virus, a factor of duration and proximity to infected patients, that is crucial to minimize. Coupled with the evolving reality that asymptomatic and presymptomatic spread in healthy younger adults, as seen in Asian states, was going to make identifying clinical cases, keeping it out, stamping it out and managing it extremely difficult. This reality was arriving to me just as the usual summer peak of international travellers was ramping up at the Auckland International Airport.
These Islands thrive on tourism, like most economies in Polynesia. New Zealand has a population of 5 million and hosts nearly that number of visitors each year. Our Northland hospital is the closest hub and hope to many travellers by sea from the north and west aos well. It would be not uncommon to have one-third of my patients in the ED to be international travellers on any given busy summer shift. I have seen the “charge master” for what visitors pay and we are quite gracious hosts. But now these visitors felt like a communicable liability. SARS CoV2 travelled around the world in angiotensin converting enzyme 2 receptor bearing tissues of the very privileged, cruise ship passengers, Kiwi skiers back from Zermatt, Londoners and New Yorkers escaping the northern hemisphere snow. Yet the data from the first Lancet article and subsequent experience showed it inflicted the severest infection on the vulnerable, of which New Zealand has plenty. Our baby boomers are aging (16% over 65) just like those elsewhere, but ours are often living in multigenerational homes, sometimes as primary caregivers for children. This is more common in the Maori and Pacific Islander populations. The indigenous communities more often live in relatively crowded housing, have more comorbidities and have in prior pandemics suffered multiples the mortality of the Pakeha population. The 1918 pandemic saw Maori suffer 7 times the mortality of the Europeans and it has been similar in infectious disease outbreaks since. The social and moral determinants of health during pandemics are well recognized in New Zealand, so much so that the publication titled “Getting Through Together” has been widely distributed reminding medical decision makers of the ethical values and cultural context we all share during a pandemic.
The ability to quarantine at home or discharge patients to managed isolation was not feasible and risked causing further spread. I drew imagined cots over iPad photos of the chapel pews. I thought we could palliate people in an adjacent meeting room, but we would have to think hard about the morgue. NZ was not going to be building new “Covid hospitals,” so when I received the initial predictive model of NZ Covid infection on March 16 from my colleagues in the ICU saying we should expect only 7 deaths in our region from the pandemic over a 6 to 8 week surge based on the H1N1 influenza data from 2010, I cringed. I thought it just couldn’t be right. It was estimated we had adequate ventilators for that prediction. “Physical capacity wise, we can look after 8-9 ventilated patients in ICU and 5-6 outside ICU utilising anaesthetic machines.” This, for a population of 180,000.
I emailed a friend at the Ministry of Health who said “Mike, no one believes those original numbers from the swine flu.” She said folks at the Ministry of Health were currently reviewing several different models and they should be released any day. I ran our numbers by friends in the US, one previously an officer in the Epidemic Intelligence Service of the CDC, and he thought we were certainly too optimistic. Each stateside colleague I spoke to was despondent, reeling from the confusion caused by politics wounding the infrastructure we took for granted would save us in exactly this situation.
I gave a scheduled teaching session on respiratory infections in children on March 12th and closed with a discussion of COVID-19 and these numbers with the ED Registrars and House Officers in attendance. The local headlines had reiterated “Northland should expect 200 coronavirus cases and up to five deaths.” However, my back of the envelope calculations from the experience in Wuhan, then Italy, Spain and NYC suggested a minimum of 20 but perhaps 100 times that number of deaths and a predictable surge of very sick patients that would need prolonged hospital admission and who would not die. Even as late as mid-March, I was unable to get believable predictions I needed to build a patient flow algorithm fit for purpose and scalable, so I just took a guess we should prep for a 4 to 6 week surge with a peak reaching 100 cases a day with 10 admissions, a quarter of those in the ICU. Each of those would stay for 10 days on average. While I could assure the house officers we would not be overwhelmed by children with COVID-19, I predicted we would be unable to clear beds by the third week enough to accommodate the volume. Our healthcare system would likely collapse in mid April. The prospect of facing what I found out later to be similar large numbers being discussed by the Prime Minister Jacinda Ardern and her team of scientists, was ominous.
The modelling being reviewed by the Prime Minister has since been released. Sent to the Ministry of Health on March 16, it assumed a reproduction rate or R0 of 2.0, such that every one person with the virus passes it on to two others. What Jacinda was hearing in that scenario from researchers was that uncontrolled spread of Covid-19 would hospitalise 124,000 Kiwis - 19,000 of whom would need intensive care treatment - and the pandemic would kill nearly 11,000 and intensive care capacity would be overwhelmed. So we might expect 400 deaths in Northland, not 7, if no measures were taken “to keep it out” or “stamp it out.”I wasn’t too far off.
In the absolute worst case scenario, if New Zealand was unable to eradicate the virus, modellers found dire results. "A total of 3.32 million New Zealanders would be expected to get symptomatic illness; 146,000 would be sick enough to require hospital admission; 36,600 would be sick enough to require critical care (in an ICU); and 27,600 would be expected to die," researchers informed the Ministry. In all results, more than 10,000 New Zealanders would be killed if the country took no action.
Even "mitigation" strategies, which seek to increase social distancing while keeping society functioning and allowing schools and workplaces to remain open, would barely put a dent in the death toll. With an R0 of 2.5 but social distancing measures only 25 percent effective, a March 23 paper found deaths would jump to 12,700 - nearly 50 percent more than under the 50 percent social distancing scenario.
As recommended in the report and ultimately to the Prime Minister by her advisors, New Zealand's best shot was suppression strategies. With a lockdown in place, combined with more effective and widespread testing and speedy tracing of contacts, the outbreak in New Zealand could be brought under control. This is the "containment" phase. Next is eradication - bringing the number of active cases in New Zealand down to zero or near zero. NZ has the advantage of being an island nation with effectively closed borders. If community transmission is halted, the only way for new cases to come in are with returning New Zealanders, who are being quarantined if symptomatic, or “otherwise made to self-isolate for 14 days.”
This is Part I of a three-part piece. You can read Part II here and Part III here.
