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The @nzherald have just published a COVID-19 op-ed written by me and Dr Veronica Playle, on how "Plan B" is totally flawed, inequitable, and totally unworkable for our unique NZ situation.
https://www.nzherald.co.nz/opinion/news/article.cfm?c_id=466&objectid=12369227
For those who love details, here's a THREAD with references /1
https://www.nzherald.co.nz/opinion/news/article.cfm?c_id=466&objectid=12369227
For those who love details, here's a THREAD with references /1
First, why did we write this? Unfortunately, it is very likely that we will have to face-off with COVID-19 again in NZ (although I hope this is a long way away). When alert levels rise again, there will be dissenters. Plan B will be back in the news. We can't let that happen /2
We are 6 months into the pandemic. Yet Plan B is still a bare bones 10-point plan, hopelessly lacking in detail. We couldn't find any modelling on the Plan B website to show how it will impact our communities and hospitals. Yet they receive disproportionate news coverage /3
While their own Plan B "plan" hasn't received nearly as much criticism as they've dished out on the (expert-advised) government strategy. Being sticklers for detail, Ronnie and I took a look. There are at least 5 key flaws with Plan B. Let me explain: /4
Plan B consistently tries to de-emphasise how severe COVID-19 can be for certain groups. In this painful interview with @jacktame, Dr Simon Thornley cites a single meta-analysis of the IFR by epidemiologist John Ioannides. But this isn't the only IFR /5 https://www.tvnz.co.nz/shows/q-and-a/clips/plan-b-epidemiologist-claims-the-science-shows-this-virus-isn-t-as-serious-as-first-thought
An IFR is the infection fatality rate (or proportion); the proportion of COVID-19 deaths from all those infected. The WHO's IFR estimate is considerably higher (0.5 - 1.0), as is this meta-analysis by @GidMK & Merone (0.53 to 0.82) /6 https://www.medrxiv.org/content/10.1101/2020.05.03.20089854v4.full.pdf+html
This is VIP - a good plan for NZ would acknowledge the existence of higher IFR estimates and how this would impact mortality rates. It wouldn't cite lowest estimates, cross fingers, and hope for the best. Because a small % difference in NZ could mean thousands of lives /7
Ioannides' paper itself calculated that IFRs could go much higher than Thornley suggested to @jacktame. They display "heterogeneity" ie. they are highly variable. Death rates depend on the population's demographics and vulnerability, health care access, govt response etc /8
So obviously certain subgroups would be worse affected. Citing a single IFR and saying "this isn't too bad" isn't being honest. What groups in NZ do we know of who are more medically vulnerable, who have worse health care access? Let's look at how Plan B copes with them - /9
Plan B says that everyone over 60, and people with comorbidities should self-isolate, shield away. Stay at home. This is Plan B's 2nd problem. It is NOT WORKABLE for many. 2018 census data shows that for the over 60s alone, it would be 975,000 people!!! /10
There's not a huge amount of diversity in the Plan B team (feminists, you know what I mean); I wonder if they just didn't factor this in. What about families who rely on over 60s family members for child care so parents can go to work? What about families caring for elders? /11
What about multigenerational households? Or even just overcrowded households? Or households where children go to school and there's a medically vulnerable parent (or child)? How are we to shield when our lives are intertwined? Plan B poses a dangerous, impossible conundrum /12
Just recall that this shielding for at least 1 in 5 NZers would be indefinite - until there is a vaccine or the pandemic ends.
@JFaalili Pacific health researcher said this: “Plan B assumes that our elderly play no role in our country’s economy.” https://www.moanaresearch.co.nz/plan-a-leaves-a-better-legacy/ / 13
@JFaalili Pacific health researcher said this: “Plan B assumes that our elderly play no role in our country’s economy.” https://www.moanaresearch.co.nz/plan-a-leaves-a-better-legacy/ / 13
And now we come to Plan B's 3rd major problem. It is INEQUITABLE. Plan B asks people with comorbidities - diabetes, cardiovascular disease, cancer etc, to self-isolate indefinitely too. This includes many working age people. Because of existing health inequities, this will /14
Disproportionately affect Māori and Pacific people. Take diabetes alone. Among 45 to 64 yr olds, ONE in FIVE Pacific people and ONE in SIX Māori have diabetes, compared with one in twenty NZ Europeans. The number of undiagnosed diabetics is even higher /15 https://pubmed.ncbi.nlm.nih.gov/23474511/
That's only diabetes. We need to shield people with cardiovascular disease, and severe respiratory disease, and cancer. For many diseases, there are stark inequities, with Māori and Pacific peoples faring worse. I covered this in a previous piece /16 https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12360358
So on top of almost 1 million over 60s isolating, we need more than 20% of Pacific people in the working-age bracket 45 - 64yrs to stay home, and almost as many Māori. Plan B says they will need government support (benefits). Remember - indefinitely /17.
Asking this many working-age Māori and Pacific people to stay home is incomprehensibly unjust and unworkable. So much so that I have to devote a gif to this particular point. /18
Many families will try to shield, and won't be able to. There will be inequitable hospitalisations, and deaths. This excellent NZMJ study by @nicsteynnz @hendysh @Knhannah @MichaelPlankNZ @AASporle estimates the IFR for Māori would be 50% higher than non-Māori /19
Low paid workers, who may also be essential workers, may not be able to afford to stay home. We saw area differences in mobility in the first lockdown in Auckland: https://www.stuff.co.nz/national/health/coronavirus/300011189/coronavirus-there-were-two-quite-different-covid19-lockdowns-in-new-zealand /20
And increasingly there is COVID-19 data to show that spread is worst in disadvantaged communities. Public Health England data in September from people under 40 has shown that spread is highest in the most deprived areas /21: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/919676/Weekly_COVID19_Surveillance_Report_week_38_FINAL_UPDATED.pdf
This fantastic and alarming thread by ID expert @mugecevik sets out the science on how the social determinants of health mean that vulnerable and disadvantaged communities are more impacted by COVID-19: /22 https://twitter.com/mugecevik/status/1308080056384843777?s=20
Plan B doesn't really comment on inequity, it doesn't (in its present form) recognise it's own inequities, which is surprising for public health academics. This deserves another gif. This was the best one I could find. /23
But its fourth flaw is that it doesn't detail how our already stretched health care system would cope. This recent paper reports that NZ has only 4 per 100,000 critical care beds - that's VERY low amongst OECD countries. /24 https://www.nzma.org.nz/journal-articles/intensive-care-in-new-zealand-time-for-a-national-network
Germany for instance, had 33 ICU beds per 100,000 *at the start of the pandemic*. Even NZ's surge capacity would not (to my knowledge) reach this level of ICU staffing. COVID-19 admissions average 2 weeks (non-ventilated) and 4 weeks (ventilated). The Lancet paper reference /25
which gives these figures is here: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30316-7/fulltext. These are *very* long admissions by modern medical standards. This is why COVID-19 clogs hospitals. /26
We can't compare the "cost" of lockdown by comparing it to status quo, or smooth Level 1 functioning - it needs to be compared to how much a COVID-19 wave would impact on our health system. I can't emphasise this enough as often headlines are misleading. /27
With a COVID-19 hospital wave, the risk of healthcare worker infection also rises. In our first COVID-19 wave, HCWs were 10% of all infections in NZ. What everyone needs to understand is how this impacts care /28 https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12365504
When a HCW is infected, all their close contacts need to be isolated for 14 days. In NZ, we have a lean healthcare workforce, working in close proximity in busy, crowded, spaces packed with essential workers. Our specialist teams are small. One infected team mate could /29
jeopardise the functioning of an entire medical department. During the last Level 4 lockdown, some essential teams had to ensure that there were always specialists isolating at home, in case an outbreak amongst the team occurred. In Victoria, HCWs have consistently 15% of /30
active infections. Rolling outbreaks amongst essential health care workers were thought to have prolonged the Victorian epidemic - you can't shut down a hospital /31 https://www.theage.com.au/national/victoria/healthcare-worker-infections-putting-recovery-at-risk-experts-warn-20200903-p55s2a.html
Some Victorian hospitals were so compromised due to worker outbreaks, that they appealed to NZ nurses to fly over to help with critical staffing shortages. /32 https://www.rnz.co.nz/national/programmes/morningreport/audio/2018761155/covid-19-kiwi-nurses-needed-in-melbourne
Coping with a hospital COVID-19 surge means makeshift ICU wards, postponing elective surgeries and planned admissions causing delays in treatment, and redeploying staff to care for COVID-19 patients. The risk of hospital overwhelm in NZ is real. /33
Here is the FIFTH and final point - Plan B has not kept up with the latest clinical research into LONG COVID.
One in ten infected people have symptoms lasting over 3 weeks, and some have symptoms lasting several months. Here's a good @BMJ overview https://www.bmj.com/content/370/bmj.m3026 / 34
One in ten infected people have symptoms lasting over 3 weeks, and some have symptoms lasting several months. Here's a good @BMJ overview https://www.bmj.com/content/370/bmj.m3026 / 34
Even young, previously healthy people with no chronic illnesses can struggle to recover completely after COVID-19. Here is an informative CDC report on this: /35 https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm
And there are still many aspects of COVID-19 that medical researchers are still trying to understand. This JAMA study found that 60% of recovered people had ongoing cardiac muscle inflammation 2-3 months after infection - BUT /36 https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916
It's really important to say that we don't know what this will mean in the long term. This is a wonderful piece by @edyong209 that articulates these uncertainties: https://www.theatlantic.com/health/archive/2020/09/covid-19-heart-pandemic-coronavirus-myocarditis/616420/ /37
So let me sum up. Plan B is flawed. It is not feasible to implement. It is worryingly inequitable - that is, unjust. It will not work. It risks hospital overwhelm. It risks long-term illness for many. Why do they keep getting so much media airtime? /38
Ronnie and I, we are all for scientific debate. But it needs to be *robust*. The science, the ideas - should be based on best (and comprehensive) evidence. A good plan should take into account our unique NZ situation, our inequities, our health system limitations. /39
In the meantime, ongoing airing of Plan B makes a superficial appeal that there is an easier way for NZ - preying on us when times are difficult. But the Plan B way would be disastrous for many. And Plan A is showing real strengths. /40
I'm often asked - what if we don't get a vaccine? What's the plan then? Here's a Nature article by @florian_krammer "The data available so far suggests that effective and safe vaccines might become available within months rather than years" https://www.nature.com/articles/s41586-020-2798-3 /41
But also, NZ has been successful in containing COVID-19 - twice. Because of our successful strategy, we don't have to be as pressured to take the first vaccine off the rank because our hospitals are stuffed, we can select the best based on efficacy and safety data /42
Thanks for reading, if you got this far. In case you're wondering who Dr Veronica Playle is? She is an Infectious Diseases physician, Clinical Microbiologist, and genomic sequencing researcher. Thank you to @nzherald for publishing this free of charge, because we asked. /END
