As Aotearoa/New Zealand steps up restrictions in the wake of new COVID-19 cases, the latest edition of the COVID-19 wrap examines how the country has responded until now.
Public health researcher Alison Barrett also reports on lessons from Taiwan, new research estimating how many thousands of lives have been saved in Victoria to date, a global approach to public health communications, and an example of healthcare adaptation.
Successful Elimination of Covid-19 Transmission in New Zealand
Baker, MG, et al., The New England Journal of Medicine, 7 August 2020
On 11 August, after 102 days without any community transmission of COVID-19, New Zealand reported four cases in Auckland that are currently being investigated, with no known source identified. As Auckland moves to level three restrictions until the source is found, it is a reminder of the volatile nature of the coronavirus.
Up to this week, public life in New Zealand had largely returned to normal after success in eliminating the virus.
In this article, Baker and colleagues highlight some of the key aspects of New Zealand’s response to the pandemic.
Quick, evidence-based decisions were made and interventions implemented at multiple levels, including border control, community and case-based control measures and health, wellbeing and economic support.
- Non-citizens were banned from travel into New Zealand.
- Cruise ships were banned.
- Incoming travellers were placed into quarantine for 14 days.
- From June, all international arrivals were required to undergo testing on the third and twelfth day while in quarantine.
Community-transmission control measures
- Level four stay-at-home policies introduced from March 26.
- Public events cancelled and large gatherings restricted.
- Workplaces and schools closed.
- Public transport and domestic movement restricted.
Case-based control measures
- People with respiratory symptoms tested.
- Extensive contact tracing.
- Asymptomatic people screened in selected populations and workplaces.
Health, wellbeing and economic support
- General public information campaigns.
- Income support from government.
- Wellbeing initiative, ‘Getting Through Together.’
Effective, empathetic leadership
Prime Minister Jacinda Ardern communicated effectively to the public throughout the pandemic, framing their fight against it “as the work of a unified team of 5 million”.
She has been praised for her empathetic leadership in the face of the crisis, the public had confidence and trust in her, and followed her advice.
In conclusion, the authors write that “future lessons for New Zealand include the need for stronger public health agencies that can better assess and manage potential threats and for greater support for international health organisations, notably the World Health Organisation.”
As with her earlier response to the pandemic, PM Jacinda Ardern responded to the latest cases with speed and empathy.
Victoria’s response to a resurgence of COVID-19 has averted 9,000-37,000 cases in July 2020
Saul, A, et al., Medical Journal of Australia, Preprint, 4 August 2020
After a steady increase in coronavirus infections in June, stage three restrictions were reintroduced in various Melbourne locations from 1 July.
The increase in coronavirus infections and deaths in June were linked to numerous outbreaks, including hotel quarantine, childcare centres and families.
On 22 June, Victoria had 1,847 confirmed COVID-19 cases and nineteen deaths. Victoria’s Chief Health Office Professor Brett Sutton said: “We’ve had more than 120 new cases in the past seven days and the main cause for this increase has been through cases in families – where people have not followed our advice around physical distancing, hygiene and limiting the number of people you invite into your home.”
By 8 July, confirmed cases had increased to 2,942 and twenty-two people had died; the stage three restrictions expanded to all of Melbourne and Mitchell Shire, and state border control measures were implemented to contain the virus in Victoria. On 22 July, it became compulsory to wear face masks when in public.
Despite these measures, daily confirmed cases in July continued to be high, peaking at 723 new cases on 30 July.
Researchers from the Burnet Institute analysed daily case numbers between 10 and 30 July to determine if the control measures were having an impact on COVID-19 transmission.
Their results show that approximately 18,686 cases of COVID-19 were prevented as a result of the stage three restrictions in Melbourne in July.
If the growth rate of the infection in Victoria (Reff 1.75, which is the average number of people infected by one infectious person) had continued as it was prior to the restrictions being implemented, a total of approximately 27,000 cases would have occurred.
Instead, 8,314 new COVID-19 cases were recorded and the growth rate decreased to 1.16 by 30 July. The decrease in growth rate means that instead of seventeen people becoming infected from every ten cases as it was in June, by the end of July, just over eleven people were becoming infected from every ten.
While the authors acknowledge some limitations in the analysis (for example, measuring total number of cases instead of new community cases may underestimate the short-term impact of the interventions), the results provide some hope that the stage four restrictions currently in place in Melbourne will prevent more cases, deaths and slow down their outbreak.
It may be too early to tell how successful stage four restrictions are, but since 7 August, confirmed daily cases have been trending down.More details on Victorian COVID-19 cases are available here.
Design for extreme scalability: A wordless, globally scalable COVID-19 prevention animation for rapid public health communication
Adam, M et al., Journal of Global Health, June 2020
Public health messages that are engaging, accessible to a diverse audience, and are free of text and cultural associations have the potential to be relevant to people across the world.
This is particularly important when the public health message, such as those about preventing COVID-19 infections, is the same message globally; and when, as the authors write: “delays in producing compelling, evidence-based health communication can leave a vacuum that is quickly filled with misinformation”.
The authors describe three main points based on their experience in developing a COVID-19 prevention animation that was rapidly disseminated and shared around the world on 22 March 2020.
- Due to the rapid-moving nature of the virus, the animation needed to be quickly designed without losing quality and accuracy of the health message.
- The message needed to be simple and conveyed in a way that was understandable to a global audience and avoided cultural, language and health literacy barriers.
- The creators followed best practices from entertainment-education, communication theory and the animation industry.
To create their animation, they chose information from the World Health Organization that was unlikely to change in terms of preventing the virus: handwashing, social distancing, and self-isolating when sick.
They developed a short, simple storyline to communicate the key messages, chose music that was tone-appropriate; for example, tense music to emphasise the seriousness of situation and uplifting music to convey hope and self-efficacy.
They made changes in response to feedback sought from global health academics in Germany, South Africa, United Kingdom and Canada, and then it was published on Stanford Medicine’s YouTube Channel.
The animation was shared widely on social media and viewed 1.2 million times in the first ten days of its release. The creators received requests from many public health agencies and media outlets to repost, and were thanked by deaf communities for creating an accessible message.
While the animation received positive feedback and was widely shared on social media – an example of one metric for determining a positive outcome – more research is required to determine the impact the animation had on affecting behaviour change.
It is also worth noting that while the authors have found this approach successful in terms of views, reach and feedback, the “one size fits all” approach rarely addresses inequities in health.
It is important to consider tailoring messages to specific audiences to address this, such as the tailored COVID-19 messages developed by Aboriginal Community Controlled Health Organisations, focusing on cultural and community values important to Aboriginal and Torres Strait Islanders.
Stanford Medicine’s YouTube channel includes other animations in the series:
- The Great Race: A COVID-19 story – highlighting the importance of mask-wearing
- Staying safe when COVID-19 strikes
- Global COVID-19 Prevention – the original COVID-19 prevention animation.
Technique, radiation safety and image quality for chest X-ray imaging through glass and in mobile settings during the COVID-19 pandemic
Brady, Z et al., Physical and Engineering Sciences in Medicine, 13 July 2020
In response to the potential increase in demand for Emergency Department and Intensive Care Units during the pandemic, an innovative technique to safely perform mobile chest x-rays through glass has been evaluated by medical physicists and radiology staff at The Alfred and Sandringham Hospitals in Melbourne.
The technique, where mobile chest x-rays can be performed through glass from outside a patient’s room, reduce the risk of COVID-19 infections, as only one radiographer is required in the room with the patient during the x-ray and transport of the infected patient through the hospital is reduced as the x-ray is taken while the patient remains in the room.
Images provided by Juntos Marketing
By reducing the demand on the permanent x-ray units and need for full disinfection after each x-ray of an infected patient, a great deal of time is also saved, potentially helping the hospitals better deal with an influx of patients.
In evaluating the through glass technique, the authors assessed x-ray technique, quality and penetration settings, radiation safety requirements and image quality, of which 90 percent of were found to be acceptable quality.
In implementing and reviewing the through glass technique, the authors provide a comprehensive outline of the method and settings in this paper.
The authors highlight that their evaluation was completed on one type of mobile x-ray unit and that further experiments would need to be conducted for use of the technique on other models. The technique is only intended for use during the COVID-19 pandemic.
However, their evaluation provides useful information for an innovative technique that will save time and reduce infections in busy hospital settings.
Dr Zoe Brady, lead author and medical physicist at The Alfred, said: “As a medical physicist, I have a role to play in the pandemic, I am not a frontline healthcare worker, but by enabling the use of this technique I can ensure the quality of chest x-rays for COVID-19 patients and help keep my colleagues safe.”
Reopening safely – Lessons from Taiwan’s COVID-19 response
Lin, C et al, Journal of Global Health, 28 July 2020
Along with a handful of other countries, Taiwan has been successful in eliminating COVID-19. As of 11 August, the country had experienced 480 cases and seven deaths from the coronavirus.
Lessons from Taiwan’s response are similar to New Zealand’s, especially in terms of their rapid delivery, extensive testing and strict border control. Aspects of Taiwan’s response are outlined below:
Scaling up testing-treatment capacity and strengthening direct care worker safety
Taiwan’s Centers for Disease Control (CDC) implemented rapid testing kits from mid-January in hospitals, health systems, private clinics and rural health centres that were easy to access for all, including those with minor or no symptoms.
Reserves of personal protective equipment were stockpiled for health care workers and those on the frontline.
Thorough contact tracing
Contact tracing teams work with law enforcement and use multiple sources of data to trace contacts of infected people, including cell phone GPS, social media posts with consent to assist people with recall and community security videos.
In Taiwan, the first phase of the case investigation is normally completed within ten hours; and every close contact is interviewed and tested. Even if negative, the close contact is required to quarantine at home for fourteen days. Other potential contacts are required to monitor their symptoms for two weeks.
The public is notified via the media if a potential infection has occurred in a large public space; and also educated about how the infection can be transmitted.
Enforcing quarantine, in a thoughtful manner
Passengers who self-report or are detected to have COVID-19 by airport health screening are tested and taken to hospital; passengers who arrive from high-risk areas are asked to self-quarantine at home for fourteen days.
The Taiwanese Government subsidises disease-prevention taxis and compensates people who do not have access to sick leave.
Quarantined people are visited by civil officers and told how to set GPS parameters on their smart phones (so their location can be electronically monitored) and given a care package. Counselling, information and healthcare arrangements for the quarantined can be made via a 24-hour hotline.
If people violate their quarantine, they may be fined between US$3,300 and US$33,000.
Reinforcing public awareness, sustaining universal hygiene practices, and implementing social (physical) distancing
Due to their experience with SARS in 2003, Taiwan acted quickly to encourage the public to implement regular handwashing, mask-wearing and self-monitoring of symptoms. From late January, temperature checks and hand sanitiser application had become normal procedure before entering public locations, such as schools, businesses, and hospitals.
While schools and businesses remained open in Taiwan, guidelines were provided about physical distancing, mask-wearing, and for businesses to collect visitor information for contact tracing purposes if needed. Plexiglass dividers were placed in classrooms between students, and in banks, food courts and other businesses.
As Taiwan relaxes their travel restrictions and people start to move about the country more, school and business policies are being re-examined in case future outbreaks and widespread community transmission occurs.
From early in the pandemic, the government delivered consistent and transparent messages about COVID-19 prevention measures, and followed principles of advance planning, collective commitment and a people-centred approach. Policies were robust and included social provisions, such as paid sick leave and a counselling hotline.
The authors write that “sustaining a robust public health emergency preparedness and response system that leverages the intelligence of a coordinated infectious disease network has been key to Taiwan’s success”, and has enabled them to continue with their testing, contact tracing and quarantine regime.
Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.
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