New Zealand’s success in executing a Covid-19 elimination strategy means it is one of an exclusive group of countries now at a fork in the road. That may not, however, be such a bad place to be, writes Laura Walters.

As the world looks towards the Covid-19 endgame, the World Health Organisation says countries that have pursued an elimination strategy face a “genuine dilemma” in how they will reopen. But leading epidemiologist Michael Baker says that’s a good problem to have, in the scheme of things.

Most countries saw the virus slip silently through their borders at the beginning of the pandemic, where it has remained ever since. As these countries gain higher levels of vaccine coverage, and bring down community cases, hospitalisations and deaths, they look to reopen their national economies and borders, with the acceptance that there will be some community transmission.

They talk about accepting Covid-19 as an endemic infection; one that surfaces each winter, leading to the hospitalisation and death of a relatively small number of people — similar to the flu. But countries like New Zealand, which have executed a Covid-19 elimination strategy, have a very different set of circumstances to consider when deciding when and how to reopen.

Earlier this month, Director General of Health Ashley Bloomfield said the pandemic “is probably not even halfway through”.

“We might be at the end of the beginning,” he said.

A few days later, the prime minister’s chief science adviser, Juliet Gerrard, told TVNZ’s Q+A the uncertainty about what comes next, and how the pandemic will end, “is keeping a lot of people awake at night”. 

“We are a long way from being out of the woods in terms of global vaccine coverage, so it could be a couple of years, at least, before we start to see enough coverage that we don’t have to think about Covid-19.”

During a press conference earlier this month, the World Health Organisation’s head of public emergencies said countries like New Zealand faced a “genuine dilemma” in how to move away from their zero-Covid approach. “They have protected their populations. Their communities have committed, within their borders, to a massive effort to protect their system; to protect the older and vulnerable populations, but always being at risk of the disease being reimported and sparking a major epidemic.”

As long as the majority of the population remains susceptible to infection, there was always a chance of the disease taking hold, he said. “So it is a difficult decision now for many countries who’ve managed to keep their very low or zero-Covid strategy in place for so long to open up again, with the probability the disease will be reimported from other countries in which the disease is not under control.”

Like others, Mike Ryan said the key to reopening countries like New Zealand was ensuring high levels of vaccine coverage.

Experts and officials are yet to say exactly when the borders will reopen — marking an end to the MIQ system — but associate health minister Ayesha Verrall said it would not be a matter of flipping a switch at the end of this year’s vaccination programme — it would be a managed reopening.

Before New Zealand can open up, it needs to answer a set of key questions:

• What is the real human cost of having Covid-19 circulating in the population? Including, what is the prevalence and impact of long Covid?
• What level of vaccine coverage needs to be achieved to stamp out transmission, particularly in a population described as vulnerable due to a lack of immunity from infection?
• How well does the vaccine respond in the real world, and to more infectious variants? Will booster shots or revaccination be needed?
• What public health systems are needed to maintain high levels of surveillance and respond to infections or potential outbreaks?

At this stage, it appears there are more questions than answers.

University of Otago professor of public health Michael Baker said taking all of that into account, the evidence was pointing towards a future involving progressive elimination. And New Zealand was well-placed for a quick pivot in that direction. As other countries lift their rates of vaccination, New Zealand could progressively reopen to those able to achieve, and sustain, elimination, he said.

Vaccination and public health measures, such as vaccination travel requirements, testing and tracing, the country would be able to reopen, without accepting Covid into the community.

But this approach isn’t the conventional orthodoxy in much of the rest of the world. While New Zealand maintains a vision of a Covid-free existence, others are talking about accepting the virus will be part of their lives for many years to come.

Writing in The Guardian, Australian National University infectious diseases physician and microbiologist Peter Collignon said Australia needed to eventually adopt a different attitude to what risks it was willing to accept, or face the chance of becoming a hermit nation. The effective control of Covid-19 had left countries like Australia, and New Zealand, in somewhat of a “Covid-19 limbo”, he said.

But Baker rejected the idea that New Zealand would be forced to make a decision to let the virus in again, or risk being cut off from the world. “I don’t think we should dismiss Covid-19 as being sufficiently benign that we would be happy to accept it.” This approach was based on “naive assumptions” about the evolution of the virus, he said. It was more likely the virus would mutate and become more dangerous, not less.

Elimination does not mean zero-Covid. There may be single imported cases, but elimination and eventually eradication, meant using vaccines and public health measures to stamp out any potential outbreaks — similar to the measles approach. “Unfortunately, a lot of the mass of people who are commentating on Covid-19 and how to manage it, happen to be concentrated in Europe and North America, who made a terrible mess of managing the risk assessment and risk management throughout the pandemic,” Baker said.

“They are imposing their own failed models on places like New Zealand and Australia and the Asia Pacific Region, which has done much better. We need to be very wary about just accepting their failed models.”

Baker said he was disappointed that the WHO used slogans like “the world won’t be safe until everyone’s safe” while not properly engaging in a discussion about elimination approaches. There was “a huge upside globally” for eliminating transmission, and rejecting the notion that countries had to live with the virus.

It’s good New Zealand, Australia and much of the Asia Pacific had forged their own path, Baker said. And they should continue to do so in a coordinated way that allowed for a safe reopening, where everyone was safe, and no-one was left behind.