A plane-load of evacuees have arrived on an Air New Zealand flight from Wuhan. They’ll go into quarantine. But what does ‘quarantine’ mean, in practice, and what are the other realities for public health workers on the frontline? Richard Simpson, formerly of Auckland Regional Public Health Service, lays it out.
Standing in front of the television cameras at Auckland International Airport, I was trying to reassure the New Zealand public that we are ready for the virus, but all I could think is how my “Public Health” baseball cap made me look 18, not 32.
No, it was not the “Wuhan” coronavirus, it was at the stubby nose of what came to be known as the “swine flu” response.
Back in 2009, the ongoing concern about pandemics was mainly a hangover from SARS and the H5N1 “bird flu” scare in the mid-noughties. But before Contagion and Brad Pitt’s marauding ant-swarm zombies, the most accurate picture most people had of a public health “emerging disease” response was Dustin Hoffman going on a monkey hunt.
We are now evacuating New Zealanders from China and sending them on an obligatory holiday in Whangaparaoa. Country after country is closing the doors to Chinese nationals at the border. For all the debate about staying calm, there are still many false claims, inflammatory posts even, in the mainstream media.
So what led us to this stage? And why are some people demanding to know why it took so long?
Yes, there is a lot to be nervous about, but this is why we should separate fact from the BS and support the people who are actually trying to help.
I don’t work for that public health service any more, but I can remember what it was like.
From 2009 to 2017, I found myself on the cutting edge (figuratively) of New Zealand’s public health emergency preparedness. It started in January 2009 when I applied for a three-month contract as “pandemic planning and international health regulations (2005) coordinator” with Auckland Regional Public Health Service.
I was tasked with working on “lessons learned” from a recent pandemic exercise, a job I probably scored less because of my background in office management and PR and more because of my manic, wide-eyed optimism in the interview as I raved to one of the Senior Medical Officers of Health about how much I enjoyed reading Flu by Gina Kolata.
I moved into the wider area of public health emergency management until I left in 2017, but pandemics and border control were always my bread and butter.
Recall the beginning of the 2009 “swine flu” incident. It was unclear how it had started (such as the debate about whether to call it “Mexican flu”), and nobody knew whether it was a “mild” strain or the next superbug.
That’s how these things always begin; a baffling Carmen Sandiego game with a mix of possible signs and symptoms to look out for, and a studied guess about where in the world it could be.
The Public Health Nurses and Health Protection Officers at the airport (and I) also had no idea whether the Tamiflu antivirals we were taking would actually do anything. My wife was pregnant, so I took no chances and slept on the couch for a couple of weeks.
Then there’s spread; it might float through the air, on dirty toilets, or lurk on the back of a plane seat. The experts also need to establish a rough tally of how many people you may infect if you’re left to go about your usual unsuspecting ways.
At some stage, national health officials must look at what the World Health Organisation (WHO), the CDC in America, and other experts are saying, then decide how to react based on the relative risk to each country. This is why on a long-haul flight you may see someone with a gown and a thermometer wand thingy at one country or a guy with a mask, baseball cap and a handwashing brochure at another.
The official trigger is what we call a PHEIC, or Public Health Emergency of International Concern, issued by the WHO when a new disease has a new SUIT – that’s being serious, unusual, internationally spread (potentially) and threatening to travel and trade. A new influenza strain that jumps species to humans often fits the bill. A rise in cholera cases in Sub-Saharan Africa may be “serious”, but unfortunately, it is not necessarily seen as “unusual”.
When there’s a PHEIC, there’s a whole lot of things countries are required to do at their borders. Before that, their choice of what to do is mixed. Of course, this includes all those unfortunate countries that have land borders, where setting up a strict health screening process is an even bigger hassle than for planes and ships.
Novel coronavirus (2019-nCoV) is a PHEIC.
Nobody in fact relies solely on a PHEIC declaration. In 2009 the WHO took some time to make their PHEIC declaration, and our health sector couldn’t wait while the WHO debated whether the virus had established itself in Japan.
Also, in situations in which we’re waiting on an official PHEIC decision, New Zealand needs enough time to work through the implications of adding something to the official list of “quarantinable infectious diseases”. This includes locking in the “case definition” of what to look for. If health authorities suddenly decided to stop and question everyone who arrives at the border with diarrhoea it would be hard to maintain a response even for a few days, but we do want to know what might stand out if one of these travelers has cholera (even if there is no PHEIC at the time).
Even when superbugs are not in the news, public health agencies are ready all the time for what could be coming over the horizon.
If those health folks get a call out of the blue from a worried pilot, Customs agent or paramedic, they need to have a definite idea about whether to wear masks, or gloves or face shields or coveralls when they turn up. And when there is also a lurking threat like 2019-nCoV, health officials need to give clear advice to private and government agencies to make sure they take the appropriate level of precautions. If they’re taking less precautions than is actually needed then it’s a risk to staff. If they’re taking a lot more than the health worker standing next to them, it’s probably not sustainable. It also looks a bit silly.
We also hear demands from people in the news, on Facebook and in line at the supermarket about how the health sector should be “screening” people properly. So, what do they mean by “screening” in this context anyway?
After nearly 10 years working with local and national health emergency teams, I think the likelihood you’ll step off a plane into New Zealand and be greeted with plastic tunnels and oxygen-tank-wearing medics a la Stranger Things is nigh on nil.
Remember, at the beginning the health authorities don’t know much about a new bug, let alone whether these people were exposed. And at the early stages, that new bug may or might not be serious. What is the actual risk if these people may or may not have been coughed on by someone who may or may not have some rare disease? You’re much better off asking them about definite risk factors for whatever new disease you’re worried about. Emerging Ebola threat from that region? “Did you play with any monkeys on your holiday?”
There are no hand scanners at the airport that start to beep when they smell MERS … or SARS … or plague … or 2019-nCoV… Blood tests or swab results will likely take a few days at the best of times, which means more potential time in quarantine and isolation. At the airport, the most you would usually know is there is a sick person who discloses a certain travel history and has some weird symptoms that boil down to a high temperature and either acting really ill or showing serious problems with their body fluids.
I remember boarding a cruise ship with some public health nurses to help interview a few families in voluntary quarantine for some nasty unknown bug. Upon seeing us boarding, one of the wharfies said in a stage whisper to his mates, “Don’t cough, the health guys are here!”.
That’s the main problem with the whole thing and the not-so-secret-secret of border control. Infrared thermal scanners? Even if this country brought in some fancy scanners, they’re hardly going to be effective. Many of the alerts will be false positives and the final decision will still rely on human judgement. Anyone who is infected and possibly infectious but not symptomatic (and anyone exposed during the trip) won’t trigger the scanner. And anyone who is sick enough to trigger the machine already has had to fool the check-in desk, flight crew, overseas Customs and Immigration, our local airport agencies and other passengers, as well as the public health people who are already greeting the plane.
So, a large expense, more logistical issues for our busy airports, and no actual evidence that scanners are more effective than existing measures to achieve the only thing it’s actually designed for. To give us peace of mind that we’ll also spot the rare putz who already feels ill but would rather infect others and avoid free medical care (that could save their life) than miss their booking at Hobbiton.
After all, much of what you see at the border is about compliance. These big thermal scanners are not the health equivalent of the bag scanner at the airport. They are the equivalent of those scary MPI “Declare” signs posted to convince you that you’re going to get caught with that piece of fruit anyway, so it’s in your best interests to front up. We can’t forget that a thermal scanner would simply be an expensive supplement to the important stuff; advice, awareness and good processes.
Another pressing question then becomes what to do with everyone else on the flight. Which invites the question, what does that word “quarantine” actually mean?
The New Zealand evacuees from Wuhan, who arrived yesterday on an Air New Zealand flight, will be in “quarantine” at an army barracks, but the Ministry of Health is still advising other New Zealanders returning from mainland China to head straight home and stay there for a couple of weeks.
If the person is sick with something potentially nasty, you put them in “isolation”, which, in a first world country, most often means dedicated wards in a major hospital. If someone may have been exposed but is not sick, that’s when (in the worst case) they may be placed in a ‘quarantine’ setting. But this term covers a range of options.
Remember, in the beginning, we don’t know much about the bug. If it is a sudden alert from a ‘normal’ flight, the focus is firstly on anyone sitting a few rows in front and back of the sick person, especially since air conditioning flows laterally (sideways) on commercial planes. But what about the flight crew who dealt with them, others who sat beside them in the gate lounge, and the next person who used the airplane toilet? Identify? Question? Advise? Detain?
Do you take responsibility for quarantining people or do you simply suggest they stay at home and away from mosh pits for a few days, just in case? Do you give them a brochure about symptoms to look out for? Hospitals can be overflowing even on a typical day, but if you go down the “facility quarantine” route, these people will need somewhere to stay.
A quarantine managed by the health sector for possible high-risk contacts needs highly trained health workers, pulled out of caring for people who are actually sick to babysit a lot of grumpy travelers. If there’s a definite risk but there’s non-medical staff involved who don’t know their personal protective equipment donning and doffing procedures, you might just make the situation worse.
What about families with kids who need nappies and baby food? How should you deal with a foreign diplomat who is vegan and lactose intolerant and demands free toll calls to family overseas? Bored teenagers? How much is this all going to cost?
So let’s say the “quarantine” measures you choose are going to be reasonable. That means that if someone is arriving from a certain area you recommend they stay at home and away from mosh pits, and you take responsibility for putting high-risk potential contacts into a quarantine facility.
But once they leave the airport and go into “quarantine” – self-imposed or otherwise – what does this mean if someone can simply walk out the door?
I should add that if you quarantine someone in an army barracks or a dedicated hospital ward (or elsewhere), you also need to pay for drivers, security, kitchen staff and cleaners. If you think they or any of the medical staff should be required to wrestle someone to the ground or block the fire escapes to prevent people from leaving, you’re living in the wrong country. In fact, for at least the past decade, New Zealand has been moving even further in the opposite direction.
A big part of the Health (Protection) Amendment Act introduced in 2016 was to say that infectious disease control – at the border or in the community – should be voluntary for any but extreme situations. Yes, there are still options to enforce an order, but this should be a last resort. After all, our national pandemic plan also includes options for segregating the North and South Islands and for stopping every airplane and container ship into the country. Check Section 70(1) of the Health Act. The “special powers” that a Medical Officer of Health could (ostensibly) wield during a major epidemic would give Dustin Hoffman the chills. But it shouldn’t be the go-to solution for any emerging threat.
As we all found in 1918, a worst-case situation in a pandemic is pretty damn dire, but it shouldn’t be a point of contention that the start of a standard emerging infectious disease response should be based on the assumption that most people are decent, reasonably honest, and motivated to protect their own health and the health of the wider public, if not the health of the next person in line at the airplane toilet.
So what do I think health authorities should be doing for 2019-nCoV? They should be working with places that are likely to have the most travelers from the affected region to New Zealand.
For the Ebola alert in 2014 and 2015, that included contacting aid agencies who were sending people overseas to work in the affected regions. By talking with these agencies the health authorities knew precisely which flights the aid workers were coming back on. Everyone was in the loop about the precautions the aid agencies were taking and there was a friendly public health person waiting at the arrival gate.
I would assume the 2019-nCoV response personnel are continuing to work closely with the Chinese community as well as tour agencies, accommodation providers and schools. All will be ensuring that customers and students have the most recent information, and understand how the New Zealand health system works (compared to the system they may be used to), so they know how to get in touch if they are worried about themselves or others. People may start to feel sick before or after they walk through the Arrivals hall, and the plans need to cover every situation.
What else should authorities be doing?
- They should be open about what they currently do and do not know.
- They should be giving as much information as possible to people who may have been in the region, via the internet, news releases, media interviews and handouts at the border.
- They should be asking people who arrive whether they feel sick now, and if they become sick later to contact someone for their own interests and others’.
- They should look at reasonable border control measures that minimize the effect on our tourism and import/export industry, as well as our responsibilities to our Pacific neighbours.
- They should focus on supporting the people at the highest level of risk, like those coming straight from Wuhan.
They’re already doing all this.
“Pandemic” and “emerging infectious disease” freak people out. We have all been sick, and it’s not difficult to imagine getting very, very sick.
When we hear about a new, mysterious, silent, invisible thing that could invade and kill us, it is easy to demand to know what the bloody-hell those people in the health sector are doing to stop it. And why aren’t they “doing more”?
When it’s 2009 and you hear about some new strain of influenza, and some dodgy looking guy in a public health baseball cap says to “keep calm, it’s probably nothing, but yeah, the worst case is that 40% of us get sick and about 40,000 people could die” (the national influenza pandemic framework’s “standard planning model”), well, it can really freak people out.
But this particular coronavirus, although “novel”, is not non-seasonal influenza, and the risk assessment isn’t even the same. To decide on a proportionate response to an unknown risk, there’s always a bunch of major cons to consider as well as the pros .
We’re not living in a movie. 1918 aside, most alerts about new bugs are not the end of the world as we know it. In my personal opinion, the best approach to take is exactly what you are seeing.
Assess at the start, reassess, give people the info they need to look out for themselves, encourage people to wash their hands and not to sneeze on strangers, and don’t gamble away our entire import/export and tourism industry unless it involves something to do with zombies.