Why does NZ still have mandatory 7 day isolation & masks in healthcare?

A little background on not letting go and being an international outlier

Last week the World Health Organisation (WHO) publicly stated that Covid-19 no longer qualifies as a global emergency. Predictably, 1 epidemiologist/lobbyist at Otago University said while it was the right move - a statement that simply reeks of arrogance as though WHO consulted him personally - it does not change the fact that Covid is a deadly infectious disease. He emphasised the need “…for caution in easing our few remaining protections.”

Prior to WHO’s statement, on the 11th of April, Cabinet decided to keep a mandatory 7 day case isolation rule as well as masking in health care facilities. This makes New Zealand a true international outlier in holding on to these requirements.

I saw 1 media article, accompanying that April announcement, with a headline that modelling predicted removing case isolation meant deaths could rise 25%. But if you look past the headline the modeller says “…in the long-term, the difference in infection levels versus if we keep those isolation requirements is relatively small.” That’s not such a great headline though, huh?

However, I really want to point out another April news article with a quote from Peter McIntyre, a colleague of that epidemiologist/lobbyist at Otago University, who sits on the Covid-19 Vaccine Technical Advisory Group. Remarkably, he’s tried to quietly turn the narrative. He gave a gentle dig to his colleagues on trying to keep these precautions “I just think without any disrespect ... to the people who still think that’s important, I just believe the game’s moved on and we should have our attention elsewhere.”

And suggested “…the focus should now be on getting those at higher risk double-boosted, rather than worrying about infection control through increased mask-wearing or improved ventilation.”

Infection control is the sole reason for mandatory 7 day case isolation rules and health care facility masking.

The puzzle of still keeping these rules

To write the pieces I do on this Substack, I’ve gone through an embarrassing number of documents through OIAs and proactive releases, and I’ve started to pick up a few patterns. The Ministry of Health provides public health assessments and advice to relevant Ministers. I haven’t expressly requested these assessments or the Cabinet paper from the recent April decision to maintain isolation and health care masking rules. Based on experience it will either take a very long time, or I’ll be told it will be released eventually so it’s refused to me in the OIA, or be so heavily redacted or withheld as to be a waste of time.

So with that in mind - here’s my best guess of why mandatory case isolation and health care masking rules were kept, based on the history of what happened in winter of 2022, and an October 2022 public health assessment.

The winter package of 2022

The winter surge package was released within days of being cooked up. Then Covid-19 Minister Ayesha Verrall asked the Ministry of Health on the 4th of July to consider additional Covid public health measures, by the 14th of July those measures were announced to the public and implementation had begun.

I think the 2022 winter package is relevant to understanding why these rules were retained in April 2023, and timely as the government has just days ago announced this year’s winter package.

Until September 2022 when it was ditched, regular reviews of the Covid traffic light framework took place by the Covid-19 Protection Framework Assessment Committee, which were sent to the Director-General of Health to inform the Department of the Prime Minister and Cabinet (DPMC) advice to Covid-19 Ministers.

The winter package was announced between the committee’s regular June and July meetings. The package expanded access to who could get free anti-virals and 2nd Covid boosters and flu vaccinations. It also gave out more free masks and free rapid antigen tests (RATs). The reasoning was to support people testing for Covid prior to hospitalisation, so they could grab free anti-virals before their symptoms became severe.

Although the country had moved to the orange setting of the traffic light framework on the 13th of April, the committee also did a rapid review of the red and orange setting in their late July meeting. Which included whether to expand mask requirements across the settings and reviewing gathering limits at red. Although it was too soon to know the impact of the winter package changes, they noted moving to red wouldn’t do much to dampen transmission. The only way to do that would be to impose movement restrictions, such as lockdowns. A shift to red would mean the public would then expect to shift to orange, and basically the whole thing could cause confusion. The advice sent to Minister Verrall didn’t recommend changing anything.

The committee also discussed changing the case isolation timeframes which had remained steady at 7 days for most of 2022. It didn’t change, although alternatives like 5 days with a test to release were considered - but thought to be too confusing or too likely to give people a false sense of complacency.

Although they didn’t have time to consult Māori and Pacific stakeholders before submitting their review to Di Sarfati, the Director-General of Health, the committee noted “…the impact of any change to isolation and quarantine requirements would need to be modelled (eg in terms of impact on hospitalisations or deaths) prior to a decision to change the settings, or it could be considered a breach of Te Tiriti.” Because Māori and Pacific and disabled people had worse outcomes, it was assumed any loosening of restrictions would disproportionately fall on them.

The winter surge package review

A rapid review by Allen + Clarke was released on the winter package in early May 2023.

Allen + Clarke (who I’ve come across doing other Covid reviews, such as on contact tracing) interviewed 51 stakeholders between the 7th of November and 12th of December 2022.

The review is couched in gentle official-ese but if you read it - it’s nicely damning. It does not provide any analysis if the winter surge measures were effective, but it does repeatedly note the issues with the consistent lack of data to evaluate the measures which I found comforting. Instead of data they relied on the stakeholder interviews - mostly people in central government.

Some of the issues that arose with the winter package were due to the restructure of the health system - who knew that could be problematic? “A clear theme throughout our engagements was a period of turbulent change and transition, with significant changes in roles and responsibilities…”

There was confusion over many measures, for instance eligibility for the 2nd Covid booster and “…the roll-out was more difficult than anticipated because the high level of apathy towards the vaccine had not been predicted.” A footnote mentions that was aligned with global trends - so er couldn’t it be predicted?

The supply chain to roll out more masks performed well, but the review doesn’t attempt to state if they made a jot of difference. It also highlighted the further distribution of school masks. They didn’t mention it but I smugly will - the Ministry of Education still has 31.5 million masks stockpiled.

RATs were almost certainly a failure, in fact the report says there were probably enough RATs before the winter package gave out even more.

Communications of Covid measures were “over-saturated” which is why initially DPMC and the newly set-up Te Whatu Ora ran the flu and Covid vaccination campaigns separately. However the winter surge package came along and rolled them both together under a new winter illness communications campaign. This caused more confusion.

Anti-viral prescriptions increased when access was expanded, but GPs were concerned that pharmacy’s prescribing them was counter to their doctor/patient relationships and could impact patient follow up. The review has no data to see if more anti-virals prescriptions worked however and recommended “There is a need to track cases, unreported cases and antiviral prescription with real-time hospital admissions and / or deaths to identify if priority populations are being served and respond accordingly to those whose needs are not being met.”

You mean actually study the public health intervention to see if it worked? Ground breaking!

A key criticism that cropped up from interviews, was that the winter package was done too quickly and too late into winter. While case isolation is mentioned in the review, it was not expressly part of the winter surge package so Allen + Clarke didn’t review how feasible it was.

All of which is why we - firstly, see this year’s winter package version rolled out in May. And secondly, why it could make sense they wanted to keep these mandates as a way to try and fend off health care system criticisms, I mean, infections.

October 2022 public health risk assessment

The next relevant public health assessment to this story was done in October and was incorporated into the Cabinet paper for reviewing Covid measures. The assessment states “…concerns were expressed that lifting mandates for case isolation and masking in healthcare facilities, could result in disproportionate impact on these groups.” Again, this is referring to Māori, Pacific, socio-economically disadvantaged and disabled communities.

While community mask mandates had been dropped and only healthcare facility masking was still mandated, it says non-wearing of masks is common now, and if a mandate is not in place ”… it may result in security/conflict resolution situation for staff to manage if members of public do not wish to follow facility rules.” A strange footnote says while nurses admit they can’t know, they still lay the blame for any Covid on visitors who don’t wear masks.

It goes on to state “…requiring cases to isolate remains our most effective measure to reduce transmission of COVID-19, retaining case isolation will materially reduce transmission. Its retention also allows for the management of the response while removing or reducing other measures.”

The statement ‘materially reduce transmission’ wasn’t accompanied by any robust data from a New Zealand context. I haven’t yet been able to find any committed attempt to see if the mandatory isolation rule of 7 days actually ‘materially’ reduced infection rates. But if that is the rationale, in Peter McIntyre’s words - why is it still important across the general population?

Why we still have mandatory 7 day isolation & masking in health care facilities

I’ll assume prior to the April Cabinet decision to keep these rules, if they consulted Māori, Pacific and disabled communities - their response to removing these rules would have been similar over time. It could also be that as winter slowly approaches, keeping the isolation rules could be seen as something is better than nothing when it comes to a crumbling health care system.

But after going through multiple health assessments prior to the community mask mandates being dropped in September 2022 - those had pleas made from representatives of groups that dropping that mandates would disproportionately affect them too. There was also modelling showing infections and hospitalisations would rise - but the community mask mandates were dropped anyway.

They were dropped according to a response to me by DPMC, because the consumer research showed people weren’t complying and negative sentiment was rising. If a government makes rules that people ignore, it risks losing social license - the very ability of government to make rules.

I’m willing to bet, no matter what winter holds, if research shows compliance dropping - isolation requirements and health care masking will be dropped at the next review.

And on that note - look what Ministry of Health behavioral research tender just closed!