Improving our pandemic preparedness: Counterfactuals and continuous quality improvement

Phase two of the Royal Commission of Inquiry into the Covid-19 pandemic is asking New Zealanders to comment on how pandemics should be responded to in future. One approach is to think about strategic decisions and their counterfactuals. That means comparing our experience of using an elimination strategy for almost two years with what is likely to have happened if we had followed the conventional path taken by most countries. There is considerable evidence favouring elimination for pandemics that have similar or greater clinical severity to Covid-19.

We can also draw on growing evidence about interventions that worked well and those that need to be improved or delivered more effectively in the next pandemic. For example, receiving Covid-19 vaccines before being exposed to the virus greatly improved outcomes. And N95 respirator masks are highly effective at stopping airborne pathogens but were underused in Aotearoa New Zealand (NZ). There is a lot to learn and put in place given the increasing threats of pandemic diseases.

What this Briefing adds

When considering different policy options, such as how we respond to pandemics, it is useful to think about counterfactuals. For example, when reviewing NZ’s pandemic response (elimination) we can compare our experience with countries such as the UK which took a different approach (suppression/mitigation).

Measures such as excess mortality show that countries like NZ, which pursued elimination, had little or no excess mortality during 2020-21, saving thousands of lives. The reported stories and evidence from people living in countries with poorly controlled pandemics also help us to understand the consequences of these alternative scenarios.

Reviewing evidence about the technologies used to support Covid-19 control (eg contact tracing, mask use) shows that we need to improve our delivery of these measures in future pandemics. We also need comprehensive approaches to achieve high vaccine coverage and health equity in all facets of our response.

Implications for policy and practice

Given the ongoing risk of future pandemics, NZ needs to start implementing the recommendations of the Phase one report now, and strengthen our essential public health workforce and infrastructure.

New Zealanders are encouraged to make submissions on Phase Two of the Covid-19 Inquiry. Submissions close on 27 April.

First wave (Feb 2020 - Sept 2020)

…This shortage of staff necessitated redeploying staff to high-need services to help maintain a base level of service provision across critical and emergency care.

Other measures included asking retired and non-practicing doctors to return, enabling medical students to join the health services early and establishing volunteer programmes for the public.

…A lack of system capacity meant all but the most urgent of non-COVID care had to be cancelled, including many cancer treatments. This created a mounting backlog which exacerbated pressures in later waves and likely had a significant impact on patients’ mental and physical health.

In an attempt to free up capacity, hospitals were encouraged to discharge patients into care homes or their own homes. At the time testing for COVID-19 was not widely available and, even where tests were available, many people were discharged without being tested - a mistake that likely led to the deaths of many.

“Everyone is doing their best given the situation but there simply aren’t sufficient staff or beds to care for patients adequately. It’s been heart-breaking to see patients develop avoidable complications such as pressure sores or have delayed diagnoses due largely to lack of staff.”
—GP Contractor/Principal in Scotland

Second wave (Sept 2020 - Apr 2021)

Record numbers of patients were admitted to hospitals, the number of ambulances held outside hospitals or diverted elsewhere was rapidly worsening, and A&E waits skyrocketed. Increasing staff absences further reduced capacity, which impacted on patient care and pushed services into dangerously unsafe levels of staffing.

“With the workload now higher than at any time on record, we are drowning. We do not have extra staff to deal with the extra patients we are seeing. The only change is staff are having to work harder and for longer. It is breaking people.”
—Consultant in England

Third and fourth waves (May 2021 to present)

While cases of COVID-19 remained high throughout summer 2021, the exponential growth of the Omicron variant pushed the delivery of the vaccination programme to new heights through the swift delivery of third dose and booster vaccinations.

….Amid (false) media and UK Government narratives about GPs not being open for business, primary care staff faced increasing levels of abuse from patients and, in some cases, sadly violence.

“All three of us who went for training became ill… with Covid-19 symptoms. Another friend and I (all nurses and paramedics) improved but within two weeks our other friend was dead, found by paramedics at home alone after calling for help because at the time people were getting advised not to travel to hospital. She was 29 years old and died alone.”
—Healthcare professional

“Everything was shut down, they were overrun with patients…they stopped everything, people died because of not getting their appointments, and not getting their treatment, and not going and getting checked for more lumps, like myself.”
—Hospital patient

“My husband was taken into hospital and basically written off because of age and other conditions… he was negative for Covid and he was put on a ward where it was rife. We were not allowed to visit, had no idea of what was happening. He passed away and I received a phone call at 3:15am telling me he had gone.”
—Bereaved family member

“You just couldn’t get through to anybody, you couldn’t talk to anybody, we were all ringing for an update… my father rang daily for her [grandmother] to be released to us… We have everything set up here [at home]. She even had an electric bed, we had wheelchairs and everything for her. We could have helped her.”
—Carer for an elderly family member

“We were being made to play God in deciding on who went to ITU – who was given a change to live and who wasn’t.”
—Hospital nurse

“It was like a war zone, overnight 18 people became Covid-19 positive with nowhere to isolate them. They were dropping like flies, it was awful. You can’t underestimate what this did to nursing staff, not being able to offer comfort to patients was soul destroying.”
—Nurse with Long Covid

“I don’t think I’ve come back to 100% of how I normally was. It takes its toll. But it’s almost like having this piece of paper, that’s nice, and flat, and straight, and then you’ve crumpled it and then you try and straighten out that piece of paper again. It’s still creased up, no matter how much you try and straighten it out.”
—Paramedic