Just over a year ago on 29 January 2020, following the recommendations of the Emergency Committee, the World Health Organization Director-General declared that the COVID-19 outbreak constituted a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations.

A few short days later, on 2 February 2020, New Zealand closed its border to non-New Zealanders travelling from or transiting through China. This was a somewhat contentious decision at the time, but there was much more to come; by the third week of March 2020, the border was effectively closed to all travellers other than New Zealand citizens and residents, and the whole of New Zealand was in Alert Level 4, or ‘lockdown’. The key drivers of these decisions were the desire to protect people from the virus, prevent the health system being overwhelmed, ensure New Zealand was not a route for the virus to be introduced into the Pacific and—hopefully—endure a short ‘painful’ hit to the economy and then recover economically as quickly as possible.

The initial intent of these measures was to ‘bend’ the rapidly growing epidemic curve of COVID-19 infections, so that infection numbers remained at a level that the healthcare system could cope with. However, it soon became apparent that a swift and timely lockdown, coupled with the requirement of 14-days in managed isolation for all returnees from early April, had not just bent the curve but had ‘crushed’ it completely. This became known as an elimination strategy—that is, keeping the virus out of New Zealand and ‘stamping out’ any community transmission—and it has remained the Government’s strategy since.

Countries and jurisdictions pursued a range of responses, including an elimination strategy (eg, China, Vietnam, South Korea, Australia and many Pacific Island nations), while others broadly aimed to suppress or manage the virus to mitigate its impacts on healthcare systems (eg, UK, Sweden and many other European countries and the US). Not everyone agreed with the pursuit of an elimination strategy, with notable opposition from the so-called ‘COVID Plan B Group’¹ and, at times, some private sector and business leaders.

Much has been written about the comparative effectiveness of different countries’ COVID-19 responses, and most assessments consider New Zealand’s response to have been among the best globally. Features of the response that were key to its success to date: strong ongoing scientific input; rapid decision making, including at the political level; clear and consistent national communication through regular (often daily) media briefings, supported by a strong public communications campaign; the rapid scaling up of testing and contact tracing supported by rapid ICT developments; an excellent response from an already stretched health sector; and effective border management including the establishment and ongoing operation of over 30 managed isolation and quarantine facilities.

The complexity of the response is easy to underestimate, as is the relentless and intense challenge of maintaining it. In today’s New Zealand Medical Journal, Wilson et al model one aspect of one border setting (the impact of shore leave for merchant ship crews)² that has required considered policy work over recent months. Such policy work, undertaken of course with a range of other government departments (Transport, Customs and Foreign Affairs and Trade), agencies (Maritime New Zealand) and stakeholders (port authorities and maritime unions), informs a decision by Government (via Cabinet) and finally results in the development and publication of an Order under the COVID-19 Public Health Response Act 2020. Such Orders are required to be regularly reviewed to ensure that they are still necessary for maintaining a proportionate public health response to COVID-19.

Similar modelling work has been a key input into policy decisions over the last year, and the strong working relationship between government agencies and researchers (in universities, Crown Research Institutes and other organisations) has been critical to New Zealand’s overall successful response to date.

Key to developing and maintaining a successful elimination strategy has been a willingness to constantly revise and improve in response to new scientific evidence or empirical experience in other countries, or in response to emergent problems, identified gaps and formal reviews—of which there have been many! Today’s paper by Habel et al identifies areas of focus to improve the response to an in-hospital COVID-19 cluster, with many of the findings and recommendations relevant for other hospitals.³ An ongoing commitment to reviewing and refining all aspects of our response will be essential during 2021, as we continue the focus on keeping the virus out of New Zealand and ‘stamping it out’ quickly if it does find its way through the border.

New Zealand also needs to be looking to the future. The next major challenge is the rollout of COVID-19 vaccinations across the country, and work on this has been underway for some months now—at pace. Initially vaccination will protect most of those who receive one or other vaccine (New Zealand has four different vaccines on order), and later in the year we would hope to achieve sufficient coverage for population (‘herd’) immunity. To have safe and effective vaccines less than a year after the pandemic was declared is truly remarkable; the challenge now is to ensure as many New Zealanders as possible receive these vaccines.

Until that time, the country needs to maintain its elimination strategy, although there is keen interest in taking a more nuanced risk-based approach to relaxing controls at the border. Today’s article by Smith et al models the potential impact of selectively relaxing border controls on COVID-19 infection numbers.⁴ Policy work on implementing such an approach commenced late last year. However, the emergence of new variants, first identified in the UK and South Africa and that look to be more transmissible than earlier variants of the virus, has led to additional—rather than fewer—controls (pre-departure testing and testing on day 0/1 for most arrivals). New Zealand has not been alone in implementing additional controls, and some jurisdictions that had, until now, not restricted travel across borders and/or had resisted mandatory managed isolation, have moved to implement such measures; the UK is the most obvious example.

The two big tasks for New Zealand in 2021 are to keep the virus responsible for COVID-19 out of the country and vaccinate as many people as possible. The health system has a major role to play in both these tasks. It will take all our collective focus and commitment to ensure we deliver for New Zealanders—but 2020 has also shown that most New Zealanders will support our efforts if they clearly understand why it is so important. Ongoing clear and consistent communication needs to continue, particularly to build and maintain public trust and confidence in COVID-19 vaccination. And we must all continue to relentlessly review, revise and improve our response if we are to adapt successfully to the constantly changing virus and global picture.

Just over a year ago on 29 January 2020, following the recommendations of the Emergency Committee, the World Health Organization Director-General declared that the COVID-19 outbreak constituted a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations.

A few short days later, on 2 February 2020, New Zealand closed its border to non-New Zealanders travelling from or transiting through China. This was a somewhat contentious decision at the time, but there was much more to come; by the third week of March 2020, the border was effectively closed to all travellers other than New Zealand citizens and residents, and the whole of New Zealand was in Alert Level 4, or ‘lockdown’. The key drivers of these decisions were the desire to protect people from the virus, prevent the health system being overwhelmed, ensure New Zealand was not a route for the virus to be introduced into the Pacific and—hopefully—endure a short ‘painful’ hit to the economy and then recover economically as quickly as possible.

The initial intent of these measures was to ‘bend’ the rapidly growing epidemic curve of COVID-19 infections, so that infection numbers remained at a level that the healthcare system could cope with. However, it soon became apparent that a swift and timely lockdown, coupled with the requirement of 14-days in managed isolation for all returnees from early April, had not just bent the curve but had ‘crushed’ it completely. This became known as an elimination strategy—that is, keeping the virus out of New Zealand and ‘stamping out’ any community transmission—and it has remained the Government’s strategy since.

Countries and jurisdictions pursued a range of responses, including an elimination strategy (eg, China, Vietnam, South Korea, Australia and many Pacific Island nations), while others broadly aimed to suppress or manage the virus to mitigate its impacts on healthcare systems (eg, UK, Sweden and many other European countries and the US). Not everyone agreed with the pursuit of an elimination strategy, with notable opposition from the so-called ‘COVID Plan B Group’¹ and, at times, some private sector and business leaders.

Much has been written about the comparative effectiveness of different countries’ COVID-19 responses, and most assessments consider New Zealand’s response to have been among the best globally. Features of the response that were key to its success to date: strong ongoing scientific input; rapid decision making, including at the political level; clear and consistent national communication through regular (often daily) media briefings, supported by a strong public communications campaign; the rapid scaling up of testing and contact tracing supported by rapid ICT developments; an excellent response from an already stretched health sector; and effective border management including the establishment and ongoing operation of over 30 managed isolation and quarantine facilities.

The complexity of the response is easy to underestimate, as is the relentless and intense challenge of maintaining it. In today’s New Zealand Medical Journal, Wilson et al model one aspect of one border setting (the impact of shore leave for merchant ship crews)² that has required considered policy work over recent months. Such policy work, undertaken of course with a range of other government departments (Transport, Customs and Foreign Affairs and Trade), agencies (Maritime New Zealand) and stakeholders (port authorities and maritime unions), informs a decision by Government (via Cabinet) and finally results in the development and publication of an Order under the COVID-19 Public Health Response Act 2020. Such Orders are required to be regularly reviewed to ensure that they are still necessary for maintaining a proportionate public health response to COVID-19.

Similar modelling work has been a key input into policy decisions over the last year, and the strong working relationship between government agencies and researchers (in universities, Crown Research Institutes and other organisations) has been critical to New Zealand’s overall successful response to date.

Key to developing and maintaining a successful elimination strategy has been a willingness to constantly revise and improve in response to new scientific evidence or empirical experience in other countries, or in response to emergent problems, identified gaps and formal reviews—of which there have been many! Today’s paper by Habel et al identifies areas of focus to improve the response to an in-hospital COVID-19 cluster, with many of the findings and recommendations relevant for other hospitals.³ An ongoing commitment to reviewing and refining all aspects of our response will be essential during 2021, as we continue the focus on keeping the virus out of New Zealand and ‘stamping it out’ quickly if it does find its way through the border.

New Zealand also needs to be looking to the future. The next major challenge is the rollout of COVID-19 vaccinations across the country, and work on this has been underway for some months now—at pace. Initially vaccination will protect most of those who receive one or other vaccine (New Zealand has four different vaccines on order), and later in the year we would hope to achieve sufficient coverage for population (‘herd’) immunity. To have safe and effective vaccines less than a year after the pandemic was declared is truly remarkable; the challenge now is to ensure as many New Zealanders as possible receive these vaccines.

Until that time, the country needs to maintain its elimination strategy, although there is keen interest in taking a more nuanced risk-based approach to relaxing controls at the border. Today’s article by Smith et al models the potential impact of selectively relaxing border controls on COVID-19 infection numbers.⁴ Policy work on implementing such an approach commenced late last year. However, the emergence of new variants, first identified in the UK and South Africa and that look to be more transmissible than earlier variants of the virus, has led to additional—rather than fewer—controls (pre-departure testing and testing on day 0/1 for most arrivals). New Zealand has not been alone in implementing additional controls, and some jurisdictions that had, until now, not restricted travel across borders and/or had resisted mandatory managed isolation, have moved to implement such measures; the UK is the most obvious example.

The two big tasks for New Zealand in 2021 are to keep the virus responsible for COVID-19 out of the country and vaccinate as many people as possible. The health system has a major role to play in both these tasks. It will take all our collective focus and commitment to ensure we deliver for New Zealanders—but 2020 has also shown that most New Zealanders will support our efforts if they clearly understand why it is so important. Ongoing clear and consistent communication needs to continue, particularly to build and maintain public trust and confidence in COVID-19 vaccination. And we must all continue to relentlessly review, revise and improve our response if we are to adapt successfully to the constantly changing virus and global picture.