May 03, 2021
Dr Rawiri Taonui Covid Maori | Seven Variants in New Zealand and Low Rate of Maori Vaccination
The world has delivered more than 1.15 billion vaccines as countries race to inoculate populations against Covid-19. Most vaccinations have been in rich countries.
A 4th Mega-Wave driven by the B117 (Britain), B1351 (South African) and P1 (Brazil) variants is severely affecting the Indian sub-continent, Latin America, parts of Southern, Western and Eastern Europe, the Middle East and Asia. Vaccines are less effective against these strains. Companies such as Pfizer-BioNTech and Moderna, the two most effective vaccines, are preparing vaccine top-ups for delivery at the end of this year or early in 2022 to protect against these variants.
The uneven delivery of vaccines in an unequal world creates conditions for the emergence of further variants in poorer countries. New strains like B117+E484K (Britain), which combines mutations from B117, B1351 and P1; and B1617 (India) known as the ‘Double Mutation’ because it carries the mutations E484K from B1351 and P1 and L452R found in another B1427/B1429 variant, create concern that even more infectious strains will emerge in a less vaccinated poor world and make their way into rich countries necessitating a third if not annual cycles of anti-Covid-19 vaccinations.
New Zealand Summary
Between the middle of 2020 and the beginning of April this year, the New Zealand government allowed high numbers of arrivals across our borders. This peaked at 2,800 to 3,200 entries per week during the 3rd Wave which swept the globe between October and January. The government justified this on the basis that New Zealand citizens and permanent residents had a right to return home. The reality was that 34.3% of entries were not New Zealand citizens and 40.9% not New Zealand citizens. Like other countries, New Zealand also relied on a faulty pre-departure negative test requirement to protect our borders.
The cumulative impact was high numbers of active cases in Managed Isolation and Quarantine (MIQ), 16 border/MIQ beaches and failures into the community from June last year, the arrival of seven new variants between December and March, and since mid-January 28 clusters of three or more people arriving on the same flight from the same country formed in MIQ.
Government decisions over the last month, such as revising MIQ facilities, holding MIQ 500 beds in reserve, and restricting travel from the newly designated ‘Higher Risk Countries’ (currently India, Pakistan, Brazil, and Papua New Guinea), have lowered the risk to our communities.
The re-classification of travellers between Quarantine Free Travel (QFT) Green Zone countries (Australia, Niue, and Rarotonga) and Red Zone countries with higher cases also reduces risk. Had the government not made these decisions, New Zealand was heading toward a major outbreak.
The Trans-Tasman Bubble introduced on 19 April when we had vaccinated just 3.7% of the population was premature and without a cap on numbers will be a complicating risk factor despite travellers from Australia presenting lower risk.
New Zealand Case Numbers
Māori at 7.9% of all cases and Pacific Peoples at 7.4% have the lowest ratio of cases to population. This is a testament to the strength of our community responses.
The Māori and Pacific Priority
While that is great, we cannot be complacent. Jointly, Māori and Pacific Peoples are 24.7% of the population but have been 31.8% of those hospitalised with more severe disease, 55.6% of those in ICU and 23% of deaths.
Māori are the only ethnicity where both ICU admissions and deaths exceed their demographic percentage. Pacific Peoples are the only ethnicity where the percentage of hospitalisations and ICU admissions exceed their demographic. These numbers confirm that Māori and Pacific communities are at higher risk of hospitalisation and fatalities if a larger-scale outbreak occurs.
Variants in New Zealand
The World Health Organisation (WHO), Centres for Disease Control and Prevention (CDC, United States) and Public Health England (PHE, Britain) watch five Variants of Concern and nine Variants of Interest/Under Investigation.
Variants of Concern are those where evidence confirms that they are more infectious, and/or can cause more severe disease, evade antibodies, and cause higher fatalities. Variants of Interest (CDC) or Variants Under Investigation (PHE) are suspected of having those characteristics but require confirmation through research.
During the 3rd Wave, seven variants made their way into the country before 11 April this year. By February/March the variants were dominant in New Zealand. A high 98.8% or 161 of 165 variant cases were in the Manukau and Auckland regions mainly in MIQ facilities but also in the Pullman Hotel and Papatoetoe clusters.
B117, B1351 and P1 appeared in their respective countries between July and November last year. These variants are driving the current 4th Wave of Covid-19. Vaccines are particularly less effective against B1351 and P1.
Scientists have found B117 in 120 countries. B117 is dominant in Britain, Europe, North America, and the Indian sub-continent. B117 is hyper-infectious, thought to cause more severe disease and possibly higher fatalities. B117 made up 72.7% of all variant cases detected in New Zealand to 11 April. B117 was the variant in the Papatoetoe Cluster.
Researchers have detected B1351 in 68 countries. B1351 is dominant in the southern part of Africa. The Pullman Hotel MIQ cases were B1351. B1351 has a mutation E484K, which researchers believe allows the virus to evade the antibodies of patients who have recovered from earlier Covid-19 infection and antibodies produced by vaccines.
P1 is driving infections in Brazil. Experts have found P1 in 40 countries. P1 carries the same E484K mutation as B1351 and its believed to be able to evade antibodies. Vaccines are less effective against P1. Genomic surveillance has not found P1 in New Zealand since March. The threat is therefore minimal. The B1429 variant, A231, P2 and B1617 variants have also not been found since March.
The identification of B1617 in New Zealand is a concern. Known as the 'Double Mutation' because it carries the mutations E484Q (similar to E484K from B1351 and P1) and L452R (found in B1427/B1429), this strain is beginning to supersede B117 in parts of India.
Red Zone Weekly Risk
The following graph shows weekly arrivals from ‘Red Zone’ countries. The red bars and arrows show the weeks that border/MIQ breaches and failures occurred. The dark arrows show the arrival of variants. With changes in government approaches, the number of weekly arrivals has steadily decreased since late February early March to just over 1,500 in the week ending 25 April.
To mitigate the risk of new variants and the travel bubble with Australia, the writer the previous Safe Line threshold should be lowered from 2,100 entries per week to 1,400 entries per week (200 per day). Based on the metric of three breaches over the last eight weeks, each new week presents a 37.5% chance of a further breach occurring. Continuing lower numbers will lessen that risk.
Red Zone Monthly Risk
There have been border/MIQ breaches and failures every month since last year meaning there is a 100% risk of a breach every month.
Against this, there is a huge reduction in monthly arrivals from 12,918 in January to 7,840 in April. The risk is therefore lower. How much lower is uncertain? This will depend on the related risks of the number of active cases in MIQ and whether incidents occur inside the Trans-Tasman Bubble.
MIQ Active Cases Risk
Recent government decisions have reduced the number of active cases in MIQ from a peak of 108 on 11 April to an average of 27 per day last week. Along with a drop in weekly and monthly arrivals, keeping active cases in MIQ below 30 will reinforce safety.
Trans-Tasman Bubble Risk
The Trans-Tasman Travel Bubble with Australia opened last week. Already 34,100 people at an average of 3,100 per day have entered New Zealand from Australia.
There have been four incidents. An airport cleaner became infected after cleaning Green Zone (Australia) and Red Zone planes. A cluster in a MIQ facility in Perth required Public Health Services in New Zealand to track 1,000 arrivals from Perth. A New Zealand traveller avoided a temporary suspension of travel from Perth by flying to Sydney and catching a plane to New Zealand. Red Zone and Green Zone passengers mixed in the same area in Brisbane Airport shortly before Green Zone passengers left for New Zealand.
The overall risk of infection from Australia is low because of their sound management of Covid-19. However, the number of incidents, already four in 11 days, the considerable number of arrivals in New Zealand, the complicated process of mediating travel between several states in Australia and New Zealand, the large-scale effort needed to track passengers in New Zealand if there is an event, the absence of a guarantee that arrivals are using our Covid-19 app or that travel details like their address in New Zealand address are accurate, creates risk.
This is especially so because only 4.5% of our population has been vaccinated. In that regard, the Trans-Tasman is premature.
Balancing the current rate of Trans-Tasman arrivals, which equates to 90,000 per month, against the reduced risk of lower monthly and weekly Red Zone arrivals and lower active cases in MIQ, the 10-times higher number traversing the Tasman amplify the risk of a breach into the community possibly approaching that from Red Zone countries.
A safe limit of Trans-Tasman entries into New Zealand is 200 per day. The rate of arrivals should increase only after vaccination has reached 50% of our population.
The Māori Vaccination Programme
Despite the efforts of the Māori caucus to secure $39 million for a Māori Vaccination Strategy, Māori are the lowest vaccinated cultural group in New Zealand. Māori are 17% of the population and 9.2% of those vaccinated. Pacific Peoples are 8.0% of the population and 6.7% of vaccinations.
The poor numbers reflect failings in the government Māori vaccination programme. The three-committee structure overseeing vaccination delivery included only one Māori doctor, Dr Rawiri Jensen, and then only on an ‘advisory committee’, which usually means Māori give advice in one direction and Pākehā make decisions in another. Dr Jensen has rightfully resigned.
The programme fails to equate the risk for the Māori 50-year plus age group with that of the Pākehā over 65-year age group. Māori over 50 are as vulnerable as Pākehā over 65 because we get comorbidities like diabetes on average ten years earlier than for Pākehā. This creates bias because over 18.3% or 630,000 Pākehā are aged over 65 compared to just 50,000 Māori. This bias excludes the largest proportion of the 160,000 Māori in the over 50 age group.
The government rollout by age also applies a straitjacket to the dispersed under-resourced often rurality of Māori communities. The more effective strategy would be to gather whole communities together and vaccinate all adults over 18 years old.
Comparisons with Australia and the United States
The government approach is in stark contrast to that from Australia where Indigenous Australians aged over 50 are a priority group for vaccination alongside frontline border staff and health workers.
It is also disjunct with the vaccination programme in the United States where vaccines are disbursed directly to providers under the Indian Health Service who organise and prioritise their communities according to need and effective delivery. The principal approach has been to vaccinate all adults aged over 18.
By the end of the first week of April, the Indian Health Service has delivered over 1.5 million vaccines to nearly 30% of all indigenous Americans. At that stage, indigenous Americans were the highest vaccinated cultural group in the United States.
Interestingly, the disbursement of 1.5 million vaccines would equate to distributing 253,000 vaccines to Māori Health providers, something this writer recommended in a column on 24 March.
The key message going forward is to get as many Māori and Pacific Peoples as possible vaccinated.
Noho haumaru – stay safe and self-sovereign.
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