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As with a number of other jurisdictions in the Asia–Pacific region, New Zealand adopted tight border controls and other stringent public health and social measures (PHSMs)[[1]] to control the COVID-19 pandemic. The country’s clearly articulated COVID-19 ‘elimination strategy’[[2]] has been remarkably successful.[[3–5]] Despite occasional border system failures that have caused outbreaks,[[6]] the country has regained its elimination status after each instance (at least up to late June 2021).

Indeed, New Zealand has the lowest COVID-19 cumulative death rate in the OECD (data from the Worldometers website[[7]] on 26 June 2021). It has also had the lowest level of ‘excess deaths’ among OECD countries[[8]] and within a grouping of 29 high-income countries.[[9]] Similarly, New Zealand was one of only a few high-income countries where life expectancy actually increased between 2018 and 2020, with pandemic-related reductions in the others.[[10]]

New Zealand has also done better than the OECD average in terms of average changes in quarterly GDP (from Q1 2020 to Q1 2021 and with higher growth in the first quarter of 2021).[[11]] It also had relatively lower increases in unemployment than the OECD average.[[12]] Also, relative to other OECD countries, New Zealand topped a ‘normalcy index’ that assessed return to ‘pre-pandemic life’.[[13]]

However, a full and proper analysis of New Zealand’s elimination strategy response to the COVID-19 pandemic will need to take account of a multi-year perspective. In particular, it will need to be done after COVID-19 vaccination coverage has stabilised in New Zealand and comparable OECD countries. Indeed, the country is still at risk of large outbreaks until it achieves high vaccination coverage (it was near the bottom of the OECD on 24 June 2021 for people fully vaccinated[[14]] and equity goals were not being met[[15]]). The Government also needs to upgrade the outdated Alert Level system,[[16]] integrate mass masking in a systematic manner[[17]] and enhance border protections, along with other potential upgrades.[[18,6]] There are of course numerous lessons for the future in terms of enhancing New Zealand’s pandemic response capabilities.[[19]]

What are some of the health impacts of the pandemic response in New Zealand?

Much research relating to COVID-19 and New Zealand has already been reported, including the psychological distress associated with raised Alert Levels.[[20]] There was also an increase in alcohol-related emergencies involving ambulance staff attendances in 2020,[[21]] and increased smoking levels in some groups.[[22]] Potential adverse impacts of increased COVID-19-related unemployment onto cardiovascular disease have been modelled.[[23]] Publications have also considered equity issues around health service impacts,[[24]] and the perspectives of Māori[[16,25,26]] and Pasifika.[[27]] Although it appears that cancer care services were disrupted by the pandemic response, this was relatively minor overall (eg, “an 8% year-to-date decrease in radiation therapy attendances”).[[24]] There was also “little evidence of differential impact of COVID-19 on access to cancer diagnosis and care between ethnic groups,” but for lung cancer there was a decrease in new diagnoses among Māori.[[24]]

Identified benefits of the response included that the experience of the raised Alert Levels had positive psycho-social aspects for some people.[[28]] There was also a reduction in 2020 in infectious respiratory diseases.[[29–31]] These reductions in infectious diseases may have long-term implications for disease control (eg, the value of staying at home when unwell and mask wearing on public transport in winter months).

What do the new studies in this Journal show?

The 14 new articles relating to COVID-19 in this issue of the New Zealand Medical Journal span epidemiology and public health (n=4), secondary care services (n=3), telehealth services (n=3) and various other COVID-19 issues (n=4) (see Table 1 for brief summary details). Particularly notable is the evidence for increased risk of hospitalisation from COVID-19 for Māori and Pasifika by Steyn et al.[[32]] This work has immediate relevance to prioritisation with the current COVID-19 vaccine rollout, as does the article presenting the case for prioritising those with mental health and addiction issues by Lockett et al.[[33]] Also of substantial current relevance is thinking around the importance of border controls by Eggleton et al[[34]] and the health and social support needed for low-income people if raised Alert Levels are required again (the work by Choi et al[[35]]).

The articles relating to secondary care provision can all provide lessons if New Zealand needs to go up levels in the COVID-19 response Alert Level system in response to outbreaks or the threat of outbreaks (Table 1). A particularly strong theme is around the expanded use of telehealth services, with this being the major theme for three articles and also considered in three others. The overall impression given is that telehealth services were very useful when Alert Levels were raised, albeit with various limitations and issues of concern raised (eg, risk of increasing inequities). Some authors consider that increased routine use of telehealth in some areas of healthcare delivery may have long-term efficiency benefits. One study also includes qualitative data on the use of telehealth for contacting Māori patients through a marae clinic.[[36]]

A notable feature of this body of new articles is that many consider aspects of equity in terms of ethnic or income inequities,[[32,35,37]] those with chronic/underlying conditions,[[32,33]] how government funding support for general practices was not consistently pro-equity during the response[[38]] and whether telehealth in primary care exacerbates inequities.[[36]] With regard to the latter it might be that, for well-designed telehealth services (as argued for in one article[[39]]), there could be long-term equity benefits if these new services can be used to reduce waiting times and improve service delivery to underserved communities. But to facilitate this, further improvements could be made to internet broadband and mobile phone access across the country (as per some of the difficulties identified in one study[[36]]).

Conclusions

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear elimination strategy, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the Journal includes work that can help inform vaccination prioritisation decisions and preparations of primary and secondary care and social services for any future raising of levels in the Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Table 1: New studies in this issue of this Journal on COVID-19 pandemic-related issues in Aotearoa New Zealand. View Table 1.

Summary

Abstract

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear ‘elimination strategy’, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the New Zealand Medical Journal has 14 new pandemic-related articles. Some of this work can help inform vaccination prioritisation decisions and inform preparations of primary and secondary care services and social services for any future raising of levels in the pandemic Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson: Professor, Department of Public Health, University of Otago Wellington. Jennifer Summers: Senior Research Fellow, Department of Public Health, University of Otago Wellington. Leah Grout: Research Fellow, Department of Public Health, University of Otago Wellington. Michael Baker: Professor, Department of Public Health, University of Otago Wellington.

Acknowledgements

Professor Baker acknowledges funding support from the Health Research Council of New Zealand (20/1066).

Correspondence

Professor Nick Wilson, Director of the BODE3 Programme, Department of Public Health, University of Otago Wellington

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

One of these 14 COVID-19 related articles described here involved the first author of this Editorial (ie, the survey by Wilson and Thomson). He is also the sibling of the third author in the survey by Scott et al. The last author of this editorial was also a contributor to the article by Choi et al.

1) Hale  T, Angrist  N, Goldszmidt R, Kira B, Petherick  A, Phillips T, Webster S, Cameron-Blake  E, Hallas L, Majumdar S, Tatlow H. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). (Data for 19 June 2021 at: https://ourworldindata.org/grapher/covid-stringency-index). Nat Hum Behav 2021;5:529–38.

2) Baker M, Kvalsvig A, Verrall A, Telfar-Barnard L, Wilson N. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J 2020;133(1512):10-14.

3) Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020.

4) Baker MG, Wilson N, Anglemyer A. Successful elimination of Covid-19 transmission in New Zealand. N Engl J Med 2020;(7 August) doi:101056/NEJMc2025203.

5) Baker M, Wilson N, Blakely T. Elimination may be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ 2020;371:m4907.

6) Grout L, Katar A, Ait Ouakrim D, Summers J, Kvalsvig A, Baker M, Blakely T, Wilson N. Estimating the failure risk of quarantine systems for preventing COVID-19 outbreaks in Australia and New Zealand. medRxiv 2021;(3 July). https://www.medrxiv.org/content/10.1101/2021.02.17.21251946v4

7) Worldometers [Internet]. COVID-19 Coronavirus Pandemic. Worldometer (26 June 2021 data). https://www.worldometers.info/coronavirus/.

8) The Economist. Tracking covid-19 excess deaths across countries (11 May 2021 update). The Economist. https://www.economist.com/graphic-detail/coronavirus-excess-deaths-tracker

9) Islam N, Shkolnikov VM, Acosta RJ, Klimkin I, Kawachi I, Irizarry RA, Alicandro G, Khunti K, Yates T, Jdanov DA, White M, Lewington S, Lacey B. Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries. BMJ 2021;373:n1137.

10) Woolf S, Masters R, Aron L. Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data. BMJ 2021;373:n1343.

11) OECD [Internet]. Quarterly GDP. OECD, 2021 (Accessed 12 June 2021). https://data.oecd.org/gdp/quarterly-gdp.htm#indicator-chart.

12) OECD [Internet]. Unemployment rate. OECD, 2021 (Accessed 25 June 2021). https://data.oecd.org/unemp/unemployment-rate.htm.

13) The Economist [Internet]. Covid-19 data: The global normalcy index. The Economist 2021;(1 July). https://www.economist.com/graphic-detail/tracking-the-return-to-normalcy-after-covid-19.

14) Our World in Data [Internet]. Share of people fully vaccinated against COVID-19. Our World in Data 2021;(24 June data). https://ourworldindata.org/explorers/coronavirus-data-explorer?tab=table&zoomToSelection=true&pickerSort=desc&pickerMetric=total_cases&Metric=People+fully+vaccinated&Interval=7-day+rolling+average&Relative+to+Population=true&Align+outbreaks=false&country=~OWID_WRL.

15) Cheng D. Covid 19 coronavirus: Derek Cheng: How vaccination delivery failed to meet expectations. New Zealand Herald 2021;(2 July). https://www.nzherald.co.nz/nz/politics/covid-19-coronavirus-derek-cheng-how-vaccination-delivery-failed-to-meet-expectations/GMJ4KU3SLYPC7L6HILEITT2WCM/.

16) Kvalsvig A, Wilson N, Davies C, Timu-Parata C, Signal V, Baker M. Expansion of a national Covid-19 alert level system to improve population health and uphold the values of Indigenous peoples. Lancet Reg Health West Pac In press.

17) Kvalsvig A, Wilson N, Chan L, Febery S, Roberts S, Betty B, Baker M. Mass masking: an alternative to a second lockdown in Aotearoa. N Z Med J 2020;133(1517):8-13.

18) Kvalsvig A, Wilson N, Baker M. Urgently upgrading NZ’s Covid-19 response. Public Health Expert (Blog) 2021;(24 June). https://blogs.otago.ac.nz/pubhealthexpert/urgently-upgrading-nzs-covid-19-response/.

19) Kvalsvig A, Baker M. How Aotearoa New Zealand rapidly revised its Covid-19 response strategy: lessons for the next pandemic plan. J Roy Soc N Z 2021;31;51(Suppl1):S143-66.

20) Every-Palmer S, Jenkins M, Gendall P, Hoek J, Beaglehole B, Bell C, Williman J, Rapsey C, Stanley J. Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study. PLoS One 2020;15:e0241658.

21) Truebridge N. Alcohol-related emergency department visits increased in 2020 - data. Radio New Zealand 2021;(18 June). https://www.rnz.co.nz/news/national/445055/alcohol-related-emergency-department-visits-increased-in-2020-data.

22) Gendall P, Hoek J, Stanley J, Jenkins M, Every-Palmer S. Changes in Tobacco Use During the 2020 COVID-19 Lockdown in New Zealand. Nicotine Tob Res 2021;23:866-71.

23) Nghiem N, Wilson N. Potential impact of COVID-19 related unemployment on increased cardiovascular disease in a high-income country: Modeling health loss, cost and equity. PLoS One 2021;16:e0246053.

24) Gurney JK, Millar E, Dunn A, Pirie R, Mako M, Manderson J, Hardie C, Jackson C, North R, Ruka M, Scott N, Sarfati D. The impact of the COVID-19 pandemic on cancer diagnosis and service access in New Zealand-a country pursuing COVID-19 elimination. Lancet Reg Health West Pac 2021;10:100127.

25) McLeod M, Gurney J, Harris R, Cormack D, King P. COVID-19: we must not forget about Indigenous health and equity. Aust N Z J Public Health 2020;44:253-56.

26) Manuirirangi K, Jarman J. The Taranaki COVID-19 response from a Maori perspective: lessons for mainstream health providers in Aotearoa New Zealand. N Z Med J 2021;134;(1533):122-24.

27) Ioane J, Percival T, Laban W, Lambie I. All-of-community by all-of-government: reaching Pacific people in Aotearoa New Zealand during the COVID-19 pandemic. N Z Med J 2021;134;(1533):96-103.

28) Jenkins M, Hoek J, Jenkin G, Gendall P, Stanley J, Beaglehole B, Bell C, Rapsey C, Every-Palmer S. Silver linings of the COVID-19 lockdown in New Zealand. PLoS One 2021;16:e0249678.

29) Huang QS, Wood T, Jelley L, Jennings T, Jefferies S, Daniells K, Nesdale A, Dowell T, Turner N, Campbell-Stokes P, Balm M, Dobinson HC, Grant CC, James S, Aminisani N, Ralston J, Gunn W, Bocacao J, Danielewicz J, Moncrieff T, McNeill A, Lopez L, Waite B, Kiedrzynski T, Schrader H, Gray R, Cook K, Currin D, Engelbrecht C, Tapurau W, Emmerton L, Martin M, Baker MG, Taylor S, Trenholme A, Wong C, Lawrence S, McArthur C, Stanley A, Roberts S, Rahnama F, Bennett J, Mansell C, Dilcher M, Werno A, Grant J, van der Linden A, Youngblood B, Thomas PG, Consortium NP, Webby RJ. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun 2021;12:1001.

30) Trenholme A, Webb R, Lawrence S, Arrol S, Taylor S, Ameratunga S, Byrnes CA. COVID-19 and Infant Hospitalizations for Seasonal Respiratory Virus Infections, New Zealand, 2020. Emerg Infect Dis 2021;27:641-43.

31) Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand's COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. Lancet Reg Health West Pac 2021;12:100162.

32) Steyn N, Binny R, Hannah K, Hendy S, James A, Lustig A, Ridings K, Plank M, Sporle A. Māori and Pacific people in New Zealand have higher risk of hospitalisation for COVID-19. N Z Med J 2021;134;(1538):28-43.

33) Lockett H, Koning A, Lacey C, Every-Palmer S, Scott K, Cunningham R, Dowell T, Smith L, Masters A, Culver A, Chambers S. Addressing structural discrimination: Prioritising people with mental health and addiction issues during the COVID-19 pandemic. N Z Med J 2021;134;(1538):128-134.

34) Eggleton K, Bui N, Goodyear-Smith F. Making sure the New Zealand border is not our Achilles heel: repeated cross-sectional COVID-19 surveys in primary care. N Z Med J 2021;134;(1538):68-76.

35) Choi K, Giridharan N, Cartmell A, Lum D, Signal L, Puloka V, Crossin R, Gray L, Davies C, Baker M, Kvalsvig A. Life during lockdown: a qualitative study of low-income New Zealanders’ experience during the COVID-19 pandemic. N Z Med J 2021;134;(1538):52-67.

36) Wilson G, Currie O, Bidwell S, Saeed B, Dowell A, Halim A, Toop L, Richardson A, Savage R, Hudson B. Empty waiting rooms: The New Zealand general practice experience with telehealth during the COVID-19 pandemic. N Z Med J 2021;134;( 1538):89-101.

37) McLachlan A, Aldridge C, Morgan M, Lund M, Gabriel R, Malez V. An NP-led pilot telehealth programme to facilitate guideline-directed medical therapy for heart failure with reduced ejection fraction during the COVID-19 pandemic. N Z Med J 2021;134;(1538):77-88.

38) Selak V, Crengle S, Harwood M, Murton S, Crampton P. Emergency COVID-19 funding to general practices in early 2020. Lessons for future allocation to support equity. N Z Med J 2021;134;(1538):102-110.

39) March de Ribot F, March de Ribot A, Ogbuehi K, Large R. Teleophthalmology in the post-coronavirus era. N Z Med J 2021;134;(1538):139-143.

40) Wilson N, Thomson G. Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey. N Z Med J 2021;134;(1538):18-27.

41) Blakemore R, Pascoe M, Horne K-L, Livingston L, Young B, Elias B, Goulden M, Grenfell S, Myall D, Pitcher T, Dalrymple-Alford J, Le Heron C, Anderson T, MacAskill M. Higher perceived stress and exacerbated motor symptoms in Parkinson’s disease during the COVID-19 lockdown in New Zealand. N Z Med J 2021;134;(1538):44-51.

42) Scott D, Hadden P, Wilson G. Impact of the COVID-19 pandemic lockdown on public sector ophthalmic work by New Zealand’s ophthalmologists. N Z Med J 2021;134;(1538):120-127.

43) Lambracos S, Yuan L, Kennedy-Smith A. COVID-19 and the impact on Urology service provision at Capital & Coast District Health Board. N Z Med J 2021;134;(1538):111-119.

44) McAuliffe G, Blackmore T. COVID-19 serology: use and interpretation in New Zealand. N Z Med J 2021;134;(1538):144-147.

45) Cowie M, Barron C, Bergin A, Farrell N, Hansen I. How were medical students from Christchurch, New Zealand, involved in their COVID-19 response? N Z Med J 2021;134;(1538):135-138.

For the PDF of this article,
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As with a number of other jurisdictions in the Asia–Pacific region, New Zealand adopted tight border controls and other stringent public health and social measures (PHSMs)[[1]] to control the COVID-19 pandemic. The country’s clearly articulated COVID-19 ‘elimination strategy’[[2]] has been remarkably successful.[[3–5]] Despite occasional border system failures that have caused outbreaks,[[6]] the country has regained its elimination status after each instance (at least up to late June 2021).

Indeed, New Zealand has the lowest COVID-19 cumulative death rate in the OECD (data from the Worldometers website[[7]] on 26 June 2021). It has also had the lowest level of ‘excess deaths’ among OECD countries[[8]] and within a grouping of 29 high-income countries.[[9]] Similarly, New Zealand was one of only a few high-income countries where life expectancy actually increased between 2018 and 2020, with pandemic-related reductions in the others.[[10]]

New Zealand has also done better than the OECD average in terms of average changes in quarterly GDP (from Q1 2020 to Q1 2021 and with higher growth in the first quarter of 2021).[[11]] It also had relatively lower increases in unemployment than the OECD average.[[12]] Also, relative to other OECD countries, New Zealand topped a ‘normalcy index’ that assessed return to ‘pre-pandemic life’.[[13]]

However, a full and proper analysis of New Zealand’s elimination strategy response to the COVID-19 pandemic will need to take account of a multi-year perspective. In particular, it will need to be done after COVID-19 vaccination coverage has stabilised in New Zealand and comparable OECD countries. Indeed, the country is still at risk of large outbreaks until it achieves high vaccination coverage (it was near the bottom of the OECD on 24 June 2021 for people fully vaccinated[[14]] and equity goals were not being met[[15]]). The Government also needs to upgrade the outdated Alert Level system,[[16]] integrate mass masking in a systematic manner[[17]] and enhance border protections, along with other potential upgrades.[[18,6]] There are of course numerous lessons for the future in terms of enhancing New Zealand’s pandemic response capabilities.[[19]]

What are some of the health impacts of the pandemic response in New Zealand?

Much research relating to COVID-19 and New Zealand has already been reported, including the psychological distress associated with raised Alert Levels.[[20]] There was also an increase in alcohol-related emergencies involving ambulance staff attendances in 2020,[[21]] and increased smoking levels in some groups.[[22]] Potential adverse impacts of increased COVID-19-related unemployment onto cardiovascular disease have been modelled.[[23]] Publications have also considered equity issues around health service impacts,[[24]] and the perspectives of Māori[[16,25,26]] and Pasifika.[[27]] Although it appears that cancer care services were disrupted by the pandemic response, this was relatively minor overall (eg, “an 8% year-to-date decrease in radiation therapy attendances”).[[24]] There was also “little evidence of differential impact of COVID-19 on access to cancer diagnosis and care between ethnic groups,” but for lung cancer there was a decrease in new diagnoses among Māori.[[24]]

Identified benefits of the response included that the experience of the raised Alert Levels had positive psycho-social aspects for some people.[[28]] There was also a reduction in 2020 in infectious respiratory diseases.[[29–31]] These reductions in infectious diseases may have long-term implications for disease control (eg, the value of staying at home when unwell and mask wearing on public transport in winter months).

What do the new studies in this Journal show?

The 14 new articles relating to COVID-19 in this issue of the New Zealand Medical Journal span epidemiology and public health (n=4), secondary care services (n=3), telehealth services (n=3) and various other COVID-19 issues (n=4) (see Table 1 for brief summary details). Particularly notable is the evidence for increased risk of hospitalisation from COVID-19 for Māori and Pasifika by Steyn et al.[[32]] This work has immediate relevance to prioritisation with the current COVID-19 vaccine rollout, as does the article presenting the case for prioritising those with mental health and addiction issues by Lockett et al.[[33]] Also of substantial current relevance is thinking around the importance of border controls by Eggleton et al[[34]] and the health and social support needed for low-income people if raised Alert Levels are required again (the work by Choi et al[[35]]).

The articles relating to secondary care provision can all provide lessons if New Zealand needs to go up levels in the COVID-19 response Alert Level system in response to outbreaks or the threat of outbreaks (Table 1). A particularly strong theme is around the expanded use of telehealth services, with this being the major theme for three articles and also considered in three others. The overall impression given is that telehealth services were very useful when Alert Levels were raised, albeit with various limitations and issues of concern raised (eg, risk of increasing inequities). Some authors consider that increased routine use of telehealth in some areas of healthcare delivery may have long-term efficiency benefits. One study also includes qualitative data on the use of telehealth for contacting Māori patients through a marae clinic.[[36]]

A notable feature of this body of new articles is that many consider aspects of equity in terms of ethnic or income inequities,[[32,35,37]] those with chronic/underlying conditions,[[32,33]] how government funding support for general practices was not consistently pro-equity during the response[[38]] and whether telehealth in primary care exacerbates inequities.[[36]] With regard to the latter it might be that, for well-designed telehealth services (as argued for in one article[[39]]), there could be long-term equity benefits if these new services can be used to reduce waiting times and improve service delivery to underserved communities. But to facilitate this, further improvements could be made to internet broadband and mobile phone access across the country (as per some of the difficulties identified in one study[[36]]).

Conclusions

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear elimination strategy, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the Journal includes work that can help inform vaccination prioritisation decisions and preparations of primary and secondary care and social services for any future raising of levels in the Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Table 1: New studies in this issue of this Journal on COVID-19 pandemic-related issues in Aotearoa New Zealand. View Table 1.

Summary

Abstract

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear ‘elimination strategy’, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the New Zealand Medical Journal has 14 new pandemic-related articles. Some of this work can help inform vaccination prioritisation decisions and inform preparations of primary and secondary care services and social services for any future raising of levels in the pandemic Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson: Professor, Department of Public Health, University of Otago Wellington. Jennifer Summers: Senior Research Fellow, Department of Public Health, University of Otago Wellington. Leah Grout: Research Fellow, Department of Public Health, University of Otago Wellington. Michael Baker: Professor, Department of Public Health, University of Otago Wellington.

Acknowledgements

Professor Baker acknowledges funding support from the Health Research Council of New Zealand (20/1066).

Correspondence

Professor Nick Wilson, Director of the BODE3 Programme, Department of Public Health, University of Otago Wellington

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

One of these 14 COVID-19 related articles described here involved the first author of this Editorial (ie, the survey by Wilson and Thomson). He is also the sibling of the third author in the survey by Scott et al. The last author of this editorial was also a contributor to the article by Choi et al.

1) Hale  T, Angrist  N, Goldszmidt R, Kira B, Petherick  A, Phillips T, Webster S, Cameron-Blake  E, Hallas L, Majumdar S, Tatlow H. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). (Data for 19 June 2021 at: https://ourworldindata.org/grapher/covid-stringency-index). Nat Hum Behav 2021;5:529–38.

2) Baker M, Kvalsvig A, Verrall A, Telfar-Barnard L, Wilson N. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J 2020;133(1512):10-14.

3) Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020.

4) Baker MG, Wilson N, Anglemyer A. Successful elimination of Covid-19 transmission in New Zealand. N Engl J Med 2020;(7 August) doi:101056/NEJMc2025203.

5) Baker M, Wilson N, Blakely T. Elimination may be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ 2020;371:m4907.

6) Grout L, Katar A, Ait Ouakrim D, Summers J, Kvalsvig A, Baker M, Blakely T, Wilson N. Estimating the failure risk of quarantine systems for preventing COVID-19 outbreaks in Australia and New Zealand. medRxiv 2021;(3 July). https://www.medrxiv.org/content/10.1101/2021.02.17.21251946v4

7) Worldometers [Internet]. COVID-19 Coronavirus Pandemic. Worldometer (26 June 2021 data). https://www.worldometers.info/coronavirus/.

8) The Economist. Tracking covid-19 excess deaths across countries (11 May 2021 update). The Economist. https://www.economist.com/graphic-detail/coronavirus-excess-deaths-tracker

9) Islam N, Shkolnikov VM, Acosta RJ, Klimkin I, Kawachi I, Irizarry RA, Alicandro G, Khunti K, Yates T, Jdanov DA, White M, Lewington S, Lacey B. Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries. BMJ 2021;373:n1137.

10) Woolf S, Masters R, Aron L. Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data. BMJ 2021;373:n1343.

11) OECD [Internet]. Quarterly GDP. OECD, 2021 (Accessed 12 June 2021). https://data.oecd.org/gdp/quarterly-gdp.htm#indicator-chart.

12) OECD [Internet]. Unemployment rate. OECD, 2021 (Accessed 25 June 2021). https://data.oecd.org/unemp/unemployment-rate.htm.

13) The Economist [Internet]. Covid-19 data: The global normalcy index. The Economist 2021;(1 July). https://www.economist.com/graphic-detail/tracking-the-return-to-normalcy-after-covid-19.

14) Our World in Data [Internet]. Share of people fully vaccinated against COVID-19. Our World in Data 2021;(24 June data). https://ourworldindata.org/explorers/coronavirus-data-explorer?tab=table&zoomToSelection=true&pickerSort=desc&pickerMetric=total_cases&Metric=People+fully+vaccinated&Interval=7-day+rolling+average&Relative+to+Population=true&Align+outbreaks=false&country=~OWID_WRL.

15) Cheng D. Covid 19 coronavirus: Derek Cheng: How vaccination delivery failed to meet expectations. New Zealand Herald 2021;(2 July). https://www.nzherald.co.nz/nz/politics/covid-19-coronavirus-derek-cheng-how-vaccination-delivery-failed-to-meet-expectations/GMJ4KU3SLYPC7L6HILEITT2WCM/.

16) Kvalsvig A, Wilson N, Davies C, Timu-Parata C, Signal V, Baker M. Expansion of a national Covid-19 alert level system to improve population health and uphold the values of Indigenous peoples. Lancet Reg Health West Pac In press.

17) Kvalsvig A, Wilson N, Chan L, Febery S, Roberts S, Betty B, Baker M. Mass masking: an alternative to a second lockdown in Aotearoa. N Z Med J 2020;133(1517):8-13.

18) Kvalsvig A, Wilson N, Baker M. Urgently upgrading NZ’s Covid-19 response. Public Health Expert (Blog) 2021;(24 June). https://blogs.otago.ac.nz/pubhealthexpert/urgently-upgrading-nzs-covid-19-response/.

19) Kvalsvig A, Baker M. How Aotearoa New Zealand rapidly revised its Covid-19 response strategy: lessons for the next pandemic plan. J Roy Soc N Z 2021;31;51(Suppl1):S143-66.

20) Every-Palmer S, Jenkins M, Gendall P, Hoek J, Beaglehole B, Bell C, Williman J, Rapsey C, Stanley J. Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study. PLoS One 2020;15:e0241658.

21) Truebridge N. Alcohol-related emergency department visits increased in 2020 - data. Radio New Zealand 2021;(18 June). https://www.rnz.co.nz/news/national/445055/alcohol-related-emergency-department-visits-increased-in-2020-data.

22) Gendall P, Hoek J, Stanley J, Jenkins M, Every-Palmer S. Changes in Tobacco Use During the 2020 COVID-19 Lockdown in New Zealand. Nicotine Tob Res 2021;23:866-71.

23) Nghiem N, Wilson N. Potential impact of COVID-19 related unemployment on increased cardiovascular disease in a high-income country: Modeling health loss, cost and equity. PLoS One 2021;16:e0246053.

24) Gurney JK, Millar E, Dunn A, Pirie R, Mako M, Manderson J, Hardie C, Jackson C, North R, Ruka M, Scott N, Sarfati D. The impact of the COVID-19 pandemic on cancer diagnosis and service access in New Zealand-a country pursuing COVID-19 elimination. Lancet Reg Health West Pac 2021;10:100127.

25) McLeod M, Gurney J, Harris R, Cormack D, King P. COVID-19: we must not forget about Indigenous health and equity. Aust N Z J Public Health 2020;44:253-56.

26) Manuirirangi K, Jarman J. The Taranaki COVID-19 response from a Maori perspective: lessons for mainstream health providers in Aotearoa New Zealand. N Z Med J 2021;134;(1533):122-24.

27) Ioane J, Percival T, Laban W, Lambie I. All-of-community by all-of-government: reaching Pacific people in Aotearoa New Zealand during the COVID-19 pandemic. N Z Med J 2021;134;(1533):96-103.

28) Jenkins M, Hoek J, Jenkin G, Gendall P, Stanley J, Beaglehole B, Bell C, Rapsey C, Every-Palmer S. Silver linings of the COVID-19 lockdown in New Zealand. PLoS One 2021;16:e0249678.

29) Huang QS, Wood T, Jelley L, Jennings T, Jefferies S, Daniells K, Nesdale A, Dowell T, Turner N, Campbell-Stokes P, Balm M, Dobinson HC, Grant CC, James S, Aminisani N, Ralston J, Gunn W, Bocacao J, Danielewicz J, Moncrieff T, McNeill A, Lopez L, Waite B, Kiedrzynski T, Schrader H, Gray R, Cook K, Currin D, Engelbrecht C, Tapurau W, Emmerton L, Martin M, Baker MG, Taylor S, Trenholme A, Wong C, Lawrence S, McArthur C, Stanley A, Roberts S, Rahnama F, Bennett J, Mansell C, Dilcher M, Werno A, Grant J, van der Linden A, Youngblood B, Thomas PG, Consortium NP, Webby RJ. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun 2021;12:1001.

30) Trenholme A, Webb R, Lawrence S, Arrol S, Taylor S, Ameratunga S, Byrnes CA. COVID-19 and Infant Hospitalizations for Seasonal Respiratory Virus Infections, New Zealand, 2020. Emerg Infect Dis 2021;27:641-43.

31) Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand's COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. Lancet Reg Health West Pac 2021;12:100162.

32) Steyn N, Binny R, Hannah K, Hendy S, James A, Lustig A, Ridings K, Plank M, Sporle A. Māori and Pacific people in New Zealand have higher risk of hospitalisation for COVID-19. N Z Med J 2021;134;(1538):28-43.

33) Lockett H, Koning A, Lacey C, Every-Palmer S, Scott K, Cunningham R, Dowell T, Smith L, Masters A, Culver A, Chambers S. Addressing structural discrimination: Prioritising people with mental health and addiction issues during the COVID-19 pandemic. N Z Med J 2021;134;(1538):128-134.

34) Eggleton K, Bui N, Goodyear-Smith F. Making sure the New Zealand border is not our Achilles heel: repeated cross-sectional COVID-19 surveys in primary care. N Z Med J 2021;134;(1538):68-76.

35) Choi K, Giridharan N, Cartmell A, Lum D, Signal L, Puloka V, Crossin R, Gray L, Davies C, Baker M, Kvalsvig A. Life during lockdown: a qualitative study of low-income New Zealanders’ experience during the COVID-19 pandemic. N Z Med J 2021;134;(1538):52-67.

36) Wilson G, Currie O, Bidwell S, Saeed B, Dowell A, Halim A, Toop L, Richardson A, Savage R, Hudson B. Empty waiting rooms: The New Zealand general practice experience with telehealth during the COVID-19 pandemic. N Z Med J 2021;134;( 1538):89-101.

37) McLachlan A, Aldridge C, Morgan M, Lund M, Gabriel R, Malez V. An NP-led pilot telehealth programme to facilitate guideline-directed medical therapy for heart failure with reduced ejection fraction during the COVID-19 pandemic. N Z Med J 2021;134;(1538):77-88.

38) Selak V, Crengle S, Harwood M, Murton S, Crampton P. Emergency COVID-19 funding to general practices in early 2020. Lessons for future allocation to support equity. N Z Med J 2021;134;(1538):102-110.

39) March de Ribot F, March de Ribot A, Ogbuehi K, Large R. Teleophthalmology in the post-coronavirus era. N Z Med J 2021;134;(1538):139-143.

40) Wilson N, Thomson G. Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey. N Z Med J 2021;134;(1538):18-27.

41) Blakemore R, Pascoe M, Horne K-L, Livingston L, Young B, Elias B, Goulden M, Grenfell S, Myall D, Pitcher T, Dalrymple-Alford J, Le Heron C, Anderson T, MacAskill M. Higher perceived stress and exacerbated motor symptoms in Parkinson’s disease during the COVID-19 lockdown in New Zealand. N Z Med J 2021;134;(1538):44-51.

42) Scott D, Hadden P, Wilson G. Impact of the COVID-19 pandemic lockdown on public sector ophthalmic work by New Zealand’s ophthalmologists. N Z Med J 2021;134;(1538):120-127.

43) Lambracos S, Yuan L, Kennedy-Smith A. COVID-19 and the impact on Urology service provision at Capital & Coast District Health Board. N Z Med J 2021;134;(1538):111-119.

44) McAuliffe G, Blackmore T. COVID-19 serology: use and interpretation in New Zealand. N Z Med J 2021;134;(1538):144-147.

45) Cowie M, Barron C, Bergin A, Farrell N, Hansen I. How were medical students from Christchurch, New Zealand, involved in their COVID-19 response? N Z Med J 2021;134;(1538):135-138.

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As with a number of other jurisdictions in the Asia–Pacific region, New Zealand adopted tight border controls and other stringent public health and social measures (PHSMs)[[1]] to control the COVID-19 pandemic. The country’s clearly articulated COVID-19 ‘elimination strategy’[[2]] has been remarkably successful.[[3–5]] Despite occasional border system failures that have caused outbreaks,[[6]] the country has regained its elimination status after each instance (at least up to late June 2021).

Indeed, New Zealand has the lowest COVID-19 cumulative death rate in the OECD (data from the Worldometers website[[7]] on 26 June 2021). It has also had the lowest level of ‘excess deaths’ among OECD countries[[8]] and within a grouping of 29 high-income countries.[[9]] Similarly, New Zealand was one of only a few high-income countries where life expectancy actually increased between 2018 and 2020, with pandemic-related reductions in the others.[[10]]

New Zealand has also done better than the OECD average in terms of average changes in quarterly GDP (from Q1 2020 to Q1 2021 and with higher growth in the first quarter of 2021).[[11]] It also had relatively lower increases in unemployment than the OECD average.[[12]] Also, relative to other OECD countries, New Zealand topped a ‘normalcy index’ that assessed return to ‘pre-pandemic life’.[[13]]

However, a full and proper analysis of New Zealand’s elimination strategy response to the COVID-19 pandemic will need to take account of a multi-year perspective. In particular, it will need to be done after COVID-19 vaccination coverage has stabilised in New Zealand and comparable OECD countries. Indeed, the country is still at risk of large outbreaks until it achieves high vaccination coverage (it was near the bottom of the OECD on 24 June 2021 for people fully vaccinated[[14]] and equity goals were not being met[[15]]). The Government also needs to upgrade the outdated Alert Level system,[[16]] integrate mass masking in a systematic manner[[17]] and enhance border protections, along with other potential upgrades.[[18,6]] There are of course numerous lessons for the future in terms of enhancing New Zealand’s pandemic response capabilities.[[19]]

What are some of the health impacts of the pandemic response in New Zealand?

Much research relating to COVID-19 and New Zealand has already been reported, including the psychological distress associated with raised Alert Levels.[[20]] There was also an increase in alcohol-related emergencies involving ambulance staff attendances in 2020,[[21]] and increased smoking levels in some groups.[[22]] Potential adverse impacts of increased COVID-19-related unemployment onto cardiovascular disease have been modelled.[[23]] Publications have also considered equity issues around health service impacts,[[24]] and the perspectives of Māori[[16,25,26]] and Pasifika.[[27]] Although it appears that cancer care services were disrupted by the pandemic response, this was relatively minor overall (eg, “an 8% year-to-date decrease in radiation therapy attendances”).[[24]] There was also “little evidence of differential impact of COVID-19 on access to cancer diagnosis and care between ethnic groups,” but for lung cancer there was a decrease in new diagnoses among Māori.[[24]]

Identified benefits of the response included that the experience of the raised Alert Levels had positive psycho-social aspects for some people.[[28]] There was also a reduction in 2020 in infectious respiratory diseases.[[29–31]] These reductions in infectious diseases may have long-term implications for disease control (eg, the value of staying at home when unwell and mask wearing on public transport in winter months).

What do the new studies in this Journal show?

The 14 new articles relating to COVID-19 in this issue of the New Zealand Medical Journal span epidemiology and public health (n=4), secondary care services (n=3), telehealth services (n=3) and various other COVID-19 issues (n=4) (see Table 1 for brief summary details). Particularly notable is the evidence for increased risk of hospitalisation from COVID-19 for Māori and Pasifika by Steyn et al.[[32]] This work has immediate relevance to prioritisation with the current COVID-19 vaccine rollout, as does the article presenting the case for prioritising those with mental health and addiction issues by Lockett et al.[[33]] Also of substantial current relevance is thinking around the importance of border controls by Eggleton et al[[34]] and the health and social support needed for low-income people if raised Alert Levels are required again (the work by Choi et al[[35]]).

The articles relating to secondary care provision can all provide lessons if New Zealand needs to go up levels in the COVID-19 response Alert Level system in response to outbreaks or the threat of outbreaks (Table 1). A particularly strong theme is around the expanded use of telehealth services, with this being the major theme for three articles and also considered in three others. The overall impression given is that telehealth services were very useful when Alert Levels were raised, albeit with various limitations and issues of concern raised (eg, risk of increasing inequities). Some authors consider that increased routine use of telehealth in some areas of healthcare delivery may have long-term efficiency benefits. One study also includes qualitative data on the use of telehealth for contacting Māori patients through a marae clinic.[[36]]

A notable feature of this body of new articles is that many consider aspects of equity in terms of ethnic or income inequities,[[32,35,37]] those with chronic/underlying conditions,[[32,33]] how government funding support for general practices was not consistently pro-equity during the response[[38]] and whether telehealth in primary care exacerbates inequities.[[36]] With regard to the latter it might be that, for well-designed telehealth services (as argued for in one article[[39]]), there could be long-term equity benefits if these new services can be used to reduce waiting times and improve service delivery to underserved communities. But to facilitate this, further improvements could be made to internet broadband and mobile phone access across the country (as per some of the difficulties identified in one study[[36]]).

Conclusions

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear elimination strategy, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the Journal includes work that can help inform vaccination prioritisation decisions and preparations of primary and secondary care and social services for any future raising of levels in the Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Table 1: New studies in this issue of this Journal on COVID-19 pandemic-related issues in Aotearoa New Zealand. View Table 1.

Summary

Abstract

In response to the COVID-19 pandemic, Aotearoa New Zealand adopted a clear ‘elimination strategy’, which has (up to June 2021) been very successful in both health and economic terms compared to other OECD countries. Nevertheless, the pandemic response has still been a very major shock to the New Zealand health system. This issue of the New Zealand Medical Journal has 14 new pandemic-related articles. Some of this work can help inform vaccination prioritisation decisions and inform preparations of primary and secondary care services and social services for any future raising of levels in the pandemic Alert Level system. Particularly strong themes are around the value (and challenges) of telehealth services, and also the need for responses throughout the health system to ensure health equity and support for the most vulnerable citizens.

Aim

Method

Results

Conclusion

Author Information

Nick Wilson: Professor, Department of Public Health, University of Otago Wellington. Jennifer Summers: Senior Research Fellow, Department of Public Health, University of Otago Wellington. Leah Grout: Research Fellow, Department of Public Health, University of Otago Wellington. Michael Baker: Professor, Department of Public Health, University of Otago Wellington.

Acknowledgements

Professor Baker acknowledges funding support from the Health Research Council of New Zealand (20/1066).

Correspondence

Professor Nick Wilson, Director of the BODE3 Programme, Department of Public Health, University of Otago Wellington

Correspondence Email

nick.wilson@otago.ac.nz

Competing Interests

One of these 14 COVID-19 related articles described here involved the first author of this Editorial (ie, the survey by Wilson and Thomson). He is also the sibling of the third author in the survey by Scott et al. The last author of this editorial was also a contributor to the article by Choi et al.

1) Hale  T, Angrist  N, Goldszmidt R, Kira B, Petherick  A, Phillips T, Webster S, Cameron-Blake  E, Hallas L, Majumdar S, Tatlow H. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). (Data for 19 June 2021 at: https://ourworldindata.org/grapher/covid-stringency-index). Nat Hum Behav 2021;5:529–38.

2) Baker M, Kvalsvig A, Verrall A, Telfar-Barnard L, Wilson N. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J 2020;133(1512):10-14.

3) Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020.

4) Baker MG, Wilson N, Anglemyer A. Successful elimination of Covid-19 transmission in New Zealand. N Engl J Med 2020;(7 August) doi:101056/NEJMc2025203.

5) Baker M, Wilson N, Blakely T. Elimination may be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ 2020;371:m4907.

6) Grout L, Katar A, Ait Ouakrim D, Summers J, Kvalsvig A, Baker M, Blakely T, Wilson N. Estimating the failure risk of quarantine systems for preventing COVID-19 outbreaks in Australia and New Zealand. medRxiv 2021;(3 July). https://www.medrxiv.org/content/10.1101/2021.02.17.21251946v4

7) Worldometers [Internet]. COVID-19 Coronavirus Pandemic. Worldometer (26 June 2021 data). https://www.worldometers.info/coronavirus/.

8) The Economist. Tracking covid-19 excess deaths across countries (11 May 2021 update). The Economist. https://www.economist.com/graphic-detail/coronavirus-excess-deaths-tracker

9) Islam N, Shkolnikov VM, Acosta RJ, Klimkin I, Kawachi I, Irizarry RA, Alicandro G, Khunti K, Yates T, Jdanov DA, White M, Lewington S, Lacey B. Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries. BMJ 2021;373:n1137.

10) Woolf S, Masters R, Aron L. Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data. BMJ 2021;373:n1343.

11) OECD [Internet]. Quarterly GDP. OECD, 2021 (Accessed 12 June 2021). https://data.oecd.org/gdp/quarterly-gdp.htm#indicator-chart.

12) OECD [Internet]. Unemployment rate. OECD, 2021 (Accessed 25 June 2021). https://data.oecd.org/unemp/unemployment-rate.htm.

13) The Economist [Internet]. Covid-19 data: The global normalcy index. The Economist 2021;(1 July). https://www.economist.com/graphic-detail/tracking-the-return-to-normalcy-after-covid-19.

14) Our World in Data [Internet]. Share of people fully vaccinated against COVID-19. Our World in Data 2021;(24 June data). https://ourworldindata.org/explorers/coronavirus-data-explorer?tab=table&zoomToSelection=true&pickerSort=desc&pickerMetric=total_cases&Metric=People+fully+vaccinated&Interval=7-day+rolling+average&Relative+to+Population=true&Align+outbreaks=false&country=~OWID_WRL.

15) Cheng D. Covid 19 coronavirus: Derek Cheng: How vaccination delivery failed to meet expectations. New Zealand Herald 2021;(2 July). https://www.nzherald.co.nz/nz/politics/covid-19-coronavirus-derek-cheng-how-vaccination-delivery-failed-to-meet-expectations/GMJ4KU3SLYPC7L6HILEITT2WCM/.

16) Kvalsvig A, Wilson N, Davies C, Timu-Parata C, Signal V, Baker M. Expansion of a national Covid-19 alert level system to improve population health and uphold the values of Indigenous peoples. Lancet Reg Health West Pac In press.

17) Kvalsvig A, Wilson N, Chan L, Febery S, Roberts S, Betty B, Baker M. Mass masking: an alternative to a second lockdown in Aotearoa. N Z Med J 2020;133(1517):8-13.

18) Kvalsvig A, Wilson N, Baker M. Urgently upgrading NZ’s Covid-19 response. Public Health Expert (Blog) 2021;(24 June). https://blogs.otago.ac.nz/pubhealthexpert/urgently-upgrading-nzs-covid-19-response/.

19) Kvalsvig A, Baker M. How Aotearoa New Zealand rapidly revised its Covid-19 response strategy: lessons for the next pandemic plan. J Roy Soc N Z 2021;31;51(Suppl1):S143-66.

20) Every-Palmer S, Jenkins M, Gendall P, Hoek J, Beaglehole B, Bell C, Williman J, Rapsey C, Stanley J. Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study. PLoS One 2020;15:e0241658.

21) Truebridge N. Alcohol-related emergency department visits increased in 2020 - data. Radio New Zealand 2021;(18 June). https://www.rnz.co.nz/news/national/445055/alcohol-related-emergency-department-visits-increased-in-2020-data.

22) Gendall P, Hoek J, Stanley J, Jenkins M, Every-Palmer S. Changes in Tobacco Use During the 2020 COVID-19 Lockdown in New Zealand. Nicotine Tob Res 2021;23:866-71.

23) Nghiem N, Wilson N. Potential impact of COVID-19 related unemployment on increased cardiovascular disease in a high-income country: Modeling health loss, cost and equity. PLoS One 2021;16:e0246053.

24) Gurney JK, Millar E, Dunn A, Pirie R, Mako M, Manderson J, Hardie C, Jackson C, North R, Ruka M, Scott N, Sarfati D. The impact of the COVID-19 pandemic on cancer diagnosis and service access in New Zealand-a country pursuing COVID-19 elimination. Lancet Reg Health West Pac 2021;10:100127.

25) McLeod M, Gurney J, Harris R, Cormack D, King P. COVID-19: we must not forget about Indigenous health and equity. Aust N Z J Public Health 2020;44:253-56.

26) Manuirirangi K, Jarman J. The Taranaki COVID-19 response from a Maori perspective: lessons for mainstream health providers in Aotearoa New Zealand. N Z Med J 2021;134;(1533):122-24.

27) Ioane J, Percival T, Laban W, Lambie I. All-of-community by all-of-government: reaching Pacific people in Aotearoa New Zealand during the COVID-19 pandemic. N Z Med J 2021;134;(1533):96-103.

28) Jenkins M, Hoek J, Jenkin G, Gendall P, Stanley J, Beaglehole B, Bell C, Rapsey C, Every-Palmer S. Silver linings of the COVID-19 lockdown in New Zealand. PLoS One 2021;16:e0249678.

29) Huang QS, Wood T, Jelley L, Jennings T, Jefferies S, Daniells K, Nesdale A, Dowell T, Turner N, Campbell-Stokes P, Balm M, Dobinson HC, Grant CC, James S, Aminisani N, Ralston J, Gunn W, Bocacao J, Danielewicz J, Moncrieff T, McNeill A, Lopez L, Waite B, Kiedrzynski T, Schrader H, Gray R, Cook K, Currin D, Engelbrecht C, Tapurau W, Emmerton L, Martin M, Baker MG, Taylor S, Trenholme A, Wong C, Lawrence S, McArthur C, Stanley A, Roberts S, Rahnama F, Bennett J, Mansell C, Dilcher M, Werno A, Grant J, van der Linden A, Youngblood B, Thomas PG, Consortium NP, Webby RJ. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun 2021;12:1001.

30) Trenholme A, Webb R, Lawrence S, Arrol S, Taylor S, Ameratunga S, Byrnes CA. COVID-19 and Infant Hospitalizations for Seasonal Respiratory Virus Infections, New Zealand, 2020. Emerg Infect Dis 2021;27:641-43.

31) Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand's COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. Lancet Reg Health West Pac 2021;12:100162.

32) Steyn N, Binny R, Hannah K, Hendy S, James A, Lustig A, Ridings K, Plank M, Sporle A. Māori and Pacific people in New Zealand have higher risk of hospitalisation for COVID-19. N Z Med J 2021;134;(1538):28-43.

33) Lockett H, Koning A, Lacey C, Every-Palmer S, Scott K, Cunningham R, Dowell T, Smith L, Masters A, Culver A, Chambers S. Addressing structural discrimination: Prioritising people with mental health and addiction issues during the COVID-19 pandemic. N Z Med J 2021;134;(1538):128-134.

34) Eggleton K, Bui N, Goodyear-Smith F. Making sure the New Zealand border is not our Achilles heel: repeated cross-sectional COVID-19 surveys in primary care. N Z Med J 2021;134;(1538):68-76.

35) Choi K, Giridharan N, Cartmell A, Lum D, Signal L, Puloka V, Crossin R, Gray L, Davies C, Baker M, Kvalsvig A. Life during lockdown: a qualitative study of low-income New Zealanders’ experience during the COVID-19 pandemic. N Z Med J 2021;134;(1538):52-67.

36) Wilson G, Currie O, Bidwell S, Saeed B, Dowell A, Halim A, Toop L, Richardson A, Savage R, Hudson B. Empty waiting rooms: The New Zealand general practice experience with telehealth during the COVID-19 pandemic. N Z Med J 2021;134;( 1538):89-101.

37) McLachlan A, Aldridge C, Morgan M, Lund M, Gabriel R, Malez V. An NP-led pilot telehealth programme to facilitate guideline-directed medical therapy for heart failure with reduced ejection fraction during the COVID-19 pandemic. N Z Med J 2021;134;(1538):77-88.

38) Selak V, Crengle S, Harwood M, Murton S, Crampton P. Emergency COVID-19 funding to general practices in early 2020. Lessons for future allocation to support equity. N Z Med J 2021;134;(1538):102-110.

39) March de Ribot F, March de Ribot A, Ogbuehi K, Large R. Teleophthalmology in the post-coronavirus era. N Z Med J 2021;134;(1538):139-143.

40) Wilson N, Thomson G. Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey. N Z Med J 2021;134;(1538):18-27.

41) Blakemore R, Pascoe M, Horne K-L, Livingston L, Young B, Elias B, Goulden M, Grenfell S, Myall D, Pitcher T, Dalrymple-Alford J, Le Heron C, Anderson T, MacAskill M. Higher perceived stress and exacerbated motor symptoms in Parkinson’s disease during the COVID-19 lockdown in New Zealand. N Z Med J 2021;134;(1538):44-51.

42) Scott D, Hadden P, Wilson G. Impact of the COVID-19 pandemic lockdown on public sector ophthalmic work by New Zealand’s ophthalmologists. N Z Med J 2021;134;(1538):120-127.

43) Lambracos S, Yuan L, Kennedy-Smith A. COVID-19 and the impact on Urology service provision at Capital & Coast District Health Board. N Z Med J 2021;134;(1538):111-119.

44) McAuliffe G, Blackmore T. COVID-19 serology: use and interpretation in New Zealand. N Z Med J 2021;134;(1538):144-147.

45) Cowie M, Barron C, Bergin A, Farrell N, Hansen I. How were medical students from Christchurch, New Zealand, involved in their COVID-19 response? N Z Med J 2021;134;(1538):135-138.

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