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A vigorous elimination strategy should be considered and equity needs to be top of the list of priorities for future severe pandemics, researchers say.

An historical review, published in the international Emerging Infectious Diseases Journal, led by University of Otago, Wellington researchers compares the outcomes and strategies employed during the fast-moving influenza pandemic of 1918-19, and the COVID‑19 pandemic that began in 2020, but is still present more than three years later.

Senior author Professor Michael Baker says the two pandemics are the largest to affect Aotearoa New Zealand, so it is important to compare them to identify ongoing lessons for today and future pandemic planning.

While both pandemics were caused by respiratory viruses, the influenza wave swept through the country in less than two months, infecting about half the population and killing more than 9,000 people, before largely disappearing. By contrast, the first case of COVID‑19 in New Zealand was reported on 28 February 2020 and more than three years later the pandemic is continuing with 20 people a week still dying from it and a death toll that as of Sunday was sitting at 3,347.

“It is important to establish whether a more strategic response, as was taken with COVID‑19 elimination, performed better than the minimal public health response to influenza in 1918 and also whether we were able to deliver a more equitable response in 2020, compared with 1918 when the Māori mortality rate was more than seven times higher than for European New Zealanders,” Professor Baker says.

The findings strongly support the vigorous elimination strategy taken by Aotearoa for COVID‑19.

“By largely keeping COVID‑19 from circulating in New Zealand for almost two years, we saved an estimated 20,000 lives compared with the high excess mortality seen in other countries. In the United States, COVID‑19 has now killed 1.13 million people, far more than the 675,000 people who died from the influenza pandemic in 1918-19.  Deaths from COVID-19 in New Zealand are 3,347 to date, far fewer than the 9,000 people killed in the 1918 flu pandemic.”

Despite being more than 100 years apart, the main tools to stop both pandemics in the early stages remain the same,” he says.

“In the initial stages before we have vaccines and antivirals, we are still reliant on basic public health and social measures, like border management, isolation of cases, and quarantine of contacts.

“The other realisation is how valuable the modern tools are, particularly molecular biology which gave us very sensitive tests, whole genome sequencing for tracing the spread of infection, and rapid vaccine development. There have also been huge advances in treatment of severely ill people, including new antivirals, use of immuno suppressants, and better intensive care.”

Co-author Associate Professor Matire Harwood (Ngāpuhi), of Waipapa Taumata Rau, University of Auckland, says one similarity between the two pandemics is “incredibly disappointing”.

“Unfortunately we are still seeing persisting high health inequities in the COVID‑19 pandemic, with Māori and Pacific Peoples hospitalised and dying at significantly higher rates than the European population.”

The death patterns seen in 1918 highlighted health inequities and the factors driving them, notably differential exposure to the determinants of health such as poverty and inadequate housing.

Māori in 1918-19 experienced higher rates of chronic disease and discriminatory outbreak management approaches. More than 100 years later, those health inequities from chronic disease still exist,” Associate Professor Harwood says.

Although the Government has acknowledged the failings in the response and provided some targeted support to Māori providers – and other services such as those for Pacific and disabled persons  –  cases, hospitalisations and death rates for COVID‑19 are disproportionally higher in those groups .

“Rates of COVID‑19 vaccination are also lower among Māori adults and children than among other ethnic groups. Therefore the principles of equity, partnership and active protection, as guaranteed in the Te Tiriti of Waitangi continue to be inadequately addressed more than 100 years after the influenza pandemic,” she says.

Co-author Professor Nick Wilson, of the University of Otago, Wellington, says the study’s findings show a need for a pandemic plan that covers a wide range of pandemic organisms and scenarios and a systematic approach to reduce health inequities.

“The plan at the start of 2020 was for influenza which had been the main cause of pandemics in New Zealand during the past century, in 1918, 1957, 1968 and 2009. It was not designed for coronaviruses which are an emerging problem as we saw with SARS in 2003 and now COVID‑19.

“Future plans need to be far more versatile and even include the possibility of engineered pathogens that are used in warfare or escape from laboratories,” he says.

“Our previous plan largely accepted that we would simply let the pandemic wash over us – a mitigation strategy – as we did in 1918. Yet, as this analysis shows, we had much better outcomes with an elimination strategy.”

Publication details:

Improvements and Persisting Challenges in COVID‑19 Response Compared with 1918–19 Influenza Pandemic Response, New Zealand (Aotearoa)

Jennifer Summers , Amanda Kvalsvig, Lucy Telfar Barnard, Julie Bennett, Matire Harwood, Nick Wilson, and Michael G. Baker

Emerging Infectious Diseases

DOI: 10.3201/eid2909.221265

For more information please contact:

Professor Michael Baker
Department of Public Health
University of Otago, Wellington

Associate Professor Matire Harwood
Department of General Practice and Primary Healthcare
Waipapa Taumata Rau, University of Auckland

Lea Jones
Communications Adviser, Media Engagement
University of Otago
Mob +64 21 279 4969

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