Photo: RNZ
Five years since the pandemic began, Covid remains New Zealand's most harmful infectious disease. But experts are concerned lessons learnt in infection prevention and control are being ignored, and too many people are getting sick and dying after catching the virus in healthcare settings.
Based on Australian data, it is likely between 10 and 15 percent of Covid deaths are from hospital-acquired infections, representing hundreds of people. Avoidable infection and death are also costly to the health system.
Meanwhile, Covid policies continue to be rolled back.
In New Zealand and internationally, there are calls to boost reporting requirements for hospital-onset infections, and infections among healthcare workers. And to put in place long-term measures that will mitigate not only the spread of Covid, but other respiratory illnesses.
Auckland clockmaker Michael Cryns has experienced chronic illness since childhood. For this reason, the 70-year-old was "always scared of getting [Covid] and careful to avoid it".
Admitting luck must have also played a role, he remained Covid-free until December 2024, when he tested positive after being in hospital for a planned surgery.
While the operation went well, his stay was extended because the breathing tube had irritated his airway. He was transferred from a private to a public hospital, where he spent 10 days recovering. Two days before he was due to be discharged, he got a runny nose and started coughing.
"They sent me home on Friday night, and I was coughing all night."
A rapid antigen test (RAT) the following morning was "severely positive". His condition deteriorated quickly.
"I could hardly breathe."
An ambulance took him back to hospital where he received treatment for another week.
"I was incredibly ill; I could only hold my head up."
His partner also caught Covid but had a comparatively "minor" illness - perhaps owing to a previous infection in 2022, and the fact she was vaccinated. (Cryns had had one Covid shot, in 2021.)
Months later, he was still experiencing ongoing symptoms. Even short outings sapped his energy and required long naps to recover.
"You lose confidence in being able to do anything."
Five years on
On 31 January 2020, the World Health Organisation (WHO) declared the novel coronavirus to be a public health emergency of international concern, the WHO's highest level of alarm.
New Zealand's response has been described as world leading. The country's isolation and initial elimination strategy delayed widespread transmission until after vaccination was available and Omicron, regarded as less severe for individuals than the earlier Delta variant, was the dominant strain, in 2022.
But the strict public health measures were also disruptive, polarising, and expensive.
In May, 2023, the WHO ended the global emergency status for Covid. New Zealand's remaining restrictions under the Covid-19 Public Health Response Act 2020 were revoked in August.
From July, 2024, Health New Zealand got rid of Covid-specific sick leave for health workers. And from December, while getting vaccinated for Covid is still recommended, it's not expected of new employees.
From an infection prevention and control perspective, hospitals across the country now manage Covid "as they would any other infectious disease", according to a Health New Zealand Te Whatu Ora spokesperson. "Guidance for managing Covid-19 in hospitals is regularly reviewed to ensure it is fit for purpose and updated if required."
The organisation doesn't collect data on hospital-acquired Covid-19, the spokesperson confirmed.
When asked whether there were any estimates of the cost to the health system of hospital-acquired Covid, the spokesperson said there was "no specific data" on the issue.
In October 2024, a Te Tāhū Hauora Health Quality and Safety Commission paper found healthcare-associated infections in public hospitals were estimated to cost the system $955 million in 2021, and to have caused more disability than road traffic crashes.
The economic burden was calculated based on data from the point prevalence survey that year.
The survey, of 5500 patients across 31 hospitals from all 20 district health boards, reported a healthcare-associated infection rate of 7.7 percent. That was comparable to Europe, Wales and Switzerland, and less than that of Australia and Singapore.
The most common, accounting for 74 percent of all infections, were surgical site infections, urinary tract infections, pneumonia, and bloodstream infections. (The survey's timing from February to June meant it avoided the usual winter peak period of respiratory illness, plus due to border restrictions the amount of circulating respiratory viruses was very low.)
Prior to the survey, there was limited information on the prevalence of healthcare-associated infections, but research suggested between five and 10 percent of patients were affected.
Across the ditch
Last year, Australian infection control experts raised concerns about the lack of precautions against airborne viruses in healthcare settings, after ABC News revealed that's where a significant proportion of fatal Covid infections originated.
About 14 percent of Covid deaths in New South Wales in 2023 were patients who caught the virus in hospital, according to reported data.
In Victoria, hospital-acquired Covid in 2022 and 2023 accounted for about 12 percent of all deaths "from or with Covid-19".
Stéphane Bouchoucha, an associate professor in nursing at Deakin University and president of the Australasian College for Infection Prevention and Control, told RNZ if hospitals were recording similar numbers of deaths from "golden staph" (staphylococcus bacteria), swift action would be taken.
The life-threatening bloodstream infection is tracked and reported, with hospital targets in every Australian state. This is also the case in New Zealand. But there's no comparable surveillance of Covid in either country.
"We seem to want to revert to a pre-pandemic world, despite what we've learnt from Covid and other respiratory viruses," Bouchoucha said. "We know through wastewater testing when there are Covid peaks and troughs, but we need surveillance also in clinical settings."
During surges, hospitals could reintroduce masking, for example, he added.
"If you don't monitor for something, you won't find it."
Instead, hospitals were scrapping policies countering Covid spread.
South Australia Health, for example, was consulting on relaxing requirements for health workers who tested positive for the virus. A letter circulated to staff outlined a proposal to do away with special leave for Covid, and the directive to stay home after testing positive.
In clinical areas, employees with Covid who were well enough to work, "may be required to wear personal protective equipment [...] or be assigned duties in alternative areas", according to the letter.
"People are going to turn up to work sick," Bouchoucha said. "We seem to ignore the people at the centre of this. We're dealing with people losing their lives. [The proposal] might benefit the system, but what harm are we causing to patients?"
Associate Professor Suman Majumdar, chief health officer for Covid and health emergencies at Melbourne's Burnet Institute, agreed it is "feasible to detect and prevent" airborne infections such as Covid in hospital settings.
While the number of people coming into hospital with Covid has stabilised in recent years, "we know Covid waves are ongoing", he told RNZ.
Lessons learnt from the pandemic could help prevent other respiratory illnesses such as influenza, too. This is because the Covid has evolved our understanding of how these illnesses spread.
At first, it was thought Covid spread either through contact or droplet transmission. Public health advice focused on sanitising surfaces, hand washing, and distancing. It soon became clear these measures weren't enough, as scientists suggested Covid could also spread over long distances.
It was not until late-2021 the World Health Organisation acknowledged Covid was airborne, a term previously reserved for only a few, select pathogens that could linger in the air, such as measles and tuberculosis.
Last year, the WHO published a report updating its formal guidelines for classifying the ways pathogens spread. The new categories do not rely on droplet size or spread.
"We should be using airborne mitigations, such as masks and improved ventilation, for most respiratory infections," Majumdar explained.
With colleagues at the Burnet Institute and the Victoria Department of Health, he published a study that assessed the cost-effectiveness of clinical staff N95 masks and admission screening testing of patients to reduce Covid-19 hospital-acquired infections.
In short, "all scenarios that used testing and masks were cost saving with health gains, compared to not using them".
Regardless, Majumdar acknowledged it was a tall ask for policy makers to think long-term, "spending money up front to save money later, in a "fiscally-constrained environment".
Building on this, improved baseline standards for hospital ventilation had to be a top priority for mitigating Covid and other respiratory illnesses, he said, "given ventilation doesn't rely on human behaviours and potentially has the same or greater effectiveness as masks and testing".
"It can have a high upfront cost, but you only need to do it once and get it right to potentially save lives and money."
'It's unacceptable'
Otago University public health professor Michael Baker described the Australian data on hospital-acquired Covid as "really alarming".
It was reasonable to extrapolate it, meaning of New Zealand's 4500-odd deaths attributed to Covid to date, it's possible about 600 were from hospital-acquired infections, he said.
"It's unacceptable. Hospitals should be places of safety, not places where you contract Covid."
Citing Majumdar's paper, he said there's evidence basic measures such as testing and masking would be cost-effective, even as the number of Covid cases and deaths were declining.
"It's so expensive if people have to stay even one more night in hospital."
(The cost of a night in hospital - excluding procedures - is about $1200, according to Pharmac. In intensive care, it is about $5500.)
The "number one thing" in controlling hospital-acquired infections "is to count them", he said. "Good surveillance is the first step in managing and preventing these avoidable infections.
"Ideally, you'd do it everywhere but at the very least, you'd do it at one or two sites to get a sense of the scale of the problem."
Dr Michael Maze, respiratory physician and senior lecturer in medicine at Otago University, Christchurch, said while there's been progress in our understanding of hospital infection prevention and control since the pandemic, "everything costs money".
"Single rooms would reduce transmission, but the biggest barrier would be cost."
On surveillance testing as an inexpensive intervention, he pointed to potential ethical issues. For one, RATs are less sensitive than PCR tests, but processing PCRs "sucks up a huge amount of money and time".
"All tests have false positives as well as false negatives. If I get Covid today, I might return a positive PCR test months later [without being contagious]. Imagine if I went into hospital with a nasty break, tested positive for the above reason, and then had to wait longer for a special theatre."
In 2020, when missing a positive case would have had "profound consequences", you'd "tolerate distress for the greater good". Five years later, "it's a more finely balanced decision. You'd want to be very careful testing people without [Covid] compatible symptoms. It's about getting that appropriate pre-test probability."
Even if patients were tested on admission, "we're never going to be testing visitors", he added.
"The other thing is, influenza also kills people. So does human metapneumovirus, and RSV. Do we do a single [Covid] test, or a combination one?"
Like others, he believed the focus needed to be on improving airflow.
"We could have much better ventilation in many hospital environments and a much greater proportion of single rooms."
Dated infrastructure
Hospital-acquired infections "have always been a big issue", infectious diseases professor David Murdoch told RNZ. "But with something like Covid, you learn a lot about ventilation and even just engineering standards [for infection prevention and control]."
While "you'll never get rid of" nosocomial infections, they "should be a priority", he said.
Indeed, New Zealand's Covid inquiry noted: "Dated infrastructure made it difficult to apply best-practice infection control measures, including air ventilation, in many healthcare facilities."
Te Tāhū Hauora national clinical lead for the infection prevention and control programme, Dr Sally Roberts, said healthcare has moved on since most of our hospitals were built in the 1960s and 1970s.
"If you're relying on open windows, air movement is very restricted, so you get areas of stagnant air and particles tend to stay suspended in that."
Most hospitals have a target number of air changes per hour, Roberts said. This refers to the number of times the volume of air in a space is completely replaced per hour.
Evidence suggests air change rates of between four and five are good, six is better, and more than six is best. Australian guidelines state "the peak efficiency for particle removal in the air space often occurs between 12 and 15 [air changes per hour]".
"If you have a hospital from the 1960s, it won't have any air handling systems at all," Roberts said.
New Zealand doesn't have - and doesn't need, in Roberts' opinion - its own standards: "But we need to look to international standards that meet our needs."
And what we do need is a document "that says this is how we build a hospital in New Zealand", because in the absence of one, "infection prevention and control cost-cutting measures are going on all the time".
There hasn't yet been acceptance that designing and building to reduce the risk of airborne transmission is expensive, she said. It requires consideration of not just ventilation and single rooms but also having enough space (2.4 metres) between beds in shared rooms, doors that open automatically, surfaces that are easy to clean, wide corridors, and so on.
"People say, Covid has gone, we don't need all these spare air-handling units. But we know every year we'll have seasonal influenza epidemics. And RSV and pertussis. And we know bird flu is on the horizon. We're getting increasingly challenged by these respiratory infections.
"We need these units serviced and maintained so when we need them, we can switch them on."
Future-proofing
Health Minister Simeon Brown at the 2025 Infrastructure Investment Summit acknowledged "many hospitals and facilities" need upgrading: "Health New Zealand is grappling with outdated infrastructure that is inhibiting changes to models of care that improve patient outcomes and drive efficiencies."
The new hospital being built in Dunedin represents New Zealand's largest ever health infrastructure investment, with a budget of $1.88 billion.
Clinical transformation group chair Dr Sheila Barnet told RNZ the hospital was designed to meet the updated Australasian Health Facility Guidelines: "These set the standard for everything from hand hygiene facilities and floor surfaces, through to air conditioning, isolation room numbers, and construction guidance."
The hospital is designed to respond to a pandemic in four stages, she said. First, through use of isolation rooms for a limited number of cases. Then, a subsection of the hospital can become a "red zone", linked by a dedicated lift and with "the highest ventilation standards". Once the initial red zone has been exceeded, it can be expanded. Finally, the whole inpatient building can become "red", and the outpatient building used for "green" patients.
When asked whether infection prevention and control plans had fallen victim to cost-cutting measures, Te Whatu Ora said "detailed designs have not yet been finalised" for the new hospital.
"But based on the broad changes that have been proposed, the pandemic response plan [...] has not been scaled back or significantly altered."
Michael Cryn said he doesn't blame hospital management for his Covid infection. His stay coincided with a nurses' strike, and he got the impression the ward was understaffed.
Given the "huge turnover" in ward staffing, as well as the "constant stream of visitors", he thinks regular testing of staff and patients should be a "first line of defence".
Or: "Before we go to the GP, we're asked to declare that we're symptom-free. At the very least, why can't staff and visitors do the same when entering hospital?"
He wrote a letter of complaint, "and got a nice apology letter in reply", but no indication anything would change or improve.
Mid-March, he was still struggling with Covid-related symptoms, exhaustion, and dizziness: "There's no end in sight."
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