Katie
Kenny, Digital Explainer Editor
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.
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“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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