Covid-19 Elimination Strategy (P.61/2020): second amendment [P.61/2020 Amd.(2)]

STATES OF JERSEY

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COVID-19 ELIMINATION STRATEGY (P.61/2020): SECOND AMENDMENT

Lodged au Greffe on 18th May 2020 by the Chief Minister

STATES GREFFE

2020  P.61 Amd.(2)

COVID-19 ELIMINATION STRATEGY (P.61/2020): SECOND AMENDMENT ____________

1  PAGE 2, PARAGRAPH (a) –

After the word "implement" for the words "a new" substitute the words "an updated".

After the word " Covid-19" delete the word "elimination".

After the word "strategy'," for the words "arising from which the Government of Jersey should revise its" substitute the words "adapting the".

After the words " safe exit framework' to" insert the words "ensure the continued control and suppression of the virus in a safe and sustainable way that protects Islanders by causing the least overall harm".

Delete the words "reflect this new strategy".

2  PAGE 2, PARAGRAPH (b) –

After the words "that the" for the word "elimination" substitute "Covid-19".

After the words "plan of action that will" insert the words "seek to keep the virus at very low levels and".

After the words "be implemented" delete the words "with the explicit aim of eliminating the virus in Jersey".

After the words "measures used to" insert the words "control, suppress and ultimately".

After the words "eliminate infectious diseases" insert the words ", based on professional advice including".

In the third bullet-point, after the word "quarantine" insert the words "and/or rigorous testing".

In the fourth bullet-point, after the word "lockdown;" delete the word "and".

In  the  fifth  bullet-point,  after  the  word  "strategy"  delete  the  words  "for elimination", and after the semi-colon insert the word "and".

3  PAGE 2, PARAGRAPH (c) –

After the words "to request the Chief Minister to publish this" for the word "elimination" substitute "Covid-19".

After the words "and to publish updated versions of the strategy whenever" for the word "guidance" substitute the word "it".

CHIEF MINISTER

Note:  After this amendment, the proposition would read as follows –

THE STATES are asked to decide whether they are of opinion

1. to request the Chief Minister to develop and implement an updated Covid-19  strategy',  adapting  the delay,  contain, shield' policy and the safe exit framework' to ensure thecontinued control and suppression of the virus in a safe andsustainable way that protects Islanders by causing the leastoverall harm;
2. that the Covid-19 strategy' must detail a plan of action that will  seek  to  keep  the  virus  at  very  low  levels  and be implemented  through  well-recognised  measures  used  to control, suppress and ultimately eliminate infectious diseases,based on professional advice including –

• rapid case detection identified by widespread testing, and rapid case isolation and contact tracing;

• continued intensive hygiene promotion;

• border  controls  with  high-quality  quarantine  and/or rigorous testing of those arriving in Jersey;

• intensive  physical  distancing  that  may  include  various severities of lockdown;

• a co-ordinated communication strategy; and

3. to request the Chief Minister to publish this Covid-19 strategy' in  a  report  to  the  States  within  2 weeks  of  the  date  this proposition is adopted, and to publish updated versions of the strategy whenever it is altered, in order to ensure that everyone remains fully informed about the current strategy.

REPORT

Introduction

The Government welcomes the opportunity of this proposition to present and debate the pandemic  public  health  strategy  in  the  States  Assembly.  The  core  intent  of  the proposition is also accepted: to acknowledge that the measures to date have proven effective in supressing Covid-19, and to require the Government to review the strategic options before us at this key moment, with the obligation to publish an updated public health strategy within 2 weeks.

This amendment is lodged because the Government is concerned the term elimination' is potentially misleading, and may be interpreted to require the Government to pursue complete elimination of Covid-19 irrespective of the collateral harm of measures required to do so. The Government instead proposes to continue to pursue a strategy that suppresses the virus to very low levels and causes least harm overall. Further, the version of an elimination strategy posited in the conclusion to the P.61/2020 Report seems to recommend a further period of intense lockdown which the Government, having received medical advice, believes is neither necessary or justifiable at this time.

The current position

The Government of Jersey is pursuing a delay, contain and shield public health strategy to combat the Covid-19 pandemic. It comprises 2 key goals.

The primary goal of the public health strategy, as developed in March, has been to flatten the epidemic curve. This led us into a period of lockdown. The lockdown measures were necessary to avoid a sharp peak of Covid-19 cases and, thanks to the support of Islanders, these measures have been very successful, with daily new cases now in single figures, and similarly low numbers of Islanders requiring Hospital treatment for Covid-19 (as of 18th May).

The lockdown measures were beneficial in halting an aggressive increase in daily Covid-19 cases and the significant damage that widespread illness and an over-run health service could have inflicted. Avoiding the crisis has however come at a high price. The lockdown imposed restrictions which have harmed livelihoods, prevented proper schooling and education, affected Islanders' mental and physical wellbeing, and limited civil liberties.

The Government has been clear these restrictions must not extend any longer than absolutely necessary. The second goal of the public health strategy is therefore to exit the more restrictive pandemic  measures as quickly as we can safely do, and the Framework for a Safe Exit from the Covid-19 Pandemic1 setting out this approach was published on 1st May 2020.

Having successfully protected ourselves from the first potential wave of Covid-19 and reduced the number of new cases of Covid-19 in Jersey to near-zero, this is the right moment to take stock of the public health strategy. The Government welcomes the opportunity of this debate.

1 Government of Jersey (2020). Framework for a Safe Exit from the COVID-19 Pandemic'.

Jersey: Government of Jersey.

In the Government's view, the challenge we now face as an Island community is to continue to navigate through the pandemic in a way that keeps cases at a very low level, causes least harm overall and maximises wellbeing. We must continue to protect the most vulnerable in our community from contracting Covid-19. That is not negotiable. But we also need to acknowledge and address the collateral damage that the pandemic has wrought on Islanders. For example –

• Currently,  2,228 Islanders  are  registered  as  Actively  Seeking  Work –  a comparable increase of over 2½ times on the same period last year; there are 6,500 active Income Support cases – 15% up on this time last year; a new scheme established to support Islanders with fewer than 5 years' residency (CRESS')  has  already  got  over  300 active  cases;  and  to  date  nearly 11,000 workers (employees and business owners) work in businesses that have applied for payroll support and consequently may be uncertain about their futures;

• G.P.s are handling about one-third fewer consultations every day (c.800 vs c.1200), compared to before the pandemic; Hospital waiting lists have been paused, and diagnostic capability has been reduced as resources have had to be diverted;

• States of Jersey Police are recording an increase of 14% in domestic incidents, and a 37% increase in concerns for welfare; psychological wellbeing has also been affected – presenting, for example, in increased demand for counselling and family support.

While there is no vaccine, and no clear prospect of a vaccine for months or possibly years, we need to move forward, safely, towards a way of living and working with the virus that we can sustain – a way that protects those vulnerable to Covid-19, and that enables family life, education, routine healthcare and work to resume within the new normal.

The risks of defining Jersey's pandemic public health strategy as an elimination strategy'

The Government has 2 concerns about defining Jersey's pandemic public health strategy an elimination strategy'.

• First, the term elimination' may be misleading for Islanders. While it can mean a reduction to zero of the incidence of infection in a defined geographical area, it  can  also  mean  a  reduction  of  case  transmission  to  a  (sometimes predetermined) very low level, which is how the WHO used the term with regard to tuberculosis in 1991. It is also important to highlight that elimination is also different to eradication, which is the permanent reduction to zero of worldwide incidences of infection caused.

• Second, defining the strategy as an elimination strategy' risks suggesting that the over-riding goal for Government is the full elimination of Covid-19 in Jersey – no matter how high the personal cost to Islanders, or how extensive the harm that might be inflicted to achieve that goal.

As stated above, the Government believes that we must continue to navigate through the pandemic in a way that causes least harm overall, and in a way that is sustainable over a fairly prolonged period of time. In formal public health terms, the Government's strategy is to control Covid-19 through continued, deliberate measures which will reduce its prevalence, and especially consequent morbidity and mortality, to very low levels in Jersey.

This means keeping Covid-19 cases suppressed at a very low level, but also carefully and slowly easing restrictions that are also causing significant harm now and into the future. At all times, our decisions must be informed by the latest evidence on Covid-19, evidence on the benefits and harm associated with public health measures to control the virus, and by the expert medical advice.

The Government accepts the core intent of the proposition to require the Government to take stock at this key moment, to review the strategic options before us, and to publish an updated public health strategy within 2 weeks that aims to keep cases at a very low level.

Many elements of the approach are the same

While the Government has concerns about defining Jersey's pandemic public health strategy as an elimination strategy', the approach and component elements are welcome and very similar to the current delay, contain, shield strategy. The Government's Safe Exit Framework, for example, has already drawn upon the model of the New Zealand Alert Level System2 alongside WHO guidelines, and insights from Centres for Disease Control, Public Health England and others.

Paragraph (b) of P.61/2020 sets out 5 essential elements of an elimination strategy, sourced from Baker et al (2020). The following table maps these elements against Jersey's current strategy and demonstrates significant commonality3 –

2 New Zealand Government (2020). COVID-19 Alert System'. Wellington: New Zealand

Government.

3 Where differences appear in the table, this is in part because the Jersey strategy also draws on

other important sources such as the World Health Organisation's 6 criteria for countries as they consider lifting restrictions: transmission is controlled; health system capacities are in place to detect, test, isolate and treat every case and trace every contact; outbreak risks are minimized in special settings like health facilities and nursing homes; preventive measures are in place in workplaces, schools and other places where it's essential for people to go; importation risks can be managed; communities are fully educated, engaged and empowered to adjust to the "new norm".

Similarly, the Government agrees that all the measures mentioned in the conclusion to the Report are important to successfully suppressing new Covid-19 cases to a very low rate –

• Strict border controls in the form of 14 days' self-isolation upon arrival are in place, and any future alternative measures will need to minimise the risk of inbound transmission. The Government's diplomatic success in negotiating no quarantine requirement for Islanders when they enter the UK should not be misinterpreted: Jersey will only enter a bubble' arrangement with another jurisdiction if that jurisdiction has both a comparable low level of transmission and robust strategy to strongly suppress Covid-19.

• The measures in levels 3, 2 and 1 of the Safe Exit Framework enable a careful, staged approach to enabling socialising – and work – to begin to resume, alongside the slow, controlled and cautious opening of schools, cafés and restaurants opening, and making our health and care settings as safe as possible – amongst many other measures.

• And in recent weeks the Government has been able to grow our testing and tracing capability into a sustainable large-scale programme that has significantly increased our containment capability, as most recently announced on 15th May.

In summary, while the Government proposes to continue to pursue a strategy that maximises wellbeing and causes least harm overall, and therefore disagrees defining the strategy as an elimination strategy', the measures in place significantly overlap with those in jurisdictions pursuing so-called elimination strategies and share the aim of keeping cases at a very low level.

A further period of intensive lockdown is not appropriate at the current time

The conclusion to the P.61/2020 Report states that: "Islanders would be better served by a short period of intense lockdown whilst we achieve elimination, followed by a longer period of relatively free internal movement".

The Government strongly believes that extending lockdown is neither necessary or justifiable at this moment in time. The epidemiological evidence points to very low numbers of new cases daily, and similarly very low hospitalisations; and the health system is prepared and has an expanded capacity to care for anyone who develops serious complications, should new cases arise in the community.

The health of Jersey's economy is also intimately connected to people's quality of life, livelihoods and wellbeing. Downturns have long-term social and economic effects, and the most profoundly affected are those who lose their jobs, and their families. A further period of lockdown, especially if even more intense that the recent level 4 lockdown, would have significant economic consequences, and we could well see more businesses failing, and more livelihoods lost.

Given this evidence, the harm associated with lockdown, and the curtailment of civil liberties it involves, it is morally right to step down restrictions as quickly as we can safely do.

Monitoring international examples: New Zealand and Australia

The Government's public health team is monitoring public health strategies across a number of key jurisdictions. It is important to highlight that every country's strategy is evolving as they pass through different phases of the epidemic, and as global knowledge of Covid-19 develops.

New Zealand's strategy is evolving. While some  experts and commentators have interpreted elimination as total or near-zero cases at all times, the New Zealand Ministry of Health defines the strategy as –

"... a version of an elimination strategy that seeks to eradicate or minimise cases of Covid-19 from New Zealand to a level that is manageable by the health system, until a vaccine becomes available to achieve population-level immunity"[5].

Moreover, having reached near-zero new cases recently, the New Zealand Government is also now considering future easing of measures, such as a trans-Tasman bubble to allow travel between Australia and New Zealand, and allowing international students to return to New Zealand, if this can be done within safe parameters.

As another jurisdiction with sea boundaries, Australia has the potential to protect its population from inbound infections too. It is progressing what it defines as a "suppression/elimination strategy"[6] as well as a 3-step relaxation plan with the explicit aim of "a sustainable Covid safe Australia in July 2020"[7].

Both the New Zealand and Australian strategies, as well as strategies in other relevant jurisdictions, alongside a review of the balance of harm (both quantitative and qualitative), will inform the strategic stocktake and revised public health strategy to be reported to the Assembly.

Population-level immunity

When most of a population is immune to an infectious disease, this provides indirect protection to those who are not immune to the disease. Indirect protection is also sometimes described as herd immunity'. For any infection, not just Covid-19, indirect protection emerges as a consequence of a large proportion of a population either having been infected and developed some level of immunity, or having received a protective vaccine. When that happens will depend on a number of factors, foremost when and whether an effective vaccine can be developed.

The Government's strategy has never been to introduce lax measures'[8] to try to accelerate progress towards indirect protection. On the contrary, the swift introduction of lockdown measures, and the careful, staged Safe Exit Framework, both evidence that the Government's strategy is to control the epidemic and pro-actively suppress the spread of Covid-19 so that the health service is not overwhelmed – and in so doing, to save lives.

Conclusion

The Government welcomes the opportunity of this proposition to present and debate the pandemic public health strategy in the States Assembly, and is happy to commit to publishing an updated public health strategy within 2 weeks.

The term elimination' is, however, considered to risk misleading Islanders and to misrepresent the careful, balanced wellbeing approach the Government is seeking to take to the Covid-19 pandemic, which aims to keep cases at a very low level whilst causing least harm overall. Further, the Government, having received medical advice on the positive and negative impacts of restrictive measures, strongly believes a further period of intense lockdown is neither necessary nor justifiable at this time.

The Government thanks Members in advance for their support and consideration. Financial and manpower implications

The Government's public health strategy is under regular review, as scientific knowledge of Covid-19 develops rapidly, and circumstances in Jersey evolve. The work to review and publish an updated public health strategy can therefore be achieved within existing resources.

There has not been time since the lodging of this proposition on 14th May for any calculation of wider economic or fiscal costs of a further intensive lockdown. It is, however, likely to have a significant negative effect, with knock-on social and wellbeing impacts.