Stepping up to Protect Public Health /
Dr Cheryl Brunton’s fascinating career in public health
Dr Cheryl Brunton has devoted her career to disease prevention, protecting public health and seeking to promote better health for all. As COVID-19 hit our shores, she was in the frontline of mounting a rapid regional public health response to the threat. In this issue, she reflects on that response and looks back on her life’s work in public health.
On a crisp bright Level 2 morning, I have travelled into central Christchurch to meet with one of Canterbury’s leading public health physicians, Dr Cheryl Brunton. At the time of interview, there is no vaccine for the virus that has caused a deadly global pandemic. New Zealand’s death toll stands at 22, yet we seem to have halted the threat for now. Public health units (PHUs) have had a key role nationally in identifying and managing cases and contacts, but I want to learn how that played out in Canterbury. I’m also curious to ask Cheryl about her role and what drives her passion for public health.
Her credentials are impressive: a senior lecturer in population health at the University of Otago, Christchurch, she is also a Medical Officer of Health at the Canterbury District Health Board’s Community and Public Health (CPH) unit and was named the Public Health Association’s Public Health Champion in 2009. Along with Dr Ramon Pink, they led the public health team tasked with overseeing the job of tracking, tracing and stopping the spread of COVID-19 in Canterbury.
Cheryl tells me she began her career in public health, from a background in general practice and emergency medicine, more than 30 years ago. ‘ Working in emergency medicine draws you to public health because you see so much that can be prevented – like the impacts of drink-driving and workplace injuries.’
Protecting people from harmful viruses has been a particular focus for Cheryl, although the virus she’s most associated with is not coronavirus but hepatitis C. While a registrar in the PHU in 1991, she investigated an outbreak of hepatitis C at a Christchurch prison. She wound up speaking to 273 prisoners and offering them a blood test. The results showed that just under a quarter had been exposed to hep C with the likely source of infection narrowed down to injecting drug use.
As a leading hep C researcher and advocate, Cheryl has worked closely with people who inject drugs, and the needle exchange programme. She helped set up Auckland and Christchurch hep C support groups, and was instrumental in establishing the Christchurch Hepatitis C Resource Centre. ‘Hepatitis C has been a major research interest for me, but it has always felt to me that the reason you do the research is you want to find out stuff so things can change for the better. You can make a difference but you have to be prepared to be persistent and invest your time and energy over a long time. It is hugely satisfying for me that we now have an effective treatment for hepatitis C and there is finally a prospect of eliminating it.’
Just as the long battle with hep C is ending, along comes another challenge: COVID-19.
Before we get into that, though, Cheryl makes the point that communicable disease work is just one part of public health. In Canterbury, CPH employs over 100 staff and in normal times they are involved across many areas of community health and wellbeing, for example, working in drinking water quality, environmental health, alcohol licensing, smoking cessation and promotion of healthy lifestyles. The unit works in teams and with others in and out of the health system, from microbiologists and GPs to border agencies, airlines, government and community agencies.
As Medical Officer of Health for the West Coast, Cheryl has been involved in community development and health promotion work over the Southern Alps for many years. She reiterates the point that the job of public health professionals is much bigger than most people realise. ‘There are always outside factors that influence how people are able to live and whether they can achieve their potential and lead lives that are fulfilling and enjoyable. Trying to influence these determinants of health in a positive way is a big part of what we do. One of the things CPH is known for since the earthquakes, for example, is our work with the Mental Health Foundation and the All Right? campaign to promote mental health wellbeing in our community.’
Yet in a crisis like COVID-19, CPH’s particular expertise with communicable disease outbreaks is what matters most. Like most PHUs, CPH has had a lot of experience with managing large outbreaks, including measles last year and the H1N1 ‘swine flu’ pandemic in 2009.
However, Cheryl says this one stretched their resources to the limit. For one thing there is no vaccine to protect people from COVID-19. Compared to a measles outbreak, the scale and intensity of COVID-19 has been so much bigger. ‘Even before this virus arrived, we had to stand up a response at the border. We had public health teams out meeting flights and making sure anyone who was unwell was appropriately assisted. If we suspected they had the virus they then had to be isolated and cared for. We were trying to keep it out and stamp it out at the same time.’
Fortunately, Cheryl says CPH has a highly adaptable staff, skilled in multiple roles. People who usually worked in health promotion, information and policy stepped up to assist health protection staff in the local pandemic response. ‘Scaling up is something we are used to doing, using a Coordinated
‘It is hugely satisfying for me that we now have an effective treatment for hepatitis C and there is finally a prospect of eliminating it.’
Incident Management System (CIMS) in just the same way that fire or police do in an emergency. It provides us with a way of working when it’s not business as usual so we can plan and manage what we need to do.’
Identifying, isolating and managing cases and contacts quickly grew into an enormous job. There was just one case of COVID-19 in New Zealand at the start of March, but 500 cases by the end of that month as we entered
Level 4 Lockdown. By then there were already 46 cases in Canterbury, generating many more contacts and hundreds of calls having to be made every day. ‘Many people were struggling in isolation and it helped that they had someone to talk to and to assist with any issues, such as how to arrange testing if one of their contacts was unwell. We could link them to support. It was important that people could do what we asked them to do.’
In the early phase of the outbreak here, Cheryl and her colleague Dr Ramon Pink were working 12-plus hours a day but with an expanded Medical Officers of Health team under CIMS, key operational roles were then able to be rostered between them. The combined public health response covered not just Canterbury but also South Canterbury and the West Coast.
The Rosewood Rest Home & Hospital cluster in Linwood turned out to be New Zealand’s most deadly. The first case was confirmed in the home’s specialist dementia wing in early April. Managing the outbreak was handled jointly by CPH and Canterbury DHB’s infectious diseases and infection prevention and control teams. ‘Sadly, we know that outbreaks at dementia and aged care facilities are the most challenging to manage because the people being cared for are already very frail. That was not the first such outbreak in Christchurch either.’
Once that first case arose at Rosewood, the focus for CPH was to track other infected people and their contacts. Cheryl notes that testing through Canterbury Health Laboratories was very quick. ‘As soon as a test was returned positive, we heard about it and were able to alert our team.’
How residents would be cared for quickly became a pressing question, as Rosewood staff who were contacts had to be stood down. It ultimately led to the decision to relocate residents to a ward at Burwood Hospital. ‘That was also to protect the remaining people still at Rosewood in other units.’
It is clear that PHUs could have been better resourced to do their job before this pandemic happened. Dr Ayesha Verrall’s report urged the Ministry of Health to expand the contact tracing capacity of PHUs by three- to four-fold for as long as the virus remained a public health threat.
Nationally, the gold standard is for all contacts to be identified and isolated on the same or following day after notification. The CPH team got pretty close to that, in spite of resources being tight, achieving 87 per cent of all cases and contacts isolated within 48 hours of notification. ‘We improved our timeframes further, particularly in more recent weeks when most people identified were already known to us as contacts of confirmed cases.’
I can’t help but wonder how much worse things could have been in Canterbury without the huge effort of people like Cheryl and the CPH team. This, combined with going early into lockdown, seems to have broken the chain of transmission but Cheryl warns we’re not out of the woods yet. In fact, Dr Verrall’s report recommended developing a preparedness plan for New Zealand to enable rapid scaling up of case identification and contact tracing to potentially deal with up to 1000 cases a day.
‘We have been part of preparing uplift planning and have submitted our plans to the Ministry of Health to show how we could manage our share of a thousand cases a day,’ explains Cheryl.
Just before this edition went to print, COVID-19 cases were again being caught at the border and in quarantine. Sadly, it looks as though we will be living with the consequences of this global pandemic for many months to come.