Notes from a small island a small island
New Zealand’s daily Covid case numbers are now mirroring those of a tiny island on the other side of the world. Keith Lynch reports on how the Isle of Man is trying to keep Delta at bay.
Tens of thousands of years ago, as sea levels rose at the end of the ice age, the island that is now the Isle of Man came to be.
This dramatic (but very slow) separation from what is now the British mainland ultimately allowed the Isle of Man to pretty much forge its own way in the world.
On Thursday, October 21, it counted 106 new cases of Covid19. According to Dr Tim Kerruish, an emergency department consultant who works on the island, the numbers simply don’t make the kind of splash they do here. Kerruish is a New Zealander who has previously lectured at the University of Otago.
The Isle of Man forged its own Covid path – like New Zealand, it sought to eliminate Covid and successfully stamped out three incursions. Then things changed.
What is the Isle of Man?
The island is fairly definitive on what it isn’t: ‘‘The Isle of Man is not, and never has been, part of the United Kingdom, nor is it part of the European Union. It is not represented at Westminster or in Brussels.’’
No, the Isle of Man is what’s called a self-governing British Crown Dependency.
The Queen is the head of state, but it has its own government, its own parliament and its own laws. The parliament is called Tynwald (which, as an aside, was the first legislative body in the world to allow women to vote).
It’s about 52 kilometres long and 22km wide and home to about 90,000 people, according to the CIA factbook. Close to 30,000 of those live in the capital, Douglas. At 572 square kilometres, it’s not very big. Nelson, for instance, is 422km2.
The median age is in the mid40s. New Zealand’s is about 37.
Why are you telling me this?
The Isle of Man experience will look familiar to New Zealanders. It successfully pursued a policy of elimination, beating back multiple waves of Covid-19.
Its pandemic started on March 19, 2020, when the virus arrived via a man who had been in Spain. He flew back to the island from Liverpool. Days later, the Isle of Man shut its borders to non-residents and went into its first lockdown.
During the pandemic the island has restricted access and mandated 14-day self-isolation. Yes, it is an island, but it’s certainly not as remote as New Zealand. In December last year a man made it to the island from Scotland, via jet ski, to visit his girlfriend. The trip took four hours, and he’d never driven such a vehicle before.
By June there were no active cases, and life pretty much went back to normal. Some 336 people had caught the virus and 24 had died, almost all of them in a single rest home.
New Zealand’s deadliest Covid cluster was also in a rest home. Age is by far the most important factor in determining someone’s risk.
So, like Aotearoa, the Isle of Man fought off the first incursion. But Covid seems to find a way. In January 2021, the island once again entered a snap lockdown as a handful of cases popped up. At that time, the BBC’s Sadhbh O’Shea wrote people were shocked but defiant.
‘‘The island had beaten back the virus during the first wave, and there was a sense it could be done again.’’
It was. For the Isle of Man, elimination worked once more.
A third wave was only weeks away, though, and another lockdown was announced on March 3. But again, the island managed to stamp it out and all restrictions were lifted by the end of April.
What happened next?
By that time, the government was already laying out plans to ‘‘live with Covid-19’’. The island’s Covid journey was, of course, intrinsically linked to the UK’s.
Long-term elimination was simply not realistic for a tiny island hemmed in between Ireland and the British mainland. Instead, the island pivoted towards ‘‘mitigation’’, which it notes carries a higher acceptance of risk.
The emergence of the Delta variant in the UK slowed the island’s plans a touch. Instead of fully opening to the British Isles by the end of June, it decided to allow fully vaccinated UK and Irish people to travel without undergoing isolation.
At the time, about 72 per cent of the population had received their first dose. Only about 50 per cent were fully vaccinated.
When the border settings changed, the virus came. On July 1, seven new cases were found. At the time, health minister David Ashford said people ‘‘must now adapt to live with the virus as part of our lives’’.
The BBC reported this meant ‘‘being less concerned with case numbers’’. The only reason this was at all feasible was because of the vaccine rollout, Ashford said.
The vaccination numbers at the time were quite interesting. Initially the island’s health authorities went for a threeweek gap for the Pfizer jab and four weeks for AstraZeneca. That later changed to mirror the UK’s approach, which prioritised giving people the first dose as soon as possible.
If there are a limited number of doses, giving someone two means another person theoretically misses out on their first dose and is entirely unprotected. Therefore, the Isle of Man enacted a longer gap between doses.
This is why it reached 70 per cent first dose coverage early in its rollout, and also explains why it was able to ramp up delivery of the second dose. By early August, 70 per cent of the entire population was fully vaccinated.
Over that time, case numbers soared. The island even needed to drop mandatory isolation and testing for close contacts of Covid cases to keep the place up and running.
By July 21 there were 1100 active cases, and three people in hospital. Each case had some four close contacts, so about 5 per cent of the entire population would have had to isolate if the rules had stayed as they were.
So their plan changed?
No two places are the same, and comparisons can only go so far.
New Zealand and the Isle of Man both successfully eliminated Covid, but their paths diverge.
The current iteration of the Isle of Man’s strategy document is titled Learning to Live with Covid-19. It outlines that modelling suggests more than 90 people’s lives were saved and more than 30,000 infections avoided because of the elimination strategy. Remember, this is an island of 90,000 people.
It adds that the vaccines alone will not be enough to stop Covid. It suggests high vaccination coverage, along with public health measures, will lead to an ‘‘endemic equilibrium’’.
‘‘As we learn to live in a world where the virus becomes endemic, a sustainable level of balance needs to be found between protecting against the virus, and maintaining a new normality as far as possible.’’
It talks of the need for the government to support people in making their own personal choices and says: ‘‘Individuals who may be at a higher level of risk from serious illness may need additional advice and guidance around the risks posed, and may need to consider additional mitigations, such as further shielding from time to time.’’
The plan states very clearly that uncontrolled spread of the virus cannot be allowed to occur. It pretty much rules out future lockdowns, unless the virus threatens to overwhelm the health system (there are six ICU beds on the Isle of Man).
Where is the Isle of Man at now?
According to the Weekly Surveillance Report published on October 21, the island is experiencing widespread community transmission. Another wave is expected over winter. The impact, it says, is being significantly mitigated by the vaccine rollout.
On October 21, this was the situation:
■ There were 106 new cases. The seven-day average was 82 and case numbers were creeping up.
■ There were about 700 active cases.
■ About 8400 people have had the virus in total since February.
■ Younger people were being infected.
■ There were nine people in the hospital. That’s gone up recently, with the local hospital forced to bring back a dedicated Covid ward. None were in ICU.
■ At the time of writing, there were 57 Covid-related deaths. (The Isle of Man defines Covid deaths as those where the virus is mentioned on the death certificate, which is different to how the UK does it.)
■ There are still some border restrictions. Fully vaccinated people can enter, though.
■ Businesses can operate normally.
■ About 75 per cent of the population is fully vaccinated. That’s about 85 per cent of the eligible population.
■ The health service is giving 12 to 15-year-olds one dose of the Pfizer jab and offering the booster jab to the most vulnerable. The push is on to vaccinate younger people.
Interestingly, at the time of writing, the nine people in hospital, out of a total of 718 active cases – equates to a hospitalisation rate of 1.25 per cent.
There were 46 New Zealanders in hospital on Thursday, and 891 active cases (including those at the border) – a rate of about 5 per cent.
Why’s that then?
‘‘It’s the vaccines,’’ says Kerruish. As of Thursday, only three fully vaccinated people had ended up in hospital during the course of New Zealand’s current outbreak.
When that outbreak started, only about 34 per cent of our entire population had received their first jab. The numbers were much higher on the Isle of Man when Delta penetrated.
The really ill people Kerruish sees are unvaccinated, he says. Age is the biggest risk factor, but he also talks of obesity being common in seriously sick Covid patients.
As Covid-19 symptoms are generally very mild in children, Kerruish believes the Isle of Man case numbers are also an underrepresentation of the true spread of disease, which likely translates to a larger pool of collective immunity than we have in New Zealand – something our modellers have noted. He also says a laser focus on case numbers above all else isn’t necessarily always helpful – which Finance Minister Grant Roberston alluded to during Thursday’s press conference.
Once Covid is present, what matter most, Kerruish says, are hospitalisations, ICU occupancy, and death.
Kerruish contacted Stuff to tell the story of the Isle of Man. He says the island is an excellent comparison for rural or smalltown New Zealand.
But the similarities go only so far. The island, for example, doesn’t have a south Auckland, a densely populated and underprivileged urban area, a place where we’ve seen this virus ruthlessly take hold.
‘‘Covid, like most diseases, has largely been a disease of the poor. And I think that’ll be the same in New Zealand,’’ he says.
Yes, the island is pretty much open, and he says he and his family are still cautious when they go out. He’s also worried about a winter wave. ‘‘People get condensed indoors with Christmas coming up. There are lots of parties, lots of rammed pubs.’’
The island’s latest surveillance report warns of major pressure on the health system if a Covid-19 wave hits at the same time as flu or another respiratory virus.
There’s also the issue of waning immunity in the vaccines, as the rollout began in January. The vaccines’ protection against infection appears to diminish over time. That said, they should stop the vast majority of people from getting very sick over a much longer period.
Kerruish’s message is quite simple really: ‘‘If we were unvaccinated it’d be a disaster. We’d have been overwhelmed.’’
That’s where the Isle of Man and New Zealand converge again. It’s all about vaccinations.