COVID-19 media update, 16 November 2022

Speakers:

• Andrew Old
• Dr Ian Town, Chief Science Advisor
• Dr Pete Watson, National Medical Director

>>  Welcome all to this update on COVID-19 in Aotearoa. I am Andrew Old and joined today by the Ministry of Health Chief Science Advisor Doctor Ian Town and the National medical director Doctor Pete Watson. Thank you both for your time today.

 I will start by providing our latest assessment of the COVID outbreak before moving on to what we can do to best protect ourselves and our loved ones over the coming months. I will then hand over to Pete will cover the work underway to address pressures on the health system now and also looking ahead to the summer months. Ian will then provide an update on COVID-19 vaccination including a recent decision in vaccine are.

But first, the numbers. As you will have seen from our weekly updates, COVID-19 cases have been increasing over recent weeks. After four weeks of steady increases, the last two weeks have seen a stabilisation of numbers with the seven-day rolling average sitting just over 3000 cases per day. The latest wastewater results also support the trend of stabilisation. However, as you can see here, the number of patients in hospital with COVID-19 has increased slightly as of midnight, Sunday, 13 November, with 339 people in hospital with COVID-19 from 322, the previous Sunday. But certainly it is too early to say to the current plateau in cases will be sustained and as was reported yesterday, cases in the last two days do show some signs of increasing again. The takeaway is really that the outlook for summer, with more people travelling and with the unpredictable mix of variance circulating, at this point remains uncertain. As always, we will be watching the numbers closely and continue to plan for a continued increase in cases possibly, and increases in hospitalisations through to the end of the. The mix of Omicron some variance now circulating makes it more difficult to predict how things will seek let. At this stage there is no evidence to suggest the new sec letting variance lead to higher hospitalisations, but some lead to  These sub variants are starting to outcompete more established variance internationally and now here at home. Most notably BA5 which as you know was dominant recently and is now losing ground, particularly to BQ1.1, accounting for about 78% of cases. Overseas, the impact of these new variants has varied between countries. With some experiencing relatively small increases in cases. Encouragingly in some parts of Europe, a wave of BQ1.1 cases has not yet lead to the same levels of hospitalisations. This could also be the case in New Zealand particularly given our level of hybrid immunity from vaccination and cases at the moment, and we are watching this relationship closely. As has been the case throughout the pandemic, our response needs to prepare and plan for a range of potential scenarios, including now when the future shape of the outbreak is uncertain such as now. To continue to inform our response, COVID-19 Ling  Aotearoa has provided new data links to new variants as well as accounting for waning immunity and changes in behaviour. It's important to note that modelling is not forecasting and models always have a high level of uncertainty, with now increasing antiviral use and increasing population. The impact of antiviral medicines on the future shape of the brick will be considered by the group with future models. Given the limited real-world information on new variants, many assumptions required for this modelling have been borrowed from those used for the previous wave of BA5, which suggest that the new variants have a great advantage of about 10% which is consistent that has been seen overseas. It is yet to be seen if variance will be behaving this way the New Zealand context but we need to prepare for that possibility. Bearing all those assumptions in mind, the model shows daily cases could rise to a similar level to our peak in July, between 10 and 11,000 cases per day. Daily COVID-19 hospital admissions could under these assumptions peak at just over 100 admissions per day, slightly higher than the midwinter July peak, while COVID-19 deaths could peak at a similar level to July. These are not predictions of what will happen but are plausible models that help us to plan. As you can see on a graph with the grey shading, the confidence intervals around these estimates are very wide. The ministry will continue to closely monitor the circulation of new variants and trends and case counts which all feeds into updated modelling and continue updating advice on public health settings. One respected modeller was commenting this week on the difficulty caused by the many variables, noting that while we can say they will almost certainly be a continued rise in cases, the timing and height vary widely depending on what parameters you plug into the model. Something else I want to note at this point is reinfection rates are now climbing, accounting for about 20% of all new daily infections. Of those, just 1% within the previous 90 days, the rest are beyond 90 days. Those changes are likely related to a combination of waning immunity and the emergence of new variants as noted. It is important to also say that the increase in cases depicted in these models is not unexpected and we have planned for it in the shapes of these waves are very consistent with the patterns we have seen internationally and indeed over the last couple of years. Having said that, neither is it inevitable and there are steps we can all take to minimise the possible disruption of COVID-19 in our lives and the coming weeks. Three factors essentially will dictate where things go next for Aotearoa. Waning population immunity, increase in new variants, and the changes in our collective behaviour. Of the three, the one we can control is our behaviour. As has been consistent since the arrival of vaccines, the single most effective thing New Zealanders can do to protect themselves from severe disease remains being up-to-date with your vaccinations. There are currently about 1 million eligible people over the age of 16 who have not yet had their first booster dose and a further 820,000 people aged over 50 still to get their second booster. If you are due for a booster, my message today is book it in before you go on holiday. Secondly, please continue to get tested if you feel unwell. This is important both for yourself but also to protect those around you, particularly people more vulnerable to severe diseases such as elderly relatives. If you're eligible for antivirals, the earlier you test yourself, get diagnosed and treated, the more effective they are at protecting you. Rapid antigen tests remain free and continue to be effective. In your holiday, take them away with you if you're going away from home. It's especially important to stay at home and test if you are unwell with symptoms that have been exposed to a known COVID-19 case because the chance that your and symptoms are in fact COVID are obviously higher. If that is your setting, please do not travel or take part in events or activities if you're sick or symptomatic, isolating yourself at home is the most effective action you can take if you are infected with COVID-19 to prevent transmission to others. Be posting events, open windows and doors to ensure good ventilation or, where possible and hopefully if the summer is a good one, we will be able to have lots of our events outdoors. Heading into summer and particularly thinking about travelling for holidays, it's important to think about what you would do if you got COVID-19 while away from home. Plan how you might be able to get home safely, talk through the plan with travelling companions, and if you cannot drive home, it's likely you will need to stay where you are for your isolation period or find alternative accommodation. Consider packing that contains RATs, masks, hand sanitiser, and prescription medications if you need them. I will now pass to Doctor Watson for how the broader health system is managing and updates for the summer.

>> Thank you Andrew. Kia ora koutou katoa. Yes, the recent increase in COVID-19 case numbers is a reminder of the need to remain vigilant. As we know, the spread of COVID-19 widely disrupted hospital systems across the world. And more than two years into the pandemic, global health systems are still facing significant challenges in providing essential health services. New Zealanders are not exempt from this trend and COVID-19 continues to stretch the capacity of our own health care. In Aotearoa, our health system continues to experience serious pressure due to ongoing high demand. Nationally, our emergency Department attendances at hospital admissions from emergency departments remains high. Similarly, hospital occupancy is high and the number of patients with a long length of stay are high and remains a real challenge. Here today, there are around 280 patients who have been in hospital for longer than seven days. The causes include patients waiting for community support or transferring to other facilities, such as aged residential care. However, we can assure everyone that work is underway to better streamline patient discharge, once patients are medically fit, to improve the hospital flow and ensure patients are in the best setting to meet their needs. This will directly impact on reducing the demand experienced in our emergency departments. General practices and urgent care clinics are also experiencing demand for acute care. Staff sicknesses and vacancies across our health system are having an impact, echoing a wider trend as COVID-19 cases have slowly begun to rise again. Pressures nation ride are being addressed by focusing on how we manage the movement of patients to hospitals, by prioritising those who need the most urgent care, and increasing regional coordination to deliver health services. This includes working with our urgent care clinics to manage those with less serious patient needs. There is an ongoing response from all parts of the system, from GPs and primary care on the front line, to our partners in aged residential care, ambulance services in our communities, and hospitals all taking actions to ensure that patients get the care that they need in the timely manner. These activities are accompanied by a consistent approach to performance monitoring so that we can evaluate, monitor, improve, and share successes, and ultimately keep delivering quality care to all who need it, when they need it. And so to workforce pressures. COVID-19 has been incredibly testing as we know, particularly when combined with winter illnesses but also staff shortages. The pressures placed on the health workforce have been unprecedented. I will shortly outline some of the workforce initiatives underway but I do want to reiterate that these challenges are not going to be fixed overnight. It will take time to recruit more people into the health sector. And again, I want to acknowledge the incredible work of our health workforce who are implementing on the ground responses. Every day, they have the sole aim of providing the highest level of care to their communities. The work you do is critical and valued. We are actively leaving a range of initiatives that the government has announced that a fixed on bolstering our health workforce. Training more doctors and nurses, and we are supporting people who have stepped up to work in the COVID-19 vaccination program to also enter the workforce. In regards to nursing numbers, we have doubled the number of nurse practitioners training each year from 50 to 100. We are easing the process for overseas nurses, entering New Zealand, and a provision of up to $10,000 per nurse in terms of financial support for international nurses to meet their New Zealand registration costs. We are also providing up to $5000 in support for New Zealand enrolled or registered nurses who want to regain their annual practising certificate to be able to return to work in a nursing role in the New Zealand health system. This year, the return to nursing workforce support fund has helped more than 200 nurses across Aotearoa get back into the health workforce, many of them in aged residential care facilities. We also boosting general practitioner training numbers, after discussion with the Royal College of General practitioners, measures are being put in place to each year increase the number of GPs training in New Zealand from 200 to 300. Weavers are taken steps to address the pay gap to reduce And removing one of the biggest barriers for young doctors going into a career of general practice with hospital registrars. Elsewhere, we are continuing to do all we can to support our hospitals, clinics, and emergency departments and continue to acknowledge the tireless work of pharmacies and other health service providers. This includes making it easy for health workers to move to New Zealand to help address some of the more immediate workforce shortages we have, whether through our international recruitment centre, offering a raft of support to help workers looking to immigrate to New Zealand, all, the international recruitment campaign that we are launching this month, tailored for foreign workers in countries that have equivalency, and we also have a program of separate communication tailored to New Zealand workers who are working abroad to return to New Zealand. We have already seen positive results from this work with more than 1900 health care workers having applied to work in New Zealand under the new immigration settings that came into effect in July. It is certainly catching to see interest in coming here and healthcare professionals arriving but we have a way to go and as I have said, it won't happen overnight and the health system cannot do it alone. Back to easing pressure on the health system, spring and summer here are on its way, and we are asking New Zealanders to choose well there healthcare, so please consider all the options for care. For example you can go and see your local pharmacist for advice on medication and minor ailments including cold and flu symptoms. We also have around 400 community pharmacies who can supply COVID-19 . Post-operative pain is better served at a local primary care practice or urgent care centre. However, if you are unsure of how urgent your condition is, please make sure you call Healthline and obtain free health advice at any time of the day or night by calling 0800 611 116. Its available 24 seven, even on Christmas Day. If it's an emergency, always remember to call 111. And finally, of course summer is a time where we come together socially, more often, there are more large-scale events, and people move across the country in bigger numbers. We need everyone to have a plan to keep well by insuring everyone make sure they make good healthy decisions while having fun wherever and whatever we're doing with friends and whānau. Leisure member that if you are unwell, stay home. If you are travelling, make sure you are aware of the risks that COVID- 19 might affect your holiday plans and think of your own self isolation plans. Make sure you have your red -- regular medications before you go away. For free COVID-19 advice, 24 hours, seven days a week, you can call the number or visit the dedicated COVID-19 health hub. Covid19.help.nz. In coming months, we will likely to see a higher prevalence of COVID-19, but we will get through, just like we have in the past. While testing and self reporting results, these public health measures which have served us well, and will help us to enjoy the summer we'll deserve. (Speaks Te Reo Māori). Thank you, and I will hand over to Ian.

>> Thank you Pete and Andrew. It's good to be back talking with you about some of our work on the COVID-19 vaccines. My name is Ian Town, and the chair of the COVID-19 vaccine technical advisory group. This group is in its third year a fairly steady work, providing advice to the director-general about how vaccine program and as we near the end of this calendar year, I would like to give a big shout out to the members of the group who have worked very hard and we have had over 50 meetings and provided nearly 45 reports to the director-general over this time. I would really like to thank the science and technical advisory team that do all the work behind the scenes to make sure our advice is evidence-based and clearly stated. Today I will be providing an update on some of the advice we have provided to the director-general recently and to Andrew Old's point which is that we have done very well in New Zealand with the vaccination program and the key thing is we get ready for summer is to give that real boost for the boosters, as we think about getting ready for summer and making sure we are well prepared for the few months ahead. As Dr Old has noted, 2.75 million people in New Zealand have had their first dose to the booster, so big shout out to them. And 360,000 people have come forward for that all-important second booster from those who are eligible. As you know, these boosters certainly lift the antibody levels which improves that vital protection against the virus. And with the ongoing number of cases, which as Dr Old has noted, are plateauing, they have been exposure to the BA.2 and BA.45 variance and we call that hybrid immunity. It increases the levels of protection, and if you do develop COVID-19, there are at least two antiviral agents which are available for those at greatest risks. A big shadow to the New Zealanders who are getting their boosters and we have been looking more closely at some of the other risk groups and those who may have serious outcomes with COVID, and one of those is to think about eligibility for the second booster. As you know, everyone over the age of 16 here in New Zealand is eligible for the first booster and currently, it's those aged over 50 years who we have targeted for the second booster program. As well as health workers and disability workers over the age of 30 years. This is in line with international best practice where the second boosters have been reserved for those at greatest risk, usually because of an underlying health condition such as diabetes, heart, or kidney disease. We have been reviewing some of the data here in New Zealand and recently provided some updated advice to the director-general, and this is to lower the eligible age for the second booster for Māori and Pacific people down to the age of 40 years. And from this Friday, 18 November, all Māori and Pacific people here in Aotearoa New Zealand will be eligible to receive the second booster as long as it is three months since any documented infection. This was based on clear evidence from data that we have been able to gather here in New Zealand and this is very pleasing to us because a lot of our early decisions were based on data from overseas, including Australia. So the work that we recently published on the Ministry website looked at all the recent information about deaths in hospital admissions from COVID-19 here in New Zealand. And what we showed in that work is that the risk of death from COVID-19 is around twice for Māori and Pacific people and that risk kicks in earlier around the age of 40, which is why the recommendation has been made as announced. Similarly, they have a two or three fold increase of the risk of being in hospital. In both of these cases, this is often due to the presence of Comorbidity, such as the conditions I have mentioned which tend to occur. I will provide a brief update on our surveillance program, particularly the waste water testing, which Dr Old has mentioned in passing. As you know, the waste water testing has been a game changer and it has led us to understand the progress of the virus around the motu. At the moment we are still detecting COVID-19 in most all of the wastewater measurement sites which total 82 across the country for so our surveillance has shown, as Dr Old displayed on a graph, that we have shifted from the middle of the year from the BA.2 dominance through to that BA.5, which is now being replaced by a number of newer variants again. And we know from the testing that still occurs in a hospital setting that those wastewater trends are also being mirrored in the results that we get from those admitted to hospital. We do expect the numbers of cases of BA.5 two slowly trend downwards as Doctor old has mentioned and there are three or four new variants which may form part of the future in terms of our experience here in New Zealand. So thinking about the next few months and for the approach means for us in Aotearoa New Zealand. Our advice remains the same, get the vaccinations are now with this extended eligibility, encourage our Māori and Pacific families and whānau to come forward for the second booster, those that are now eligible and those that are already eligible and perhaps in coming forward, there is an opportunity for vaccination, remembering that the Pfizer vaccine is is available for those between ages five and 11. Lastly, I want to mention our amazing vaccination teams, around the island, from the far north, where they have been clinics, general practitioners and pharmacies and Māori and Pacific providers. A huge thank you from a sole for the work that you do and were expecting there might be an upsurge in business over the coming weeks as people come forward to get their boosters. Back to you Andrew.

>> Thank you Ian and Pete also. In summary, an expected increase in cases along with an increasingly unpredicted mix of COVID-19 variants circulating in the community means we need to keep our collective eyes on the ball and make sure we all do our part to keep cases and by extension hospitalisations and deaths as low as possible. We remain in a strong position to manage the impact of COVID-19 including emerging variance with a highly vaccinated population and a significant proportion of us also having had an Omicron infection this year. The recent increase in cases reminds us that as much as we wish to be case, we are not out of the COVID woods yet. We need people to do their part to keep their whānau and communities safe particularly over the summer period. As Ian said, get vaccinated when your dose is due, to isolate if you test positive, test when you have symptoms, and be prepared for COVID when planning your holidays. Now is also a good time to reconsider mask used in certain settings beyond the mandated environments and healthcare. The 3Cs' arrowhead backpack at guide to places where the risks of COVID-19 is high. Those are settings that are closed, crowded, or have close contact with others such as public transport. We are now happy to take questions and I invite my colleagues to join me.

>> Did you consider a booster just for everybody?

>> Thank you. Our focus, as I mentioned, has really been on those at greatest risk of severe disease and when we looked at the hospitalisation data, the risk of ending up in hospital for those under 40 is quite low and so this combination of our first booster, and remember that quite a large number of people have had that hybrid immunity boost through exposure to BA.5, we feel that's sufficient for the. Of the around the world there is a lot of interest in what happens after six months, so we know that antibody levels tend to trend downwards. What we don't know is does the protection against severe disease and start to reduce as well? Once we get more data on it, we may review our booster recommendations. That will occur in the New Year particularly as we get ready for winter next year.

>> Can we hear more about how to get more people taking up that booster, the one that's already available to them?

>> Well, we talk about it a lot, don't we? And as I said, a big shout-out to those community-based vaccinators as particularly Māori and Pacific was to there is a bit of fatigue about some of the messaging and that occurs in a mass health campaign. The reason for today's push on that is really just to remind people that there are boosters are available, we know they work, they definitely protect against the requirement to go to hospital, so that's a really powerful message for everyone out there, and the whole point of this presentation today is to say before you go on holiday, let's get some of these things tidied up.

>> What's your recommendation for people that were going to have Christmas parties. Are you saying RAT test and things like that first?

>> One of the things we are working with our colleagues in the national public service on is a summer checklist. The exact detail of that and the specific recommendations are still being worked through but we will expect to publish that in the next few weeks and that will have a range of things that we recommend people do, considering things like actions you might like to take for visiting elderly relatives. Suggestions around Christmas parties and those sorts of things.

>> Definitely one of the things being considered.

>> You mentioned mask wearing before, which is to say you would maybe encourage people to start wearing them again on things like public transport?

>> Our advice has been consistent on that and we still believe that there is good evidence that masks reduce transmission, they protect you from catching COVID-19 but also they protect those around you if you might have COVID-19 and not know it. One of the advantage of causes now with the weather, there is lots more doors and windows open and people outside, but if you are in settings where you are in close contact with other people, if it's crowded and poor ventilation, public transport, buses, particularly these are a good example of that. We think masks are a good idea. She was like there was a story this morning about the new varied overseas, do you know anything about that or whether it's in New Zealand.

>>

>> I'm not familiar with BN.1, I'm familiar with BR.2 which is a new variant in Australia. One of the things we are starting to see commentators around the world talking about is this idea of a varied soup or swarm, which is previously when we have dealt with outbreaks, they have tended to be driven by a single dominant variant and we certainly saw that here in New Zealand with a BA.2 and then a BA.5 driven wave. What seems to be the case around the world is rather than a single parent becoming dominant, a number of variants often closely related, are starting to compete for dominance and that is reflected in that evolution of the virus, and as I mentioned, it does make it harder to predict exactly what the future shape will look like.

>> How close are we to getting an Omicron ready vaccine?

>> Yes, so you've probably read reports from overseas that both Pfizer and Moderna, those are the two RNA companies, have both developed both BA.1 and BA.45 varied vaccines. Our regulator has received an application from Pfizer from Pfizer to consider the bivalent vaccine, BA.45 vaccine. Does not a lot of data about whether that is more effective, although the theory is very sad. Once Medsafe have concluded their review, we will have a look at if that is a option for New Zealand full survey not able supply and in New Zealand the civil subjects make children under 16, but they are eligible for a booster Kyeemagh parents are quite understand -- concern. Conversations were had around expanding to children under 16?

>> When we talked about risk of severe disease and hospitalisation and we looked right down to six and seven- month-old children and their experience over the last year, the risk of severe disease and requiring hospital treatment in anyone under 16 is very very low and that's where the risks and the benefits have to be thought through more carefully and we didn't feel there was a strong argument for extending boosters to that age group at this stage.

>> Question about planned care. Emergency doctors have asked for more planned care to be scaled.

>> Every hospital, in every place were planned care has been undertaken, there is always a balance between acute demand and hospital on that day, so the theatres, the staff, and what planned care is being scheduled for that day. Also including things like ICU capacity depending on the capacity. Those decisions are made every day on a day by day basis. When we have escalating acute demand, and decisions are made about what needs to be deferred and clearly the most acute time sensitive and important work will be done. So we know that across the country, the number of COVID-19 admissions decrease, Planking was ramping up and we have been seeing that and supporting that in a range of initiatives. That will be impacted if we start to see a surge of COVID-19 acute admissions again but at this point, it will be happening in some places but not a spread.

>> So it's not happening enough in the conversation you are having with your colleagues around the country about whether more needs to be done to ease the pressure on the ED cubic

>> One of the things now about the national system as we have some greater national visibility about the pressures across the system. That something that we're doing on eight daily basis and sometimes more regularly about having a view of what's happening in the different spaces. To support is being provided, both in terms of what needs to happen locally or regionally. Which is in a number of the hospitals now that also work in the district. Those conversations that we are supporting. (inaudible) super urgent. Anything you are doing on the human

>> Not that I'm aware of, however I can say, for instance, here at Middlemore, this week we had the most acute number of minutes in our theatres ever. We had over 8000 acute minutes earlier in the week. That's a really huge amount of work of acute work coming in the door and there needs to be prioritised so we are doing that. But it still means that the planned care work, today it has dropped back down to we're flexing out on a day by day double. Even if it's for a short period of time, it's not continuing.

>> 8000, did you give any plans?

>> There was still some done but it's just a balance. Is the time sensitive work. The most time sensitive. Usually that includes cancer but other times sensitive procedures, we will be prioritising those over the lower prioritised work that needs to be done.

>> When you are trying to clear the backlog, with COVID cases rising, there has been very little respite between the two waves. Are you going to make any inroads, have you made any meaningful inroads into the backlog?

>> We are collecting all the data on the progress on planned care. As you may be aware we have a whole lot of planned activity happening. Next week we will be releasing a monthly update on the progress we are making on that and we're looking forward to that, but I would suggest that yes we are facing huge pressure in terms of acute pressure, but also workforce pressure, which means again, this is not something is going to be solved this month before Christmas but it's going to take some time as we work towards that.

>> (inaudible) woman with a broken kneecap, waited for seven days for surgery. She is barely eaten in that time to stop surely that's not acceptable?

>> That's a really disturbing story to hear. I don't know about the details of the clinical case so I can't comment on the but clearly that's not what we would expect and we certainly need to be supporting every patient to ensure that they get timely treatment. So I'm sure we will be reaching out to those people in that patient to not only understand where they are at but also ensure that they get treatment on a timely basis. If you've got hundreds of people with acute risk on the private lists.

>> We are doing that. This is in the context of us doing a whole lot of work where we outsourced from the public hospitals. Public hospitals can't do all of the elective work so we are now working with those in the private system to do that work and that tends to be the lower priority, the less urgent work, so that the hospitals can focus on the acute demand and the high complexity. That's part of what we do but we are also looking to do more for such as Maggie talked about pressures on the system and pressures on staffing. Have you got an idea of the numbers of doctors and nurses that you are down?

>> Again, workforce pressures, as I described, are significant, in terms of we came into the pandemic, now over two years ago, with workforce shortages, and that has been something that has been really exacerbated by the pandemic. We do know that we not only have those shortages that continue, so maybe five or 6% in terms of the entire workforce, but compounded by winter illness, COVID, and other stress and pressure of the workforce. In total, shortages exist currently, but we are working both to recruit internationally but also to increase our pipeline, but as we have talked about, these are things that are going to take some time, so what we need to do in the short term is to support our workforce, so we do that by working from team to team, healthcare provider to healthcare provider, to ensure that we are supporting them, but we are also looking at the tasks that are being done. Were looking to share some of the tasks. Here at Middlemore, we have our task Steve every morning that healthcare professionals, regulated and unregulated, who come together to see if they can pick up some additional tasks, for instance on a ward that has a nursing shortage, for instance to pick up and work together under supervision. We are looking at these initiatives to ensure that we can actually manage the essential work that we need to as we recruit additional workforce.

>> So what is that in terms of numbers, doctors and nurses? What are we talking about here?

>> I don't have the hard numbers on me but I'm happy to get back to you on that.

>> Tens of thousands or thousands?

>> Depending on where you are at, there will be hundreds, for instance in the hospital at the size of Middlemore, there will be a couple of hundred, but in terms of nurses, in terms of doctors, it will completely depend on the specialty and the area, for instance we might be short in some areas on radiologists or psychiatrists, but we might have our full quota of respiratory And infectious as physicians. We go specialty by specialty and it's important to understand where the shortages are. The other thing I would say is that now is a national system we are starting to plan this regionally and nationally. We can work much more collectively, and we're looking at how staff in one area can support patient demands from other areas. For instance, South Canterbury are picking up some of the planned care work because they've got capacity from their neighbouring areas such as Dunedin or Christchurch. So where we have got some workforce and capacity, we are looking to support those other areas. This is the joined up system that we are going to focus on ensuring that we can actually deliver services more equitably across all of our regions.

>> On public transport, from the newsroom, would you be looking to call on public transport leaders to enforce mask wearing on trains and buses?

>> It's not for us to make calls about enforcement. We encourage transport users to mask up on public transit, Anything if you call even when masks were mandated, we still didn't ask bus drivers to actually enforce that, that was very much a message to the community that this is something that we need to do collectively. But I think the message for today is that we do think that with cases increasing and projected to continue to increase, that now is a good time, if you are a public transport user, to reconsider your own mask use in those settings.

>> With 8000 acute cases, was that over a week, was it?

>> Minutes. Not cases.

>> What would it normally be?

>> Today when I was up in the operations centre here, there were 3 1/2 thousand acute minutes. 3 1/2 to 4000 minutes on an acute day, on a normal work day would be about normal. And it fluctuates selfishly, but I think it just goes to show that acute demand is significant and in a public hospital, we need to balance up what clinical acuity.

>> If there's any other questions, just send us an email. Thanks.