COVID-19 update, 10 March 2022 1pm

News article

10 March 2022

The Director-General of Health Dr Ashley Bloomfield leads a briefing for media organisations to provide updates on the response to the Omicron outbreak at 1pm today.

Dr Bloomfield will be joined by the president of the Royal New Zealand College of General Practitioners, Dr Samantha Murton.  

>> Kia ora koutou katoa (SPEAKS TE REO MAORI).

Nice to see you again up the road. I know that some of your colleagues are unwell at home. Wishing them all the best. It is going around, so I hear.

 I am joined today by Dr Samantha Murton, who is the chair, actually the president of the Royal New Zealand College of Gen practitioners. She is going to give you an update on what she and her colleagues are seeing in general practice primary care at the moment and we will be available to take questions. Welcome, Sam, thank you for making yourself available.

Firstly an update. Today we are reporting 21,015 new community cases of COVID-19. Of those, 845, sorry, not of those, at the moment we have 845 people in hospital, and of those 16 are in intensive care or high dependency units.

Our total number of active cases is 208,625 across the motu.

Since 23 February, roughly the last couple of weeks, about 87% of our reported cases have been diagnosed through the use of rapid antigen tests. 4% are rapid antigen tests with a confirmatory PCR test and the remaining 9% have been diagnosed with PCR tests. The vast majority of results in recent days are rapid antigen tests.

So of today's cases, 97% have been diagnosed with a rapid antigen test.

Today in the northern region, we are seeing a similar number of hospitalisations as we have seen in the last couple of days. 587. Suggesting perhaps numbers are levelling off, but my colleague Dr Andrew Old, Chief clinical Officer for the Northern Region health coordination centre will provide an update in Auckland tomorrow and will go into that in more detail.

 updating the whole genome sequencing, 21% of people hospitalised who had their genome sequenced had Delta variant. 79% were Omicron variant. Reflecting the fact that most of our cases in hospital through January were delta.

By comparison, of hospitalised patients who had samples received at ESR and whole genome sequencing in the last four weeks, none had the Delta variant.

The Delta variant in fact was last detected in any community sample that was sequenced in mid February, 15 February. ESR's latest report from this morning shows of the most recent 47 hospitalised cases where sequencing was done, they were all Omicron. And of those, 25 were the BA one sub variant and 22 where the BA to some variant. -- BA@ subvariant. If you look at all the sequencing, we have seen a growth in proportion of the BA2 variant.

 In saying that, although we don't have recent hospital admissions with Delta, we know that Delta is still in the community. At least 38 cases in the week ending 5 March were epidemiologically linked to the Delta outbreak but none of them were sequenced.

One of the challenges I know that parents have been having is reporting rapid antigen test results for their children or other dependents online. I want to acknowledge those who have been trying hard, perhaps ringing the 0800 number and experiencing delays.

There was a temporary issue on Tuesday this week where some callers felt they had a problem with registering their cell phone for a callback and were not receiving a call back. We increase capacity in that system, so that is 0800 222 478 from tomorrow parents and caregivers can report test results for children and other family members through the My COVID Record.

Once again, reflecting back on the fact that 97% of our cases today are from people having logged their positive rapid antigen test, I want to thank everyone who is doing so. It really helps us understand the extent of the outbreak and the pattern across the country.

At this point I want to hand over to Dr Murton to give us an update on primary care.

>> Kia ora, thank you.

 In general practice and across New Zealand primary care you can imagine there has been a massive change in the volume of work. It has been quite substantial.

The College put out a survey to all practices and we had 478 responses from the 1000 practices across the country. 30% were looking after more than 20 patients a week ago. 80% of them are looking after more than 20 patients now.

In my practice, in the last two weeks, I have gone from one patient to 57 patients the following week to 127 in the week following that. It has put a huge amount of work on general practice.

When you think about the fact that there are 20,000 people who have got COVID every day, and across the country 50,000 consultations normally happen every day, that is a 50% increase in workload if we had to deal with every one of those 20,000 that came through.

We recognise that the people who are physically generally well have been fully vaccinated and boosted, they will have a mild illness, they can manage that at home and it will be like a mild flu. If you have to get in touch with your GP, it is usually if other things are going on for you or if you do need some care. Just make sure you have got what you need at home. 208,625 cases in the community means there is a lot of work for us if everyone is calling their GP. Healthline is also available.

My colleagues want me to remind everyone we are working really hard, doing our best for our patients. Although we are prepared and we have done the best we could do when the outbreak occurred, it is still going to be a little bit messy for the next couple of weeks.

That is just because people want care, but there are other people who really need care and are quite vulnerable.

GPs across the motu will be concentrating on those people who are vulnerable and need the most care, and will be contacting them if they need to.

 There is also issues around isolation and needing manaaki support. Sometimes people seek that out through the GP and that's OK but it's still more work we end up doing.

The other thing we found is across the country people are stressed, stressed about having COVID, about being isolated, about not being able to go out, about having family members who might be sick, and the practices are also under pressure to deliver as much care as they can.

And so that stress can often end up with a lot of anxiety and therefore people's emotions might flare - to put it politely - so my colleagues suggested that people be kind to their practices, especially the Administration and reception staff who bear the brunt of the calls that come through. And maybe saying that your doctor will ring you back in a few hours or having to delay the care you might expect.

So please just have a bit of patience, as a patient, and be kind to the staff.

 The other thing we want to remind everyone of is, being boosted, fully vaccinated and boosted, is the best thing you can do.

Also as general practice, we are as open as we can be for providing service and don't delay or defer your care.

Because we have found previously when there was the lockdown two years ago, after a couple of weeks we start seeing people come back in who let things ride for a while. Please don't let things ride. Please be in touch with your general practice if you need to because that is what we are therefore even if we are under pressure.

Thank you.

>> Thanks, Sam.

Just a couple more things I would like to cover.

 First, and bear with me on this, I would like to explain some changes to our reporting of COVID -related deaths. From today we will be moving to a new reporting approach, a sort of dual reporting approach.

First we will automatically report all deaths of people who die within 28 days of testing positive for COVID-19. This is the approach that is used to the UK, and many other countries, and is the one we will use for our official reporting and we have used for our official reporting to the World Health Organization.

Within that total number of deaths, we will also move to report those deaths within three categories.

First, people for whom it is clear that COVID-19 is the cause of their death. As of today, that number is 34.

The second group is people who had or were subsequently found to have COVID-19 when they died, but there cause of death was clearly not COVID-19 so they died of another cause. And as of today, the confirmed number in that group is two.

Then there is another group which is the largest, which is those whose cause of death is still under investigation. Many of those will be with the coroner to determine cause of death. But we know for sure they had COVID-19 when they died. It is just not clear whether that was the cause of their death or they happened to have COVID-19. As of today, that number is 48.

If you are quick with maths, you will have noted the total is 83 which is larger than the total 81 that is the number of all people who have died within the last 28 days of having had a COVID diagnosis. So over the course of the pandemic, to date we have publicly announced those 83 deaths. In the past, our approach to announcing the deaths has not always matched up with that new definition which is everyone who has died within 28 days of a COVID diagnosis.

But from now, we will be reporting both numbers. We have also done some reconciliation of our numbers.

And over the last two weeks there has been an additional nine deaths recorded in our deaths database of people who died within 28 days of a COVID diagnosis but they haven't to date been publicly announced.

The main reason is because these people may have died in an aged care facility, a GP may have certified the cause of death but it wasn't notified through the public health unit and through our old system.

So I just want to confirm our total number of COVID-related deaths to date now sits at 91. This is when we add in these additional deaths that have occurred in the last fortnight, including one yesterday at North Shore Hospital that we are capturing from our deaths database.

Each one of these deaths represents a person and whanau and community that is grieving, so I want to acknowledge that and pass on my condolences to those who lost loved ones.

 In particular, in this last period of weeks. So our total deaths announced now that we believe our COVID- related is 91.

We will provide an update on that number as new deaths are recorded on our website. And we will also break that down into those three categories - those we know died with COVID, those who died of another cause but had COVID, and those whose deaths remain under investigation.

 I want to emphasise New Zealand's total number of deaths remains very low by international comparison. Furthermore, and this is important, New Zealand has a very low case fatality rate internationally. That means that people who get COVID here are getting the right care that they need and they are being well looked after. Whether it is care in the community, in general practice or through other community providers, or whether they require hospital level care including intensive care.

Finally I want to finish with an acknowledgement and acknowledge our health workforce across the motu who are responding extremely well to this rapid increase in workload that Sam outlined. Especially I would like to shout out today to the extra effort that our home carers are putting in for the disabled whanau, those who require home and community support services, and for those who receive those services who often because at the moment their usual carer may be unwell they are being cared for by someone different. I want to thank and acknowledge that. 

Continue to play out part by using a must protect yourself and others, physically distance and please if you are unwell or few are meant to be isolating as a contact of a case, do stay-at-home.

Thank you very much again and were now open to questions. ?

>> How many of those hospitalisations today are actually there because of COVID rather than illnesses?

>> The vast majority and it is hard for us to put it on that because the diagnosis, the final diagnosis for a person when the going to hospital is coded after they leave. We are trying to get a weekly estimate of what this might be and it will depend, so in Auckland where they have over 500 admissions, it is very hard for them to know in real time, exactly which ones are there because of COVID or those that have COVID. I should say there is quite a high turnover, many of these people admitted to hospital are only there for one or two nights. There are a lot of people coming and going so they get the care they need and then their off home again. Overseas studies suggest that it is about three quarters of people who are in hospital because of COVID but in Auckland, with high levels of circulating COVID, we would expect probably an even higher proportion of people who are there for other reasons, just happen to have COVID.

>> Outcome two years into a pandemic we cannot have two separate groups knowing the people have tested at the door and convert something else or are actually there because of COVID symptoms?

>> This is to reiterate and this is where every country does it, the diagnosis and the reason someone is admitted to hospital is coded when they are discharged from hospital and it is a specialised process. But we do have a picture and that is what we will try and create is a picture of what the proportions are likely to be but as I say, the Moe COVID there is out in the community, the more likely it is people are turning up the hospital, whether it is an injury or other illness will have COVID and by way of example, at the moment, around 40% of people turning up at Middle Moors emergency department where everyone is tested, 40% of those people are testing positive for COVID. Some, in fact many of them because they're seeking care for their symptoms but others will be found incidentally. $$TRANSMIT

>> Do hospitals have more COVID cases in them than was ever modelled or predicted?

>> We are having a look at that and Doctor Gary Jackson at Auckland has just provided an update on the modelling here and the number of cases in hospital is higher than the earlier modelling and projections had suggested at this point in time. Just to go back and reiterate that many of these people are just in overnight or perhaps for two nights, receiving the care they need and again, an important figure he is those number of people in ICU or high dependency units and in Auckland at the moment, of those, over 580 admissions, only 10 are in ICU. Most people are requiring just water level care for an initial period full stop

>> Why settlement higher than what was modelled? Has it taken by surprise?

>> Not by surprise, modelling is was a good way to inform planning, is not a prediction of the future in one of the good things about Doctor Jackson's modelling is that they update it with the real figures on a daily basis so are able to project out and see what is the likely demand for both hospital services and indeed, for primary care services.

>> The number of children getting vaccinated has not increased very much in the last few weeks, how concerned is the ministry that first those vaccinations of five to 11- year-olds have stalled at just over 50%?

>> I think were up to around 53% now overall and we are still seeing steady progress. We saw an initial surge and large numbers vaccinated in those first couple of weeks and the numbers are certainly lower on a daily basis but what is encouraging is it is still going up and we have got a range of initiatives in place just to make sure all those parents who do want to have their children vaccinated are able to access it readily.

>> Just given on mandates, vaccine mandates, do you think that there are still a justified for certain workforces given overgrown is so rampant and still infecting people who are vaccinated?

>> The mandates are in place and of course, like all those broader public health measures, some of which are quite intrusive on people's lives, a requirement to wear masks in certain settings, the use of vaccination certificates, COVID vaccination certificates for entering some places under the red settings, mandates are something that are there at the moment and are required to be regularly reviewed and are in the process of being looked at as part of the overall package of things but what I would say is that one of the reasons New Zealand is in a good position now, even though we have a very large Omicron outbreak is because we have high vaccination rates across our population and including relatively high booster rates. There is no doubt that the mandate and the use of COVID vaccination certificates have played a role in helping us get that high vaccination rate. The questions, of course it is right to be asking now is how much longer are those minutes appropriate for and if so, for which groups of people and that is the work we are involved in supporting at the moment.

>> Given the critical worker shortage we have been talking about right now, would you consider allowing unvaccinated people to jump in and help is that pressure?

>> There are a measure number of measures in place to help ease the pressure on critical workforces, both in health settings and in nonhealth sittings and those have been in place since the start of the outbreak so the critical worker exemption scheme, using rapid antigen tests. The number of people who are unvaccinated who are not able to work at the moment in those critical roles is relatively small and it is much more important that we enable those who are vaccinated to be able to return to work as soon as possible. For example, through the use of rapid antigen tests to support that.

>> Are you were people selling red -- rapid antigen tests online to stop can you (inaudible)?

>> Clearly it should not be happening and anyone who is on selling or attempting to on sell rapid antigen tests is abusing the system, to put not too fine a point on it and they should not be doing it and I would ask them to not do it. Those rapid antigen tests are there for a purpose and they are there for people to use to help keep themselves and others in the community say.

>> Also you talked about issues, people walking up to my COVID record and recording their rapid test. Are you confident the people logging on and recording their right test are providing an accurate representation of the amount of cases at the community at the moment?

>> This is a good question because we don't know how many people are testing each day and not necessarily recording. We have got a bit of an indication here, we know that at the moment, we have got a 40% positivity rate of rapid antigen tests being recorded and the Auckland region for example. It is fairly consistent around the country so the good thing here is there are a lot of people who are testing and recording their negative result. It is not really possible to know exactly how many people are testing and not recording their result but what we are intending to do here is if we assume about the same proportion of people will over time, will record their results, we look at what the trend in the positivity rate is and that will give us an indication of whether the number of cases is going up or going down.

>> So in more regions essentially where this is easier to do what you are seeing more of this happen and as in more of reasons around the country where this is an area of concern?

>> I do not have any information original variation but we are going to supplement with the positivity rate for rapid antigen tests reporting is by district health court region and we will be able to report that.

>> Just on boosters four and 18, you have some advice from the advisory group yesterday on vaccine boosters four and 18?

>> Yes, the advice has come through in the asked week or two I got a formal memo about that yesterday.

>> Can you tell us about what the decision for boosters for under 18 is was?

>> The decision will be up to ministers and they're going to have a discussion about it in the next few days. Broadly, the advice was saying that, and this is similar to the number of other jurisdictions, the evidence from studies about the balance of benefits and risks of boosters in people aged 12 to 17, it is only a limited amount of evidence so it is very much looking at what the risks and benefits might be. Overall, more countries are making it available for 16 and 17-year-olds, so routinely available if they want to get it but not for the younger 12 to 15 group. And so that is just the advice we have from our team of technical experts. The question then is the decision for ministers about making it available for that group if they want to do that. One thing I would say is that Pfizer has also applied to have the vaccine approved as a booster for 16 and 17-year-olds and that is going through the Medsafe process at the moment and will likely be decision in the next few weeks on that.

>> Talk about the huge workload primary-care is under, increasing cases, you confident about everything working at they moment (inaudible) are available to get the help they need or the care they need.

>> I will make a comment and then Sam will be really well- placed to perhaps back me up on this. We have set up the system to try and avoid the situation where people will fall through the cracks so it has a number of players on it to help ensure that people do not fall through the cracks, particularly those people who maybe vulnerable or have pre-existing conditions. As we get into the outbreak, I am increasingly confident that the systems are working and that the various layers, the safety nets to come into play as they should. Sam, I wonder if you might want to comment on that?

>> I think the work force point of view, we're getting notifications from patients with the rapid antigen chests and making sure peoples and that through so we have a notification. Then, we will filter those and make sure we are getting to the right people, which gives our workload a little bit of stability but most of our practices are looking for staff that may not be available and so it is quite tricky to make sure we are keeping up, I think as far as the safety nets and people falling through the cracks, with the systems we have and the fact that they are now reporting all the test, we know everyone who might be positive and can make sure that we are feeding into making sure they are OK.

>> Have you had any incidents of people being angry with GPs or staff and if so, what (inaudible)?

>> We have had situations and many practices were people have been abused, yelled at, things thrown at them. We have had, in my practice we have a sign on the wall which I put up a long time ago which says we value and respect our reception staff, we hope you do too. Fact we had to put a sign up like that shows the way some people respond to the services. The other thing is we are trying to protect our staff and the other patients in the building and so having to corral people at the door and ask them questions, people will infrequently but sometimes tell us lies about what is going on in their health and will turn up and be in a room and then turn out to be COVID positive and they will not have told us they had any symptoms. It is actually quite a struggle and we have to put up more barriers which makes it hard for patients.

>> On that, our places essentially needing more security in place? Is there security?

>> I think there are practices that have taken the step of putting up security guards, practices have also had locks on their doors so that you cannot just walk in. I know in my practice, we have signs everywhere that say no entry, no mask in the entry and we have worked really hard with our patients to make sure that we are doing the best that we can to serve them. We do have the option of having a lot of very good car parks and Wellington weather has been amazing for the last few weeks, so it is not too bad that is the problem we have is where we provide the care if they cannot come into the building.

>> Perhaps is still correct to refer to the subtype as an Omicron subtype or at what point do we actually likely be compelled to recognise it as a different strain entirely?

>> I'm not an expert in these matters so if people who are experts are clear that it is a sub strain of Omicron then I think it is reasonable to go without. I think what is clear we are seeing in New Zealand is that the BA2 sub variant has a slight transmission at Benton's over be a one as we have seen in other countries, our whole genome sequencing has shown that it has taken over as the dominant sub variant.

>> An American epidemiologist told a TV show this morning that people with boosters have 70 to 80% chance of protection against infection. How does that compare to the How does that compare here in New Zealand?

>> I will make two comments. First of all, there is no doubt boosters protect against getting infected in the first place from Omicron. That was unclear early on. But that is definitely the case. There is increasing evidence of that. It's also clear that like the two-dose Merhi course, the effectiveness of the boosters - - primary course, the effectiveness wanes in terms of protecting people from getting infected or getting infected with symptomatically illness. Protection stays high. Months against hospitalisation and death. What does that imply for our vaccinations? There are questions being raised, and our scientific group is looking at it, about whether there may be a need for further booster doses especially in the elderly or those who are vulnerable. That work is in progress at the moment.

>> Just on assessing COVID- related deaths, does this mean we have been incorrectly reporting deaths to the WHO up until now?

>> I would say our approach has been more inclusive than the official approach that is taken, which is anyone who has died within 28 days of a COVID-19 diagnosis. The reason for that as we have some deaths we report that might not fit that definition. For example, someone who has been in hospital for an extended period of time but the primary diagnosis and perhaps the cause of the decline and death was COVID-19. That's why you see the official number we report to the WHO with that standard definition will be lower. It is 81 at the moment, which is lower than our overall total but we report both publicly.

>> Do you retroactively assess the figures reported and review them?

>> The figure we reported to the WHO is correct. The additional deaths that we have found is by looking back over the last couple of weeks that have been captured by that 28 day rule rather than having come through our other reporting Avenue through the public health units that we have relied on previously. In

>> Can you explain why hospitalisation and case numbers in Auckland are not plateauing... (INAUDIBLE)?

>> I reading of the number today, I am not sure if I got it right but my understanding is the number was about the same as yesterday and the number in the ICU had dropped from yesterday but I am happy to come back to you on that. Certainly case numbers in Auckland appear to have plateaued over the last few days. We will know in two or three days whether that represents that case numbers have peaked in Auckland. We would expect them to peak in Auckland earlier than the rest of the country because that is where the outbreak really took off first.

>> Can you tell us, of today's numbers, how many of the hospitalisations and people in the ICU are a Maori?

>> Not off the top of my head. Stand-by, I may have the information here. I will just have a quick look in my report. Yes, just a breakdown. This is only for the Northern Region we get an automatic data feed. In the Northern Region, of the people hospitalised today, 125 are Maori, 224 Art non-Maori, and 199 are Pacific. We have that date and we can report that on our website.

>> What information are we getting overseas regarding swabbing the mouth and throat with these rapid antigen tests along with the nose?

>> I have been watching with interest the experience of people here in New Zealand, and you will have seen or heard directly from friends and colleagues who maybe had one or two negative tests before they get a positive test. It's not uncommon, especially if people test early in an illness. And some people are swabbing both the throat and the nose and finding they are returning a positive test. I have not seen anything specific internationally. The main thing is that people follow the instructions of the manufacturer for that specific test. But if people are swabbing both throat and nose, there is nothing necessarily wrong or bad about doing that. So I encourage people to follow the instructions. But certainly swabbing the nose is most important.

>> In terms of long-COVID, how much of a problem do you envisage it to be and what percentage of people who get COVID are likely to suffer long-COVID?

>> There have been a number of studies on long-COVID. Of those published, the estimates were around 30-40% of people having some sort of ongoing symptoms, and they were from people that had COVID in the first part of the pandemic. So the earlier variants. What will be interesting to see and most pertinent to New Zealand is what the rate of long-COVID symptoms are for those affected with Omicron. We will give a fuller update next week and one of the sessions including the follow- up study we are doing people with long-COVID symptoms and also an update on the work we're doing around clinical guidance and service provision for people with long-COVID symptoms. That will be next week.

>> The discount on the Ministry of Health website still says 65, -- death count, lagging behind?

>> It is still to be updated with the additional deaths we found through the reconciliation process. After this stand up, that will be updated to 81 as the official deaths within 28 days, and then 91 with the more inclusive definition. Again, divided into those three categories.

>> (INAUDIBLE) even if they were symptomatic, should New Zealand be switching to saliva tests?

>> We have those but they are PCR tests so they require lab processing. We simply wouldn't be able to do the number of tests we are doing with rapid antigen tests. One of the ways to get around the lower sensitivity of rapid antigen tests, especially early on in your symptoms, is to do them repeatedly and that is why we are providing people with more than one test. So they can test if they continue to have symptoms or if symptoms are ongoing or if they develop symptoms.

>> Are you recommending daily?

>> Usually every two or three days is enough.

>> Why isn't the majority of people -- why is the majority of people hospitalised in the Northern Region Maori and Pacific? Why is this repeating the pattern we saw last year with Delta when officials gave us assurances that steps would be taken to protect Maori and Pacific.

>> The high proportions of Maori and Pacific being hospitalised with COVID-19 reflects the high case numbers in those population groups. The highest case rates are still in Counties Manukau that have high Maori and Pacific populations. For my part I am happy those people are getting the care they need whether in the community, through GPs, or the hospital care that they need. Again we are seeing only small numbers of people requiring intensive care or high dependency care. And people being in hospital for one or two days, getting the care they need, and then being able to look after themselves at home. So we would expect to see high rates of hospitalisation amongst those two groups. Again one of the reasons for that is high rates of pre- existing conditions which are more likely to be exacerbated if they get COVID-19. So I take this as a sign that the health system is responding rather than any particular problem.

>> The highest number of hospitalisations was in Auckland yesterday, wasn't it, not Counties Manukau?

>> Talking about rates, it has been at Counties.

>> What sort of underlying conditions do you mean?

>> The sort of medical conditions... Actually, this is a good opportunity to hand over to Sam. The sorts of pre-existing or conditions that would be exacerbated?

>> If we're going to contact people we are worried about, we're looking at people with asthma, chronic lung disease, who have conducive heart failure, heart disease, and then uncontrolled diabetes. And people who have other lung conditions that make them more vulnerable. Those are the groups we are looking at, specifically in Maori and Pacific people. And especially older people over 75. There are a range of groups we look through and make sure we keep an eye on.

>> By keeping an eye on, what do you mean?

>> What we're doing in our practices, if we have someone who fits the criteria we are ringing them early. I have asked my patients who I am concerned about to make sure they test early so that I know as soon as possible that they are unwell. And then also giving them pulse oximeter is,, doing daily checks, making sure on day five they have proper testing reviews done. And making sure the information is loaded into the CCCM which is the combined platform we can use so if they need care, Healthline or the hubs can see what is going on for them. Many of those people are in larger whanau as well so there is a whole mixture of other things going on for them.

>> Any final questions?

>> Just the changes to how you report the death rate. Was the reason behind that to offer clarity around who is actually dying from COVID-19? There has been criticism in the past of the way you guys had reported that.

>> The main reason is that when we have reported deaths, invariably in our media releases and/or in the stand- ups, they are the ones reported through our public health units via the Episurv database. But with the public health units not so involved now, including in primary care, aged care and hospitals, we needed to supplement that with other mortality reporting databases, which is the other one where we found these other nine cases where people had a COVID- related death in the last few weeks but had not been reported through the public health unit. It was to make sure our reporting was accurate. But the point you raise is a good one. It's important we understand whether people have died from COVID or with COVID, just as there is a lot of interest in hospitalisations in this regard and we wanted to make that clear to the extent we could. As I said, the largest proportion of those are cases still under investigation where we know the person had COVID but it is not clear whether COVID caused the death or they just happened to be COVID- positive at the time of death. We are trying to be as inclusive as possible and provide as much information as possible. Final questions?

>> Regarding the drop in self- isolation periods from 10 down to 7 days, we have had some experts calling for a 'test to release' scheme where people might be infectious beyond seven days, so a test on days six and seven would allow us to find people who might still be infectious beyond that period. Can we get comments on that?

>> Right through the pandemic, we have never used tests as a criterion for releasing someone we know is a case. Whether it was a PCR test or any other sort of test. We know that people who are cases, the majority of them will no longer be infectious after seven days. And a test per se is not a good indicator of whether someone is infectious or not. The best discriminator is whether someone has ongoing symptoms. While we have reduced the isolation period from 10 to 7 days, if someone has ongoing symptoms like a runny nose or coughing, then they should remain away from work and others, and other settings as well. But certainly a test is not very helpful at all in terms of determining whether someone remains infectious seven days into their illness.

 Right, thank you very much. We appreciate you coming in.

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