New Zealand will be on the other side of the Omicron peak within weeks. Derek Cheng examines how the peak is shaping, what life will be like post-peak, and what will tip the balance for future waves.
Omicron will cause far more deaths than New Zealand has experienced so far, perhaps more than 1000 in this outbreak, with as much as half the country catching the virus.
And the harm will likely be ongoing – thousands of daily infections, post-peak - because the virus will, for the first time, continue to circulate widely.
How long that will remain the "new normal" is anyone's guess, though some experts believe a new variant - which could change everything in a hurry - could land here within months.
This makes it difficult to predict what life will be like well beyond the Omicron peak.
"Thinking about a 12-month, three-year, six-year horizon, and what are we likely to experience at those points ... the next three months are all about this peak, and about getting over to the other side of it," Covid-19 Response Minister Chris Hipkins told the Herald.
The scale of fatalities from the Omicron outbreak will also be far less than what has hit other countries, which have had to grapple with more virulent strains – such as Delta – that were more prevalent among less vaccinated populations.
And while hospitals are under pressure now, especially in Auckland, they do not appear on the verge of collapse. This bodes well for future waves, which will roll in when the chances of spread are greater - such as in winter.
"You might get semi-predictable waves during the winter months that are smaller than the original peak we're in at the moment, but could nevertheless still be a significant number of people getting infected," says Covid-19 modeller Professor Michael Plank.
"My expectation would be that the severity would be blunted over time, because the vast majority of people are not getting infected for the first time. On top of the majority of people being vaccinated, there will be a buildup of immunity from subsequent infections and reinfections."
This increase in population immunity points to a new way of life, post-peak: A softer version of the hundreds of thousands of people in isolation, and the disruption that's currently hitting schools, households and workplaces.
Lifestyles will still have to adapt as the level of transmission ebbs and flows.
But in general there'll be fewer people having to isolate, fewer worker shortages including in schools and hospitals, less Covid pressure on health services, and fewer Government restrictions on what you can and can't do.
One aspect of traffic light life - the two classes of people, based on their vaccination status - will be dropped, meaning the unvaccinated will be free of the current limits on gathering.
Vaccine mandates outside the health sector and border workers will be phased out.
There will also be more discretionary mask use, and more flexibility on gathering limits along the lines of what's allowed at the Women's Cricket World Cup, where venues can be at 10 per cent capacity.
The Government will still look to tighten the screws if it looks like health systems might come under pressure.
And the huge caveat of ongoing uncertainty, which has been present throughout the pandemic, still applies. A more virulent and infectious variant might turn back the clock, and even see the return of borders shutting up, mandatory MIQ stays, longer isolation periods, and even lockdowns.
But Hipkins says Covid-19 will have to become a normal part of life at some point, and we may be there post-peak.
"It's an active question: once you come down the other side of the peak, do you button everything down so much that you stop transmission almost altogether, and thereby run the risk of a higher, separate, second peak? Or do you try to spread that a bit so that it just becomes more normalised?
"Towards the end of the Delta outbreak, we got down to the point where elimination would have been possible. But all that was going to do was restart the cycle, and we were going to keep going through these cycles, which is unsustainable.
"At some point, you do have to get to the point where you can normalise things again. That was one of the big lessons from Delta."
How Omicron is peaking and how the health system is coping
New Zealand currently has one of the highest per capita Covid-19 infection rates in the world, and the number of Covid-related deaths – now at 98 - has shot up in recent weeks.
The exact timing of the Omicron peak in New Zealand will vary by region and demographic.
It will hit younger people first – 56 per cent of recorded cases are under 30 – and is likely to have already landed in Auckland; hospitalisations across Auckland this week were 520 on Monday, 533 on Tuesday, 497 on Wednesday, and 507 on Thursday, and 601 on Friday.
Under pressure but "manageable" is how director of public health Caroline McElnay described how hospitals were dealing with the outbreak.
Ministry of Health data from Tuesday shows 49 of 103 ICU/HDU beds occupied across Auckland's three hospitals, 10 of which were Covid patients. Four-fifths of the 2702 resourced ward beds were occupied, 451 of them by Covid patients – or 17 per cent of the total number of beds.
Nationwide, Covid-19 patients took up 5.4 per cent of the 296 ICU/HDU beds, and 8.7 per cent of the 7487 resourced ward beds.
This has put pressure on business-as-usual hospital operations as well as primary care, especially as the health workforce has been squeezed by isolating workers.
But there is still breathing space across the country: 62 per cent of ICU/HDU beds and 81 per cent of ward beds were occupied, while 17 per cent of ventilators were in use.
So far Omicron has hit Pasifika and Māori - who've had poorer access to vaccination services - the hardest. Of those in Northland and Auckland hospitals on Thursday, 36 per cent were Pacific people and 23 per cent were Māori.
"That is consistent with what we see in terms of it burning through the Pacific population at an incredible rate," says National Hauora Coalition clinical director Rawiri Jansen.
"Households that have 17 people in a three bedroom house - they're intergenerational households with somebody who's young, really social, going to church. Those households are at much greater risk of getting exposed."
For the 18 to 34 age group nationwide, ministry data from March 6 shows only a quarter of Māori and 34 per cent of Pasifika with a booster shot, which is far more effective against Omicron than two doses.
For the next age group, 35 to 49, it's 41 per cent for Māori and 54 per cent for Pasifika. This rises to 86 per cent for Māori and 78 per cent for Pasifika for 65s and over, but this still translates to about 7000 unboosted elderly Māori and about 5700 unboosted elderly Pacific people.
If the Omicron outbreak tracks as Delta did, Māori will become more prominent among hospital cases; the number of Māori in Auckland's hospitals jumped from 80 on Wednesday to 125 on Thursday.
Jansen remains nervous about Māori in the Lakes, Bay of Plenty and Northland regions in particular, where the booster rates among 18- to 34-year-olds are only 18, 17 and 17 per cent.
In the latter part of last year, the Government super-charged efforts to resource Māori and Pacific health providers to close the vaccination gaps – whose work played a massive role in minimising the harm of the Delta outbreak.
But Jansen says the same kind of urgency wasn't applied for Omicron.
"They've done some resourcing to make sure there's support for whanau – kai and hygiene packages, things like that – but the funding only landed about three weeks ago. The systems are not in play anywhere near the efficiency we need to get through wave one."
The Ministry of Health has conceded that Omicron spread quicker than anticipated, which contributed to a delay in 50,000 PCR test results, and delays in a system that alerted services to the clinical needs of vulnerable patients.
Adds Jansen: "Equity is about providing more resource to the population that needs it. Is that happening? Somewhat. Not so good in Lakes, not so good in Bay of Plenty, not so good in Northland. It's going to show up in those regions in ways that trouble us."
How strong will future waves be?
While it's unclear what the other side of New Zealand's peak will look like, in parts of Australia, hospital numbers have more than halved.
In NSW, the number of people in hospital hit nearly 3000 in late January, and is now just over 1000. The peak of just over 1200 in Victoria, in mid-January, has fallen to the low 200s, and South Australia's peak - just shy of 300 seven weeks ago - has now dropped to 100.
But post-peak doesn't mean the pandemic is over, or even necessarily that the worst is behind us.
There are many factors in the complex equation of the size of future waves, which could still threaten to overwhelm health services.
About 940,000 Kiwis aged 18 and over are eligible for a booster, but have yet to have it. More than a quarter of them are Māori, and more than an eighth of them Pasifika, who are more likely to suffer severe illness.
There are also 300,000 children aged under 5 who still can't get vaccinated, and a further 504,000 eligible people who are unvaccinated.
But hundreds of thousands of people now catching the virus - including the unvaccinated - will lead to a diminishing number of people susceptible to catching it.
"That means, for a constant set of public health and social measures, the Reff [the average number of people one person infects] has dropped," explains Melbourne-based epidemiologist Professor Tony Blakely.
"Imagine Reff was 2.0 at start of Omicron wave, which seems about right, as case numbers would double every four to five days. Imagine 25 per cent infected now, so the pool of susceptibles is now less, and the Reff falls to 1.5."
Flattening the next wave
The speed of spread can be slowed in many ways, one of which is people's behaviour.
Top priority is for the eligible who haven't had a booster to go and get it, says head of the Immunisation Advisory Centre Dr Nikki Turner.
"Countries with subsequent waves are still getting high rates of hospitalisation and death. The importance of a booster for high-risk adults can't be underestimated. They're the ones that remain vulnerable."
People are also being cautious about these peak weeks, with many uninfected Aucklanders staying at home or pulling children out of school; 90 per cent of Auckland schools are managing cases.
Others, though, don't have that luxury. There is anecdotal evidence of symptomatic people going to work because they don't have the financial freedom to stay home, despite a Government leave support scheme that gives a fulltime worker $600 a week.
Another factor in the size of future waves is waning immunity, which is thought to be one of the causes of the recent uptick in hospitalisations in England.
A fourth dose is already being planned for those in England aged 75 and over, following similar plans to protect the elderly with a fourth dose in Israel, Chile and Denmark.
The highest risk people in New Zealand - 34,165 people aged 12 and over who are severely immunocompromised - have had three primary doses, and a quarter of them have had four doses after they became eligible for a booster.
This gives New Zealand a buffer for deciding when, and for whom, a wider fourth dose rollout should start, says Turner.
"There's no time crunch. Those people are best protected against the current wave."
She says the goal of the rollout has now shifted from helping to prevent transmission to minimising severe disease and fatalities.
"What we've seen from Omicron is immunity to mild and probably asymptomatic disease drops off really quickly. But with a booster, protection to severe disease at this stage is still looking really high."
She says it's still too early to say when immunity from a booster will start to fizzle for protection against severe disease.
"That's what we've got to watch for. If you do start seeing it, particularly for those who are more vulnerable, that would be an argument for targeted vaccination [for a fourth dose] - the frail elderly, and people with significant medical problems."
Reinfections with Omicron, which now make up 10 per cent of cases in the UK, could also contribute to future waves, but there is also breathing space here.
"The advice we've had in the last couple of days is that you get at least three months where you're unlikely to be reinfected again," says Hipkins.
"And it may well be longer than that. That's probably a conservative estimate."
He says the Government is working on what a fourth dose rollout should look like, with an eye on the most vulnerable.
"If you think about influenza, not everyone gets a flu jab every year. But we do put a real emphasis on making sure that the vulnerable communities have access."
The closing window on mandates, passes, gathering limits
The Government can also flatten the curve by reaching for the levers in the traffic light system: mask-wearing and social distancing, vaccine mandates and vaccine passes, limits on gatherings, QR code scanning, and reminders to stay home if sick.
How they will be used in a population with greater immunity is an open question, but all of them will remain in the toolbox.
"You rest them as interventions when it's safe to do that, and when the evidence suggests that that's the right time to do it," says Hipkins.
He says Cabinet is working out how the system should be revamped, but in general, greater immunity among the population will see less of a need for restrictions.
On mandates: "As we get higher levels of vaccination - some of that's going to be from the mandates - but do you still need the mandate then? We're getting into that territory at the moment."
On vaccine passes: "The limits on the unvaccinated have been justified, but at some point, they will become unjustifiable. And we may not be far off there."
On gathering limits: "Given what we've seen with the women's Cricket World Cup, can we apply those settings more broadly? In terms of indoor environments, they're more risky but there are still ways to contain risk. And, also, do you necessarily need to when you get to the other side of the peak and into a different environment?"
On mask use: "At the moment, in a classroom setting, for example, it is helping to slow the spread. But that's not going to be the case forever."
He says the window for mandatory QR code scanning "may well be starting to close", but it can still be useful for informing people's choices.
"If you get a QR code alert, you might decide against visiting your great aunt because you were in a place where there was a Covid person."
The updated system won't be rolled out until New Zealand is on the other side of the peak.
"I don't think it's going to be a 'big bang' thing. I think it's just going to be a progressive series of changes," Hipkins says.
"If you think about vaccine mandates, we're not going to wake up one morning and say, 'Right, that's it, they're all gone.' I suspect there'll be progressively dismantled."
'Disproportionate and unethical'
Easing off on restrictions after the Omicron peak is backed by health experts.
Plank says the usefulness of the vaccine pass is "diminished" in an Omicron outbreak.
"With Omicron, the vaccine is less effective at stopping people from catching the virus and passing it on. It still has a massive impact on the risk of severe illness, but there's less of an argument for saying that unvaccinated people are a danger to those around them."
Epidemiologist Professor Michael Baker agrees, though he says there may be a place for vaccine passes when health services look like they could be overrun.
"But I don't think it's justifiable to have an indoor vaccine pass requirement at every level. That component of the traffic light system should probably be removed."
He adds that private providers may also want to still be able to use them.
"If you think about providing concerts and your target audience is older, more vulnerable people, it may actually be a selling point for vaccine passes to be required."
Plank says taking a rapid antigen test before visiting a high-risk setting, such as an aged residential care facility, was more useful than QR code scanning.
"That's more likely to be effective in preventing the virus coming in from outside than mandatory scanning at that location.
"If you're in a situation where you have thousands of infections per day, mandatory QR scanning probably isn't going to have a major impact because it becomes infeasible to publish locations of interest."
For the post-peak normal, Blakely doesn't think there's a need to limit hospitality or events, though mask use in certain settings remained important.
"A common recipe - and one I think is apt, and is being used in Australia – is masks on public transport and high-risk settings including health care and aged care venues, strongly encouraged for those at risk, but otherwise discretionary.
"And if you're a case, isolate, but close contacts only quarantine if they're very close contacts and not previously infected – and in due course, this might even be relaxed."
Blakely supported vaccine mandates in high-risk settings.
"But it does not make sense - and I argue it is disproportionate and unethical - to ban an unvaccinated teacher from teaching once the peak is over. Our vaccines do not stop us getting infected that well, so it seems 'wrong' to tell the unvaccinated they cannot work in these settings when times are not dire."
University of Auckland community and developmental paediatrician Dr Jin Russell says the mandate across the education sector was no longer needed as much because the vaccine rollout for 5- to 11-year-olds had started.
"We would still want to see all teachers vaccinated and boosted for their own protection. Our teacher workforce is also now highly vaccinated. The mandates have done the job they were designed to do."
Other workforces that have been the subject of mandates, including the police, defence force and prison staff, are also now highly vaccinated, and will remain so if and when those mandates are ditched.
A system for more than just Covid
Otago University epidemiologist Dr Amanda Kvalsvig says any upgrade to the system should account for Covid-19 as well as other infectious diseases.
"At lower levels of infectious disease threat, the aim would be to keep people safe while going about their daily lives, for example wearing face masks on public transport when we have warning signals of a flu outbreak," she says.
"At higher levels of threat – arrival of the next pandemic, for example – more stringent measures would kick in, including limits on settings that are high risk for superspreading events. Stay-at-home orders would be used as a circuit-breaker only in the event of a high level of threat to the public."
The system needed to be flexible, practical, and equitable, she says, which would mean more resources to those with the highest needs as the risk increased.
"It must work for all New Zealanders and that means upholding Te Tiriti o Waitangi in design and implementation. In the August 2021 Auckland outbreak, control of the outbreak was lost because the system couldn't reach and protect communities that were highly marginalised.
"Outbreak control doesn't work when it's inequitable. It's as simple as that."
Other experts agree that the focus should, more generally, be on respiratory illnesses.
"A future scenario I can see panning out is where mask use is more likely to be needed in winter," says Plank.
"It's already hard on the healthcare system due to simultaneous waves of flu, RSV, Covid, and other winter respiratory illnesses at the same time. The advantage of mask use is that it limits not only Covid, but all other respiratory illnesses."
Adds Turner: "We're moving into a new headspace now about how to protect those who are most at risk in our community against respiratory illness - which is both flu and Covid: a mixture of vaccination and aspects of what we've learned in public health, which is staying home when sick, social distancing, and mask-wearing in some environments."
And Baker: "Mask mandates for some indoor settings for dampening transmission, probably public transport and, in winter, maybe for flights. I think we'll see a lot more mask use in general in winter."
He adds that there are many variables that could require the response to pivot rapidly, such as how Long Covid from Omicron manifests.
"There are still more unknowns than knowns about this virus."