Poor ventilation and double-bunking led to health workers contracting Covid-19

Steven Walton and Liz McDonald19:59, Jan 22 2021

Christchurch’s Sudima Hotel is a managed isolation and quarantine facility near Christchurch Airport.
JOSEPH JOHNSON/STUFFChristchurch’s Sudima Hotel is a managed isolation and quarantine facility near Christchurch Airport.

Only the quick action of a Christchurch health worker prevented a wider Covid-19 outbreak in the city late last year, according to information in a new report.

The Canterbury District Health Board (CDHB) report by doctors working in managed isolation and quarantine (MIQ) facilities said poor ventilation and double-bunking among newly-arrived fishing crews helped spread Covid and led to two health workers becoming infected.

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The outbreak affected 31 out of 235 Russian and Ukrainian mariners plus the health workers at the Sudima Christchurch Airport Hotel during October and November.

The report has prompted changes to the way large groups are managed in MIQ – including a second group of Russian and Ukrainian mariners who arrived this month.

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It said the health worker took a Covid test the same day they developed a temperature and runny nose, and a day after feeling fatigued and receiving a negative Covid result. They then self-quarantined at home.

Before the positive test, the worker visited a local supermarket.

“We are very grateful that this staff member sought testing for mild symptoms, even though [they] just had a negative test,” a letter from public health physician Dr Daniel Williams, which was included in the report, says.

“It [they] didn’t, we’d be in a much bigger mess.”

Here’s what you need to know about the new community case of Covid-19 in Christchurch.

Emails from CDHB staff, released under the Official Information Act, show just three of the 235 fishermen spoke English.

An email written by CDHB medical officer of health Anna Stevenson said about two thirds of the fishermen were chain smokers and made up to four visits an hour to the outside smoking area.

“Compliance with requests to physically distance from other crew was patchy and in the first couple of days there [were] frequent exchanges of cigarettes, lighters, cellphones etc,” Stevenson wrote to Ministry of Health officials.

Dr Josh Freeman, a microbiologist and clinical director of infection prevention and control, also observed large numbers of mariners moving back and forth through the hotel’s corridors to go to the smoking area.

Some fishermen had to go to the outside smoking area up to four times an hour, emails released under the Official Information Act show.
JOSEPH JOHNSON/STUFFSome fishermen had to go to the outside smoking area up to four times an hour, emails released under the Official Information Act show.

“In a hotel environment with poor ventilation in corridors, these factors all added up to being conducive to the inhalation of Covid-19 aerosols,” he said.

It was these risks that led to the eventual spread of Covid-19 to two health staff, he said.

Both became infected despite “exemplary adherence” to personal protective equipment (PPE) recommendations and infection prevention protocols.

The report itself states each worker caught different strains of the virus from fishermen who were highly infectious at the time.

Both fishermen wore masks and the health workers were in full PPE, including a visor or goggles.

The Airport Sudima is one of six MIQ facilities in the city.
STACY SQUIRES/STUFFThe Airport Sudima is one of six MIQ facilities in the city.

The report recommends catering better for smokers, as MIQ was not set up to manage large numbers of chain-smoking guests, and says having more translators was “critical” for non-English speaking groups.

It also said double-bunking (two beds per room) should not be allowed to happen again, an engineering review of ventilation in Canterbury’s MIQ facilities should be done, and CCTV cameras should be mandatory.

The Sudima does not have CCTV, the report notes.

The report found the outbreak among the fishermen “severely stress-tested” MIQ protocols.

It is thought 12 of the men had Covid-19 on arrival in Christchurch, and some were highly infectious, the report said.MORE FROM


Double-bunking was labelled as “problematic” and “patently absurd” by University of Otago epidemiologist and public health expert Dr Nick Wilson.

“New Zealand just seems to … take shortcuts on the cheap.”

Wilson said people would have been lifting their masks while sharing smoking areas.

“This is just not how you do quarantine,” he said upon hearing that cigarettes were shared between returnees during their first few days.

Deputy director of public health Dr Niki Stefanogiannis​ said changes introduced included providing more translators, information and welcome packs in Russian and Ukranian, and detailing expectations before people arrived.

Double-bunking was banned, and smokers were identified ahead of time and allocated rooms with balconies to prevent groups gathering, she said.

The Ministry of Business, Innovation and Employment had also formed a special team to handle large groups and make sure plans were in place for their arrival.

Officials were “working closely with the fishing companies”, she said.

Doug Paulin, chief executive of Sealord, one of several fishing companies that brought in overseas crews, said they had required all incoming mariners to take a Covid test and provide a travel fitness certificate before leaving Russia.In your office today? Stop! Scanner timeScan a nearby Covid-19 QR code to stay safe

After the first group arrived in October, the company made the required changes for the second group this month, he said. These included booking accommodation in Moscow for mariners whose flights were awaiting official clearance to leave.

Paulin thought the Ministry of Health had provided fishing companies with sufficient guidance.

“They were working with the protocols they had at the time.”

Sealord did not intend to bring in more overseas workers until at least November, he said.

Key Findings

– Up to 12 mariners may have been infectious upon arrival in New Zealand.

– In the first days of their isolation, physical distancing was “patchy” and there were “frequent exchanges” of cigarettes, lighters and cellphones.

– The MIQ facility underwent “severe stress testing” due to the high number of infectious cases there at one time.

– NZ could have been “in a much bigger mess” if the first infected health worker didn’t get tested.

– The report calls for an engineering review of ventilation in Canterbury’s MIQ facilities and a ban on double-bunking.


October 16: The 235 Russian and Ukrainian mariners arrive in Christchurch and isolate at the Airport Sudima. It is thought 12 of them already have Covid-19.

October 20: The Ministry of Health confirms 11 positive cases inside the facility and 14 more under investigation.

October 21: Seven new cases are confirmed in the facility, bringing the total to 18 positive cases inside the hotel.

October 23: A further seven cases are confirmed. There are now 25 cases among the fishermen.

October 31: A health worker from the Sudima Hotel begins to feel “slightly fatigued” after completing a shift on October 30, the same day their last negative test was returned.

November 1: The health worker has a temperature, runny nose and mild nausea. They get a test during the day.

November 2: A positive test is confirmed and the public is told that evening. It is the first community case in the South Island since late July, when a person who later tested positive for Covid-19 in South Korea visited Christchurch.

November 3: It is confirmed the health worker visited a local supermarket while they had symptoms. The supermarket undergoes a deep clean. A close contact of the worker is a local high school student. Epidemiologists label the new community case a “border failure”.

November 4: A second health worker tests positive for Covid-19.If you value facts and being well-informed, please consider supporting Stuff.Make a contributionhttps://dashboard.presspatron.com/websites/153/custom_button

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