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Amid worrying and significant gaps and variation in COVID vaccination, what tools might help?

Introduction by Croakey: Governments must do more to support higher uptake of COVID vaccination, especially third and fourth doses, and especially for priority populations, according to a Croakey survey of experts.

They recommended improved access to vaccinations, community-led programs, better data on vaccination uptake, and more effective communications and awareness campaigns, as well as greater efforts to tackle misinformation and disinformation.

Useful structural measures include reducing out of pocket costs, making better use of nurses – the largest and most experienced immunisation workforce – implementing vaccine recall and reminders, and addressing vaccine delivery demarcation problems between state and federal jurisdictions that plagued the rollout in 2021.


Alison Barrett writes:

The Australian Technical Advisory Group on Immunisation (ATAGI) recently expanded eligibility for a fourth dose of a COVID-19 vaccine – which they call the ‘winter booster’ – to help decrease severe disease and minimise the burden on the healthcare system.

In the midst of the latest Omicron wave driven by sub-variants BA.4 and BA.5, Australian health systems are currently under extreme pressure.

As reported in The Guardian this week, more than 8,500 healthcare staff across the country are isolating with COVID-19. Hospitals and primary healthcare services are facing increasing demand from illnesses dominant in winter, such as pneumonia and influenza, in addition to COVID-19.

Vaccines are an important part of the strategy to minimise the impact from COVID-19, effective in reducing severe illness and deaths.

While most Australians who are 16 years or older have received two doses of a COVID-19 vaccine, rates of third and fourth doses are lagging.

Many health leaders have cautioned that since the advent of Omicron, two doses are not sufficient for long-term protection against COVID-19 – in other words, two doses does not mean “fully vaccinated”.

ATAGI’s updated recommendations include:

  • Adults 50 to 64 years to have a fourth dose of a COVID-19 vaccine
  • Adults 30 to 49 years can have a fourth dose of a COVID-19 vaccine – they acknowledge the evidence for benefit in this age group is less certain than in people older than 50
  • The interval between third dose or recent infection of SARS-CoV-2 and the fourth dose is 3 months.

In addition, they emphasised the importance for people who were previously eligible for their fourth dose and who are at higher risk of severe disease and death from COVID-19 to have their fourth dose.

This group includes:

  • Adults aged 65 years and older
  • Residents of aged care or disability care facilities
  • Aboriginal and Torres Strait Islander people aged 50 years or older
  • People who are severely immunocompromised
  • People aged 16 years or older with a medical condition that increases their risk of severe illness
  • People aged 16 years or older with disability, or significant or complex health needs, or multiple comorbidities.

Given that not all eligible Australians have had their third dose, some urgent catching up is required to ensure people are adequately protected to reduce severe illness and death from COVID-19.

Boosting vaccination rates around the country, in addition to other public health strategies, will also help minimise the pressure on the healthcare system.

Australia’s vaccination status

Upon review of the Australian Government Department of Health’s vaccination data as of 18 July 2022, it is evident that substantial gaps in vaccination distribution exist across jurisdictions and priority groups.

Vaccination rates are lower among Aboriginal and Torres Strait Islander people than among the national population for all doses.

Only 54.3 percent of Aboriginal and Torres Strait Islander people aged 16 years or older have received their third dose, compared to 70.9 percent of general population.

John Paterson, CEO of Aboriginal Medical Services Alliances of the Northern Territory, told ABC today that Aboriginal health organisations are working on a renewed push to lift vaccination rates in the NT, especially in remote communities, and that the NT Government should consider reintroducing mask mandates.

The five- to 11-year-old group is another group with particularly low vaccination coverage, with only 52.29 percent having received their first dose and 40.25 percent their second.

NDIS participants aged 12 and older have recorded lower vaccination rate than the national population rate for all doses.

Only 69.5 percent of aged care residents have received their fourth dose.

Australian vaccination data compiled by author, from Australian Government Department of Health COVID-19 vaccine roll-out update, 18 July 2022. Notes: As stated by the Australian Government Department of Health, people may belong to multiple groups and could be represented in the above breakdowns multiple times. *Aged care residents data as at 15 July 2022 **NDIS data as at 12 July 2022

It is concerning that the vaccine update reports two doses as “fully vaccinated”.

Additional COVID-19 vaccination data, including LGA variations, are available here.

Boosting vaccination rates

To help address concerns about low vaccination rates in specific population groups, Croakey asked a range of public health, immunisation and health promotion leaders for their advice on strategies to promote vaccination uptake.

We asked 16 individuals and seven organisations who work in public health, health promotion, immunisation, and Indigenous health. Two organisations and three individuals replied they did not have the capacity to respond. We did not hear back from the others.

Key recommendations from four experts include: more comprehensive data on vaccine-behaviours and community-level rates of fourth doses (at present limited to two); increased communication, in multiple languages and in collaboration with community leaders and behavioural experts; and more community-driven approaches.

Key resources recommended include:


Collaborations across sectors and reducing barriers

Professor Julie Leask, Faculty of Medicine and Health, The University of Sydney

Q: Who are the key population groups requiring greater COVID-19 vaccination coverage?

Several population groups are most at risk of severe COVID infection, hospitalisation and death. These groups are listed in the ATAGI recommendations. Since the vaccine’s strength is reducing the risk of severe disease, these people are the priority groups for boosters. We should not forget the 2.3 percent of Australians who have had no COVID vaccines at all and remain at greatest risk.

Q: What is the vaccination statistic that causes you most concern?

I am very concerned about the low fourth dose coverage overall – 62 percent of eligible people aged over 65. It’s even more concerning that just 54 percent of First Nations people have had three or more doses. And three doses is now what’s needed for basic protection against severe disease.

Areas of Australia have marked disparities in coverage for three or more doses. Parts of Western Sydney and Central and Coastal Queensland are in the 40-50 percent coverage range, while parts of Perth have upwards of 90 percent coverage.

While it’s good to see government share age category data on fourth dose coverage, we lack small area data so communities can see how they’re going. Information is the first step to action and empowerment. When local communities saw how they were going with two dose coverage, they acted.

Q: What strategies, policies and/or methods are required to increase vaccination rates in priority populations and who is responsible for implementing these?

The Collaboration on Social Science and Immunisation held a national forum to examine this issue with the plateauing uptake of the COVID vaccine in children. The report is here and some lessons are transferrable to adults.

The Federal Government regularly meet with the immunisation program managers in states and territories. It would be useful for the new Federal Health Ministry to learn what the barriers to higher uptake are through consultation and research and work from there. We need more comprehensive and rigorous behavioural data because we currently get a monthly report with very limited information.

Things that increase uptake include reducing out of pocket costs, state and territory performance targets, adequate provider compensation, and national strategies. Governments should also make better use of nurses who are the largest and most experienced immunisation workforce. They need to address the vaccine delivery demarcation problems between state and federal jurisdictions that plagued our rollout in 2021. But these are structural issues that won’t directly address the urgency of the current booster situation.

There is a lot State and Territory governments can do, particularly regarding inequities in uptake. They know that awareness campaigns, very convenient services, easy booking systems, welcoming services, all preceded by community engagement all made a difference. However, many of the states stood down their surge workforces, mobile clinics, drop-ins and community engagement at the end of the financial year, leaving a skeleton staff.

Since managing COVID is along game, we have to find a good balance. Yes, we need to give attention to other areas of health under constrained budgets but cannot drop the ball. For example, community engagement works and supports other health promotion activities.

How can states keep using those new relationships? For Victoria, there should be security of ongoing funding for Local Public Health Units as it’s these more units that are so crucial to working locally. Local communities can do a great deal, but only with the funding and support of government.

For providers, we need a very broad scope of provider type. In standing down state-based services, there may have been an overcorrection and heavier reliance on general practice as the mainstay of vaccine provision. However, for some rural and remote communities, it’s a two week wait to get a GP appointment, the pharmacy doesn’t provide it, and the GP is the only provider in town. So there should be attention to the structural barriers and the sustaining of state-based community and mobile vaccination services.

Q: What role to the social and cultural determinants of health have here?

See above.

Q: What impacts are misinformation and disinformation having?

Misinformation has had an impact throughout, particularly in some communities. However, it’s not the only barrier to vaccination, and misinformation itself thrives in a setting of mistrust and historically poor treatment. It has been good to see community leaders step-up and become vaccination advocates.

My colleagues in the Collaboration on Social Science in Immunisation and I have contributed to training community and professional groups in how to address hesitancy and the impacts of misinformation. We have used the COVID-19 vaccine communication handbook and Wiki from behavioural scientists who specialise in this field. There is also useful research from the social science unit at the National Centre for Immunisation Research and Surveillance.

Q: What’s the most useful academic publication (for example, journal article or report) that could help inform efforts to increase COVID vaccination rates?

Well I’m biased, but WHO has just put out a practical guide called, Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake, which I was involved in developing with a global working group. We are using these tools to help countries plan, assess and act on low coverage for COVID and for routine childhood immunisation.

Q: What else would you like to see in terms of policy to minimise the impact of COVID-19?

I would like to see governments undertake timely evaluations of the last 2.5 years, look honestly at where things went right and wrong and put into practice the recommendations. Those lessons can be applied right now as we continue to grapple with COVID. There is talk of an Australian Centre for Disease Control, with the much-treasured acronym ACDC. The government has committed to establishing one. It will be good to see this become a reality. There are many impediments, including how to unify the states and territories legislatively and practically, but we should start small and build on that.


Fix gaps in communication strategies

Dr Jessica Stokes-Parish, Assistant Professor Faculty of Health Sciences and Medicine, Bond University

Q: Who are the key population groups requiring greater COVID-19 vaccination coverage?

Only 40 percent of children between the ages of 5 and 12 have had two doses of the COVID-19 vaccination. This is particularly obvious in the states of Queensland (31 percent) and the Northern Territory (35 percent). In terms of booster doses, we need to see an increase in Indigenous populations (only 54 percent have had a booster dose) and also the general public. Only 71 percent of the eligible population has received 3 or more doses – including vulnerable groups.

Q: What is the vaccination statistic that causes you most concern?  

That only 75 percent of eligible NDIS participants have received a booster dose, and that our vaccination in children is lagging so far behind. Urgent action is required.

Q: What strategies, policies and/or methods are required to increase vaccination rates in priority populations and who is responsible for implementing these?

There is a huge gap in communication strategies for these priority populations. The communication does not meet the needs of the community and leaves gaps in their knowledge. In a time of constant change, we need nuanced messages that address the communities need. This should occur with government and state health in collaboration with communication and behaviour change experts and consumer representatives who represent the broader community.

Q: What role to the social and cultural determinants of health have here?

Exposure and access to education hugely influence how people engage with messaging around vaccination. Many of us that work in academic and hospital centres have free access to information in a language we understand – this has been largely missing over the last 12 months, or it comes very delayed. In addition to this, access to vaccination has not been easy for some – meaning that there may be willingness to vaccinate, but barriers to access the service.

Q: What impacts are misinformation and disinformation having?

Mis/disinformation are proving to be increasingly damaging. We have lost trust with some sectors of community due to lack of engagement, and the vacuum of information is being sucked up by merchants of mis/disinformation.

Q: What’s the most useful academic publication (e.g. journal article or report) that could help inform efforts to increase COVID vaccination rates?

Anything that incorporates behavioural and social drivers of health, such as the comprehensive report from the WHO Vaccination Uptake team.

Q: What else would you like to see in terms of policy to minimise the impact of COVID-19?

Stronger communication that clearly identifies positive strategies that does not use the phrase “the community needs to use common sense”. Tangible steps (such as mask wearing, ventilation strategies) together with data driven communication approaches can help us build trust amongst the community again.

See this Twitter thread by @j_stokesparish that includes the graphic below.

 


Community-driven approaches help to reduce barriers

Jane Stanley, Advocacy and Policy Manager, cohealth

This most recent release of COVID vaccination rates data shows that while Australia is overall doing well with our first and second vaccination uptake, we still have a way to go to ensure everyone has the benefits of protection. The figures show that some groups, such as Aboriginal and Torres Strait Islander people and primary school aged children, don’t have the same level of vaccination coverage.

We also know that not all areas of Victoria have the same level of uptake. Unfortunately, the figures don’t tell us how the level of vaccination coverage we’ve achieved in terms of other demographic characteristics, such as socio-economic status or cultural background.

What we do know is how important it is to continue with the successful community-led approaches that ensured vaccinations, and information about them, was delivered in communities, by trusted community members, and in culturally appropriate ways.

Delivering vaccinations in schools, churches, temples, housing estates and other pop-up locations helped overcome the access barriers some people experience. I am concerned that the shift in approach to relying on GPs and pharmacists to deliver vaccinations may create access barriers for some of the more vulnerable members of our community.

Both Federal and State governments need to ensure they continue resourcing community-led programs that deliver vaccinations and vaccination related information.


Communicating messages in multiple languages

Associate Professor Holly Seale, Infectious Disease Social Scientist, The University of New South Wales

A statement by World Health Organization (WHO) Regional Director for Europe Dr Hans Henri P. Kluge summed it up by saying “consistent application of the following five pandemic stabilizers will continue to be critical to protect people. They spoke about increasing vaccination coverage across the general population, as well as the promotion of mask use, appropriate ventilation, and the application of rigorous therapeutic protocols for those at risk of severe disease.”

There are certainly people who are prioritised for vaccination, who appear to not be receiving their third and fourth doses. It is critical that we implement reminder/recall systems to get them to have their additional doses (ensuring messages go out via multiple modes and languages). This is to prevent serious illness, keep people out of hospital.

As put by Dr Ashish Jha, the White House’s COVID-19 response coordinator: “we are at a point in the pandemic where most COVID-19 deaths are preventable”.

But we also need to be encouraging the general public over the age of 30 to think about getting an updated dose. If people are holding out thinking there is a ‘better’ vaccine coming along, they may be putting themselves at risk.

There are certainly second-generation vaccines being trialled (but they may not be available until later in the year). Getting a second booster shot now would not lead a person to become ineligible for a variant-specific vaccine.

Our new resources are available online to assist with decision making regarding the COVID vaccines (for both adults and children). The decision tools are also available in multiple languages.

The tools were developed by Dr Jane Frawley from the University of Technology Sydney and a group of public health researchers, social scientists and clinicians using the best available research about COVID-19 and COVID-19 vaccines. It has been reviewed by technical staff at NCIRS and will be updated as new evidence becomes available.


Addressing global inequities

Associate Professor Deborah Gleeson and Brigitte Tenni discussed the glaring global inequities in vaccination distribution in The Conversation this week.


See Croakey’s extensive archive of articles on vaccination

 

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