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Beyond the vaccine horse race: what are the wider issues of concern?

Marie McInerney writes:

Health Minister Greg Hunt this week famously declared “the eagle has landed”, as the first doses of the Pfizer-BioNTech vaccine touched down on Monday.

He was archly reminded on Wednesday by Victorian Premier Daniel Andrews, who was clearly relieved and pleased to be able to lift Victoria’s snap five-day lockdown from midnight, that the pandemic has a long journey still ahead.

“We’ve got one palette of vaccines that’s turned up,” Andrews said. “That great news, but we haven’t got any in anyone’s arms yet. Some might see that as the moon landing. I think it is the start of the end, (but) it is not the end of this pandemic.”

Worryingly, however, you could be forgiven for thinking — say, if you watch ABC TV’s Q&A — that the only vaccination issue is the horse race between vaccines.

But there are many critical logistical and equity issues for Australian governments and health services to address in the coming days, weeks and months, as experts from across many fields have told Croakey. These range from vaccine hesitancy, to nurses being left out of consultations, and concern that vulnerable groups, including in other countries, may struggle for access.

We have asked other organisations, including Aboriginal and Torres Strait Islander health organisations, for their views and will update this post with their responses.


Who gets what, when and how?

Professor Stephen Duckett, Health Program Director, Grattan Institute

  1. What are your major priorities re the vaccination roll out?

Pfizer appears to protect against transmission, so my first priority is hotel quarantine workers, then front-line hospital workers, then front line primary care workers.

AZ protects against severity so aged care residents, then high risk (older people first), then all population (older people first).

  1. What are your concerns, if any, to date?

Lack of clarity about who gets what, when and how.

  1. What are the key system issues?

Lack of clarity about who gets what, when and how.


Beware not to over-promise and under-deliver

Alison Verhoeven, CEO Australian Healthcare and Hospitals Association (AHHA)

  1. What are your major priorities re the vaccination roll out?

The planned 5 phase rollout prioritises at risk groups including quarantine and Border Force staff, which is very appropriate given quarantine facilities have been the source of most outbreaks. Ensuring that the rollout has appropriate reach into regional and rural areas will be important, as will effective communication with different population groups.

  1. What are your concerns, if any, to date?

Government and health leaders need to be cautious not to over-promise and under-deliver as this will create mistrust amongst Australians. This may mean modifying some of the rollout plans to ensure targets can be met (see system issues below!).

  1. What are the key system issues?

To achieve the ambitious targets being put forward by the Commonwealth Government will require engaging more broadly with the available health workforce and facilities than is currently envisaged, in our view.

While there has been a strong response to the call for Expressions of Interest from GPs and pharmacies, in countries where there has been a very rapid and efficient roll out of vaccines (eg United Kingdom and Israel) there has been a much broader involvement of workforce and mass immunisation facilities.

While we understand the rationale for voluntary vaccination, the Commonwealth Government must take the lead in working with aged care providers to encourage their staff to be vaccinated. They need to think through the mixed messaging which will occur when staff are required to have a mandatory flu vaccine, but not a COVID vaccine.

There will also need to be careful management of the vaccine rollout process in aged care facilities as staff and residents have three immunisations in coming months – two for COVID and one for flu, with two weeks allowed between flu and COVID vaccinations as recommended by health authorities.

  1. Any other comments?

We’re pleased that the Commonwealth Government has confirmed vaccinations will be made available free of charge to refugees and temporary residents. It will be important also to support neighbouring countries to access and distribute vaccines in a timely manner, for the safety and wellbeing of us all.

We participated in the Department of Health briefing on Wednesday regarding the roll-out of the COVID vaccines. Here’s a summary:

  • 142,000 Pfizer doses in country, of which 50,000 have been distributed to states and territories, and 30,000 to inreach teams for residential aged care and disability services (Phase 1A priority group). Remainder being kept in reserve to support second doses until more vaccine arrives in the country. Astra Zeneca vaccine will arrive in country next week, with Australian production likely to be available and approved for use by mid-March.
  • States and territories are employing different approaches to how they prioritise people within the Phase 1A priority group (some focusing on border and quarantine workers first, then frontline health workers).
  • Staff who will be involved in the roll out of vaccine in Phases 1B and 2A are being asked to delay undertaking online training for another week or two, by which stage an online module on the Astra Zeneca vaccination will be available.
  • EOI process for GP/GP respiratory clinics/ACCHOs:  initial allocation of locations will complement State/Territory sites and will prioritise the group who will deliver Phase 1B vaccines.

MBS item information including FAQs and explanatory notes will be released in the next few days. (See more links at the bottom of this post.)


Urgent need for expanded information campaign

Leanne Wells, CEO Consumers Health Forum of Australia

  1. What are your major priorities re the vaccination roll out?

To get the right vaccine to vulnerable people as quickly as possible

  1. What are your concerns, if any, to date?  

Concern about AZ vaccine and over 65s. If they can’t get it, will they be able to access an alternative, perhaps Pfizer? How will this affect coverage?

3. What are the key system issues?

The response to CHF’s recent webinar has demonstrated the widespread interest in the vaccine and the vaccination program and the public demand for more details. We received scores of questions from the hundreds of people who registered for the webinar and were fortunate to have the Health Department’s lead officers on the vaccination issue attend.

The volume of questions demonstrates the urgent need for an expanded and vigorous information campaign. Below is a sample of the questions grouped into the most common areas of interest and concern.

Vaccine safety: Rates of adverse reactions overall and in high-risk groups? Safety of the vaccines for older people? Have the vaccines been tested in breastfeeding and pregnant women? How can you know what is in the vaccine to work out if you might have an allergy? How will information about any reactions to the vaccine be communicated/explained to consumers?

Prioritisation of vaccinations: Who is included as having an ‘underlying medical condition’ as indicated in phase 1b? Where do adults with a chronic condition or disability sit in the schedule for vaccinations? How will additional 10 million doses of the Pfizer vaccine doses be allocated? Will the vaccine be mandatory for all health professionals? Will there be arrangements for essential workers such as warehouse workers who supply the supermarkets, and customer-facing employees who work in supermarkets to get vaccines as a priority? Is there a list of underlying medical conditions that are included in the priority groups (consumers are seeking clarity but people with rare conditions are concerned they may be missed with this approach)? Supporting our Pacific neighbours is critical. When and how will we support this?

Consumer choice:  Will consumers be given a choice of the type of vaccine they receive?  Will people be able to choose if they are prepared to pay for an alternative vaccine? To what extent will legal force be used to encourage uptake of the vaccine, e.g. no jab no play/work/travel etc.? What happens if consumers choose to wait and not get vaccinated when first offered a vaccine?  Are the vaccines halal and kosher?

Logistics: How will consumers sign up to get the vaccine and how will they be informed when they are eligible to receive it? Where will consumers be able to get the vaccine from, e.g, GP, pharmacy? Is there any out of pocket cost for consumers to receive the vaccine? How will the rollout be managed in aged care facilities? And particularly in RACFs in rural and remote regions?

Will there be vaccination notifications sent out by text/email/letters or will patients have to contact their vaccination providers on their own initiative? Will GPs only be delivering the Astra Zeneca vaccine due to lack of ability to store the Pfizer vaccine? What facilities/training will pharmacies have for managing potential anaphylactic reactions? How will pharmacies know clients details to contact them especially if the vaccine is dispensed by a different pharmacy to the one normally used by the client?

Contra-indications: Who shouldn’t have the vaccine at this stage of research and testing? Will there be published guidelines for who should not have the vaccine and when/how will this become available to health professionals and the public? Are the vaccines safe for people who are immunosuppressed and are these people more susceptible to any side effects?

Will immediate household members and carers of people who are immunosuppressed or have high risk conditions be prioritised for access to the vaccine at the same time as those patients? If you have had COVID, do you still need the vaccine? Is there a greater risk of an adverse reaction for people with severe allergies to food e.g. seafood?

Outreach to vulnerable groups:  Will there be outreach vaccinations for high-risk groups, those from culturally and linguistically diverse backgrounds and those who have transportation barriers?  What arrangements will be made for home vaccination for people who are housebound or who cannot attend clinics? Will there be any special arrangements made for people with intellectual disabilities?  Many Aboriginal and Torres Strait Islander people have questions about the vaccine: are there any Aboriginal specific resources available or being developed?

Record of vaccination: How will Australians be able to demonstrate they have had the vaccine (for travel or other purposes)?  What audit or checking process will be in place? Will consumers be able to get proof of vaccination through My Health Record?  Will a vaccine certificate be issued for every receiver?

Immunity and efficacy : How long will the vaccine offer immunity for? Will it need to be given each year?  How long will it take to have enough people vaccinated to achieve herd immunity? Will the vaccines provide protection against the recently mutated strains of COVID-19? Is this continuing to be tested?

Health consumer involvement:  How have consumers been involved in developing the vaccine rollout strategy to date? How are you assessing consumer vaccine readiness to identify and address patient concerns about receiving the vaccine?  What are the principles of the vaccine rollout that ensures and enables transparency and clarity of information for consumers?

Part of the Federal Government’s vaccination campaign

Rise of misinformation and fears

Gabrielle O’Kane, CEO National Rural Health Alliance

The Alliance is most concerned about the rise of misinformation fuelling people’s concerns and fears about the rollout of vaccines in rural, regional and remote Australia.

There is currently a lack of coordinated information on the Phase 1A rollout of the Pfizer vaccine to health care workers in rural and remote communities outside the designated vaccination hubs.

We welcome the timing of TGA approval of the AstraZeneca vaccine, which may eliminate some of the logistical issues that seem to be emerging in relation to accessing the Pfizer vaccine.

We are in close contact with the Australian Health Department and we have been assured that overall, the needs of the rural, regional and remote communities are being factored into the planning as the vaccination program structure is established and the vaccines are rolled out.

(See earlier media release: https://www.ruralhealth.org.au/media-release/prioritising-rural-health-covid-19-vaccine-rollout)


Gaps, overlaps and vaccine refusal

Professor Julie Leask, Sydney Nursing School, Faculty of Medicine and Health; Adjunct Professor, School of Public Health; Visiting Fellow, National Centre for Immunisation Research and Surveillance

The main issues are getting people to the clinics/hubs and that will require people to be aware of when it’s their turn. People will also need more detailed information and they want it now, which is a challenge with the pace of things.

This is a massive coordination exercise between the federal and state/territory governments that’s not been done quite in this way[before]. States/territories usually have greater oversight of the program. So where those responsibilities meet up, we will see gaps or overlaps.

But people are ready and Australia does have a good track record in rolling out new and challenging programs quite well, such as the HPV vaccine.

Policies around what to do about vaccine refusal will become more a subject of debate as we go. For now, it’s a matter of getting the vaccine into the arms of the at least 60 percent of Australians who want it and then addressing the hesitancy of the 28 percent who are unsure.

I have not heard much about how government are working with Aboriginal and Torres Strait Islander communities but hope that the successes from last year can be carried over and that First Nations health practitioners are at the forefront of the work with communities.


Tackle the global supply crisis for developing nations

Lyn Morgain, Oxfam Australia Chief Executive

Our priority, as part of The People’s Vaccine Alliance, is to ensure fair and equitable access of vaccines for all – especially for the most vulnerable people, wherever in the world they may be.

So far, we’ve seen rich countries buying up far more of the vaccine than they actually need to cover their populations, depriving poorer countries of the chance to access the vaccines they need.

We’ve also seen pharmaceutical companies selling vaccines at a price that’s simply unaffordable for many developing countries.

This is not a time for profit-making and hoarding of information. Not only is it the right thing to do, but it’s in all of our interests to ensure that everybody has access to a vaccine and gets vaccinated as soon as possible.

This crisis has shown all of us how interconnected we are – we literally depend on one another for our own health, wellbeing and prosperity. It’s illogical and short-sighted for governments to only consider their own populations when designing their vaccine rollouts.

While the Australian Government has committed funding to support a vaccine rollout in our region, it and other wealthy nations can and should do more.

We want to see artificial barriers to tackling the global supply crisis removed to ensure as rapid a rollout as possible. This includes suspending intellectual property rules, sharing technology and ending monopoly control.

Pharmaceutical companies and manufacturers have the capacity to produce enough vaccine for everybody, but red tape and the pursuit of profits and monopolies are holding us up. This brings with it the risk that new mutations of the virus could emerge, possibly rendering our existing vaccines obsolete.

We urgently need open-source vaccines, mass produced by as many vaccine players as possible, including crucially those in developing countries.

(See earlier media release: https://www.oxfam.org/en/press-releases/monopolies-causing-artificial-rationing-covid-19-crisis-3-biggest-global-vaccine)


Vaccine hesitancy and nationalism

Terry Slevin, CEO, Public Health Association of Australia (PHAA)

We have every faith in the way the Australian leadership has tackled this extraordinary challenge and respect for people who have worked extraordinarily hard, but this is an unprecedented challenge. We also fully support the roll out of the vaccine program and the integrity of the TGA in its independent role of assessing the safety and efficacy of the vaccines it approves.

Some issues:

Vaccine hesitancy: Some people are reasonably making the point that ‘this is new and I would like to see it unfold before I put my hand up’ so I think we are potentially making a big mistake if that is depicted as being an anti-vaxxer. I think we have to give respect to people who are weighing up as best they can what’s best for them with them and their family and, in that process, be as open and as honest as we can with the evidence.

We are also seeing debate about which is the best vaccine, further generating anxiety in a highly anxious community. That’s not to say we shouldn’t have that public debate, but those participating in it should be cognisant of the extent to which they add to that anxiety.

Vaccine nationalism: Governments like Australia are being judged on how quickly they can vaccinate their countries. As a result, we have the prospect of low and middle income countries with fewer resources finding access much harder. Clearly the vast majority of cases in Australia are coming from people arriving from overseas so it is absolutely in our interests for all parts of the world to have equal and equitable access.

Equity challenges: Additional effort is needed to ensure vaccine is equitably delivered to the most vulnerable — rural and remote populations, Aboriginal and Torres Strait Islander populations, people who experience homelessness, mental health issues, all of whom are already at the forefront of vulnerability to COVID-19. There is recognition of that in the rollout plans, and an effort and determination to address those equity challenges, but of course the question is how well can we actually deliver.

Worrying questions: What worries me is the extent to which some of the almost inevitable adverse effects of some of the vaccine experiences might rock people’s confidence in the program. There are also lots of difficult questions we need to wrestle with. It’s been agreed that the vaccine shouldn’t be mandatory but the interesting question is: who should not be allowed to continue doing the job without the vaccine and to what extent does that become a problem mandating the vaccine?


Risk of worsening equity

Tim Senior, New South Wales GP

The overarching issue is vaccinating as many people as possible. Our health system is good, but certain aspects will make it harder. We have no central list (or practice registration) to invite people during the appropriate stages.

We do pretty well with child vaccination, but that’s a smaller population than adults, so I think flu vaccination is a better comparison. The Australian Immunisation Register will be really useful, and COVID vaccination will allow a push to make recording to the AIR mandatory for immunisation providers. (Some pharmacists haven’t been uploading flu vaccination to the register, I gather).

Vaccination for COVID will need to reach a scale that we’ve not achieved with flu vaccination. Doing mass vaccination will be on top of the regular work of the health system. (In phase 1b, for example, GP practices will be vaccinating on top of their regular work – I don’t think it can be done during routine consultations in 1b, which will need building of extra capacity, which may be hard in areas where recruitment can be difficult.

There will obviously be health equity issues – rural and remote vaccination, obviously, but also where there may be racism in the health services will make people reluctant to be vaccinated.

If we have a system of vaccination passports allowing people to travel or be exempted from local lockdowns, I would expect this to worsen health equity. If we don’t aim for health equity, we will have under-vaccinated communities, which will worsen their health, and also act as a reservoir for future outbreaks, including alternative strains.


Need to build vaccine confidence, with GPs at the heart

Dr Bruce Willett, RACGP Vice President

Our priority is ensuring general practice has appropriate support to help deliver a safe and fast COVID-19 roll-out. General practice is ready, willing and able to support this effort, with over 5000 practices applying to be a vaccination clinic.

It is an enormous task, and there are many challenges.

For now while we are in Phase 1, it’s critical that we can vaccinate as many of the highly vulnerable people as efficiently as possible.

The logistics of later phases will be addressed as the rollout progresses. However, we know that we need to ensure that everyone who can be vaccinated has the opportunity to. We need to reach communities in rural and remote Australia, Aboriginal and Torres Strait Islander communities, and culturally diverse communities.

We also need to build vaccine confidence in the community. And it all needs to happen as quickly as possible. It’s also important that the vaccine is made available to as many GPs on the frontline as soon as possible, for their protection, as well as the protection of their patients.

General practice is well positioned for this job. There are GPs working and living in communities right across our country. GPs can answer their patient’s questions and concerns, and help increase vaccine confidence and uptake.

This is especially true for GPs who engage with culturally and linguistically diverse communities and Aboriginal and Torres Strait Islander peoples. Furthermore, general practices provide a safe environment for vaccination, GPs can draw on a patient history and are equipped with the necessary medical training and facilities.


“Professionally insulting”

Karen Booth, President, Australian Primary Care Nurses Association (APNA)

APNA is concerned that nurses have been excluded from consultations regarding the COVID-19 vaccine roll-out, given primary healthcare nurses administer the majority of vaccines in Australia. Their experience in the logistics of managing  vaccines and the set-up of vaccine  clinics is  not  being considered. This is professionally insulting, particularly given that organisations like APNA have responded constructively whenever the government has  needed primary  health  care nurses to play  their  part  during  this  pandemic.

We are cognisant that the entire population will need to be vaccinated twice with  the  COVID-19 vaccines  and that this will overlap  with the annual influenza  vaccine  program. This will require pro-active management of consumer through-put, especially for the frail elderly and reaching at-risk and difficult to reach groups that nurses deal with regularly.

APNA is disappointed that this has been a missed opportunity to provide flexible funding to practices to implement models of care, such as to run nurse vaccination clinics onsite in general practice. APNA also has concerns that pulling GPs out of regular care services to process Medicare items will also exacerbate backlogs for chronic care, cancer screening and other care that has been set back by the COVID-19 restrictions. Whole practice payments could have been a better option than fee-for-service.

In other concerns, I think there will be a really high public expectation about getting access to the vaccines and a high sense of urgency, particularly for families of older people wanting to get them to the top of the queue. We welcome prioritising of hotel quarantine workers and Border Control people. The rollout to aged care is critical and will require advanced planning for consents for staff and patients, to ensure the process is quick and smooth. Reluctance by aged care workers and others in health care to get vaccinated could be a concern.

See this previous Croakey article: Why aren’t Nurse Practitioners involved in the COVID vaccine rollout?


Further reading:

Via AHHA: Dept of Health resources uploaded this week

COVID-19 vaccination – Consent guidance material for residential aged care

COVID-19 vaccination – Site readiness checklist for COVID-19 vaccination in residential aged care

COVID-19 vaccination – Consent process flowchart for residential aged care

COVID-19 vaccination – Planning checklist for vaccination day in residential aged care facilities

COVID-19 vaccination – Clinical governance requirements for COVID-19 vaccination in residential aged care

COVID-19 vaccination – Resource pack for residential aged care

COVID-19 vaccination – What to expect on COVID-19 vaccination day at your residential aged care facility

COVID-19 vaccination – Australia’s COVID-19 vaccine national roll-out strategy

COVID-19 vaccination – Forum on COVID-19 vaccines – summary

COVID-19 vaccination – ATAGI advice on influenza and COVID-19 vaccines

COVID-19 vaccination – Community pharmacy COVID-19 vaccine rollout from Phase 2A

COVID-19 vaccination – Phase 1B COVID-19 vaccine rollout – General Practice EOI process – Frequently asked questions version 2

COVID-19 vaccination – How to stay informed (newspaper poster for Aboriginal and Torres Strait Islander peoples)

COVID-19 vaccination – Australian COVID-19 Vaccination Policy

COVID-19 vaccination – Expression of Interest for primary care participation in Phase 1b COVID-19 vaccine rollout

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