In this latest edition of The Health Wrap, Associate Professor Lesley Russell investigates wide-ranging challenges facing the rollout of COVID vaccines, reports on the latest news in climate and health, and reviews a stack of recent reports – on topics ranging from aged care to mental health and palliative care.
She also pays tribute to some award-winning “brilliant minds”.
Lesley Russell writes:
A recent brief from the Kaiser Family Foundation outlines the massive national mobilisation effort that that will be required in the US to roll out a national vaccination campaign for coronavirus.
This effort must ensure supply under appropriate conditions of temperature and sterility, provide coordination across federal, state and local jurisdictions, address health care and racial inequities, and overcome public scepticism.
Although the focus is on the US, many of the same issues arise in Australia. How are they being addressed here?
Over the past fortnight I’ve collected an ever-growing list of articles about the critical but arguably hardest aspect of vaccination – delivering the vaccine shot/s into the arms of citizens.
In the United States
The initial vaccine roll-out could come ahead of Inauguration Day, thus enabling Trump to step down from the presidency claiming he has saved Americans from the pandemic.
The Centers for Disease Control and Prevention (CDC) is charged with making decisions about how the vaccines will be distributed, to whom, and the equipment and staff required at the state level –although these decisions might well be over-ridden by the White House, as has so often been the case previously.
The CDC and the National Institutes of Health (NIH) both asked the US National Academies of Sciences, Engineering and Medicine (NASEM) to identify and rank priority groups for vaccination. The NASEM report, which was delivered in October, is commendable for having a focus on equitable distribution and addressing the socio-economic factors that put minority racial and ethnic groups at increased risk of infection and reduce their access to healthcare services.
At the same time, the Advisory Committee on Immunization Practices (ACIP) was also developing vaccine allocation recommendations. To date it has issued a set of ethical principles; it says that “ACIP’s allocation recommendations will be made in conjunction with specific recommendations for the use of each FDA-authorized or licensed COVID-19 vaccine”. This dual effort could be complementary, but also means there is room for confusion and misunderstandings.
There is a difficult task ahead for the states, as the CDC has to date promised only US$340 million in assistance (and only US$200 million of this has actually been distributed). State health departments have asked for US$8.4 billion for this task, and even CDC concedes that they need at least US$6billion. The actual distribution plans will vary according to which vaccines are approved, as they have different cold storage requirements.
A recent article in The Washington Post is headed “Mass vaccinations against covid-19 will be ‘mind-blowing’ challenge for Alabama, other poor, rural states”. It outlines how public health departments, already strained by the pandemic, are working against the clock. They must expand online systems to track and share information about who has been vaccinated; recruit and train the doctors, nurses and pharmacists needed to give people their shots and collect data about everyone who gets it; find safe locations for mass vaccination events; and to convince the public of the importance of getting immunised.
Governors not only want more money but clear guidance and advice from the Federal Government, little of which is forthcoming. Hopefully this will change as the Biden transition team takes over. The Biden team will also have to address the trust gap and vaccine hesitancy – which are particularly pronounced in African American and Hispanic communities.
These slides, tweeted by Carolyn Johnson, science reporter at The Washington Post, highlight some of the concerns. 
In Australia
The Australian Government has recently released the Australian COVID-19 Vaccination Policy.
This describes the shared and separate responsibilities of the Australian, State and Territory governments, as well as other key stakeholders. Each jurisdiction, including the Australian Government, is to develop supporting Implementation Plans, which will articulate how they will give effect to the responsibilities under this policy.
The policy also sets out key principles, including that COVID-19 vaccines will be made available for free to all Australian citizens, permanent residents, and most visa-holders. It outlines how COVID-19 vaccines will be provided – on a rolling basis, dependent on vaccine delivery schedules and the identification of groups for most urgent vaccination.
The Health Minister has allowed that “the roll-out of a potential COVID-19 vaccine is a significant logistical challenge”. Others have described distribution as a “mammoth task”.
Internationally
A strategic advisory group at the World Health Organization (WHO) has developed a preliminary guidance for global vaccine allocation, identifying groups that should be prioritised, but not ranking these.
Many nations already have general vaccine-allocation plans, but they are tailored for an influenza pandemic rather than the new coronavirus. They typically prioritise children and pregnant women; the COVID-19 plans do not, however, because most vaccine trials currently do not include pregnant women, and the coronavirus seems to be less deadly to children than influenza is.
The WHO guidance acknowledges past failures and urges richer countries to ensure that poorer countries receive vaccines in the earliest days of allocation.
But the WHO proposal does not suggest how nations might resolve the tension between allocating vaccines in a country versus allocating them among countries. Questions such as “should harder-hit nations receive a bigger allocation of an early vaccine before other nations have a chance to dose their high-priority groups?” remain unaddressed.
An interesting review of national pandemic allocation ethics, published earlier this year by academics at the University of Sydney, is here.
Is it possible to have too many vaccines?
Around the world, 53 vaccine candidates are currently in human clinical trials and another 155 are in the research and development pipeline.
Aside from the mRNA vaccines produced by Pfizer and Moderna, vaccines completing Phase 3 trials or even in use include: a protein vaccine from Novavax; several viral vector products made by Johnson & Johnson, AstraZeneca, China’s CanSino, and Russia’s Gamaleya Research Institute; and a whole inactivated SARS-CoV-2 virus product made by Sinovac that is already being used in China.
On the basis of just a few small, fast clinical trials, vaccine manufacturers are already bringing their data and products to the regulatory agencies in the US, UK, Europe and Australia for approval.
Comparing the various vaccines will be difficult, as a great deal about the normal human immune response to SARS-CoV-2 infection remains mysterious, including which components of the immune system are pivotal, how long people may be protected by antibodies, and how commonly they may be reinfected. The vaccine developers use their own criteria for measuring antibodies and other aspects of volunteers’ immune responses.
In the US, it is expected that the Trump Administration will demand the FDA issues emergency use authorisations for at least one vaccine before Trump leaves office on January 20.
Incoming President Biden and his team will have little or no say in a process that will saddle his government with vaccines that may not be the best available and with billions of dollars in subsidy payments and committed purchases.
Australia too has made commitments to purchase vaccines ahead of any knowledge about the final results.
Finally, with all the (preliminary) vaccine results hitting the press, you might appreciate this self-confessed “rant” from Dr Hilda Bastian “Radical Vaccine Trial Transparency & Press Release Readouts: What’s the Problem?”.
Climate change and health
A coalition of 29 of Australia’s top health groups has called for the Morrison Government to apply the same level of urgency to climate change as has been done for the COVID-19 pandemic.
They argue it is clear that Australians are willing to make sacrifices if they understand the threat, and that appropriate actions now will lead to a better future for everyone.
The “Healthy, Regenerative and Just” policy agenda relates to, and builds on, the Framework for a National Strategy on Climate, Health and Wellbeing for Australia. It calls for all levels of government and sectors of society to integrate public health, climate preparedness and environmental protection measures. To this end it includes recommendations under eight Areas of Policy Action:
- Supporting healthy and resilient communities
- Health-promoting and emission-reducing initiatives
- Emergency and disaster-preparedness
- Education and capacity building
- Leadership and governance
- Research and knowledge
- A sustainable and climate-resilient health care sector
- Thriving ecosystems.
It is accompanied by an Open Letter to the Prime Minister.
The media release from the Climate and Health Alliance is here.
An article last week in Croakey from Dr Arnagretta Hunter, based on her presentation to the Australasian College for Emergency Medicine’s online conference (#ACEM2020), draws the connections between coronavirus, the climate crisis and caring for the planet.
And also from #ACEM2020, from NSW South Coast GP, Dr Michelle Hamrosi, this deeply personal account of surviving last summer’s fires and a plea for action on climate change, which is published in Croakey.
Make sure you catch this recent article from my Croakey colleague Marie McInerney: How can journalism do a better job of covering climate disasters?
It’s worth noting there are strong expectations that soon-to-be President Joe Biden and his Climate Change Envoy John Kerry will push the Morrison Government on its current climate change policies, despite denials from the Prime Minister.
Recent reports
As the end of the year approaches, it’s a struggle to keep up with the reports that are rolling out. Hopefully this list will help.
- Your health: Report of the Chief Health Officer, Victoria, 2018
This biennial report, just released, is available here.
Key among the issues discussed are:
- The health impacts of climate change.
- Health inequalities.
- Water – safe drinking water, water fluoridation and the issue of preventing and controlling potential public health impacts from microorganisms that can cause human illness in aquatic facilities (swimming pools).
- Injury prevention.
- Oral health.
- Results that change lives. FASD Research Australia Centre of Research Excellence Impact Report 2016-2020
This report is available here.
While there have been many positive changes, the report lists the challenges that remain:
- Conflicting messages about risks of drinking while pregnant.
- Limited diagnostic services.
- No evidence quantifying the economic impact of FASD.
- Lack of funding for high quality trials of interventions.
- No confirmed ongoing funding and infrastructure for a sustained program of education and training.
- No confirmed ongoing funding and infrastructure for national surveillance and national FASD register.
- Every person diagnosed with FASD has a unique set of challenges and strengths, so no one management plan suits everyone.
- Mental health services in Australia. AIHW
This online summary was recently updated to provide the most recent data available on the national response of the health and welfare system to the mental health care needs of Australians.
- Australian bushfires 2019-20: exploring the short-term health impacts. AIHW
This report – available here – examines a range of health data sources to assess the short-term health impacts of the bushfires, including:
- Emergency department visits.
- Prescription and purchase of asthma medicines.
- Mental health service use.
- GP visits.
There is are clear associations between increased bushfire activity, including poor air quality, and people seeking assistance for their health.
This report was nicely summarised for Croakey by Nicole MacKee.
- A snapshot of palliative care service in Australia. PM Glynn Institute, Australian Catholic University
This report, available here, Investigates and explores patterns in palliative care service provision, identifies gaps in palliative care provision, and identifies areas for policy action.
It particularly recommends the RPA-Concord integrative service model of palliative care.
Recommendations for action include:
- Development of a national policy framework for palliative care for children, adolescents and young adults.
- Make Advanced Care Planning a fundamental part of routine clinical care.
- Upskilling residential aged care staff and increasing the number of palliative care specialist staff.
- Strengthening the role of GPs in the provision of palliative care in the community.
- Prioritise the systematic and comprehensive collection of palliative care data.
- Develop strategies to foster a better understanding of palliative care among medical professionals and the public.
- Reforming aged care: a practical plan for a rights-based system. Grattan Institute
This report from Professor Stephen Duckett and colleagues (available here along with an explainer and a podcast) is a follow-up to a report released in October that explored a right-based approach to aged care as the start of the solutions needed in the aged care system.
In this second report, “Reforming aged care: a practical plan for a rights-based system” Duckett et al provide a road map for tackling the current inherent problems and delivering an aged care system that protects the rights, upholds the dignity, and celebrates the contribution of older Australians.
Yes, the Grattan model would require the Federal Government to spend 35 percent more than currently – initially an extra $7 billion a year and increasing as the population ages. But, as they point out, there would be returns on this investment which would create more than 70,000 jobs.
Three key changes are needed:
- Older Australians should have universal access to care with a new funding model that matches their individual care needs. This should be documented in individual support plans, portable between settings.
- These older Australians should have face-to-face help to obtain a range of diverse and high-quality service options. This would be provided by 30 regionally-based ‘system managers’ who would manage the local service system and accredit providers.
- Regional system managers and their community representative committees should enhance the independence of older people through social participation programs, promoting healthy ageing, and better integrating the aged care system with health care.
These initiatives must be supported by a national registration scheme to improve the staff training and remuneration and regulations to mandate minimum staffing ratios and 24-hour nursing supervision in residential care.
The system requires competent national stewardship and a comprehensive public reporting system to ensure efficient and equitable care, quality and transparency.
- COVID-19 Science Updates. CDC
This series, with a new edition produced every Tuesday, is the first of its kind for a CDC emergency response.
It provides brief summaries of new COVID-19-related studies on a range of topics, including epidemiology, clinical treatment and management, laboratory science, and modelling.
- The missing report
I understand that the final report from the MBS Review is now with the Minister for Health.
When can we expect to see it?
And will there be funding for this work to continue – so far the progress made in updating the MBS has been slow and implementation of the recommendations made has been really hard work.
The best of Croakey
As part of our social journalism practice, Croakey Health Media makes submissions to inquiries that align with our mission (have a read of our Strategic Plan). Recently, we released our Submission to Digital Industry Group Inc (DIGI) consultation on Disinformation Industry Code.
And here is our story about it: Federal Government urged to take a public health approach to disinformation on digital platforms.
The good news story
This week I’m celebrating Aussie science innovation and the sheer ability of our researchers to think outside the box to find solutions to problems that beset society, as highlighted in the 2020 Eureka Prize winners’ list. They are rightly described as “a diverse group of brilliant minds tackling pressing global problems”.
You can read more about this year’s prize-winners and how they are chosen on the Australian Museum website, in this article in The Conversation here and on ABC News here. 
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
