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The Health Wrap: on COVID vaccine challenges, the latest climate and health news – and much more

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:

  1. Supporting healthy and resilient communities
  2. Health-promoting and emission-reducing initiatives
  3. Emergency and disaster-preparedness
  4. Education and capacity building
  5. Leadership and governance
  6. Research and knowledge
  7. A sustainable and climate-resilient health care sector
  8. 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