A finely tuned logistical machine will pump Covid-19 vaccines to hundreds of distribution points around the country from the second half of the year, allowing people to get vaccinated by newly-trained health workers at their GP or pharmacy, but also at community centres, marae, churches and more.
At least, that’s the hope.
The rollout of the Covid-19 vaccine to the general population will be one of the greatest logistical undertakings New Zealand’s health system has ever engaged in. Never before have so many people – experts estimate the herd immunity threshold is around 70 percent, though there’s no harm in overshooting that – been vaccinated in such a short period of time.
We also have the benefit of being able to learn from other countries’ mistakes. Given we have eliminated community transmission of Covid-19, New Zealand doesn’t face the same pressures to roll out vaccines as other parts of the world. Overseas, regulators have had to issue emergency authorisations on preliminary data, whereas Medsafe here is taking a fast-tracked approach but one that will still check all the usual boxes.
“There is no ‘emergency use authorisation’ in New Zealand. Those countries that have issued emergency authorisations have not approved (registered, licensed) the vaccines. They have issued these based on very limited data in the context of public health emergencies in their countries,” a spokesperson for the Ministry of Health told Newsroom.
Instead, Medsafe is likely to issue a provisional approval for the vaccines.
“This is a time limited, conditional approval. This pathway allows for medicines (eg vaccines) to be approved in New Zealand, often based on less available data from clinical trials when there is a significant clinical need or risk for early access. This pathway sets a time limit and allows us to place conditions on the approval, such as only approved for specific patient groups, require specific monitoring of patients or to require additional data to be provided by a certain time,” the spokesperson said.
“We have streamlined our approval processes to move swiftly, but without rushing or compromising safety in any way.”
Likewise, the chaos of the pandemic and ongoing economic disaster overseas has meant almost every country deploying vaccines – most started in December – have missed their targets so far. The United States, for example, vaccinated just 2.1 million people by the end of the year, when it had hoped to immunise nearly 10 times more by that stage. In order to meet its own target of vaccinating 13.9 million people by mid-February, the United Kingdom will have to vaccinate more people in each of the next four weeks than it has over the past month and a half.
There are lessons to be learned from these errors even as New Zealand shapes up for what one expert called a “mammoth undertaking”.
Nikki Turner, an associate professor in immunology at the University of Auckland and the director of the Immunisation Advisory Centre, says understanding our vaccination strategy is key to understanding why our rollout might not resemble that of other countries.
“New Zealand’s in an enviable position that we have time to plan in a way that Europe and North America didn’t,” she told Newsroom.
“They’ve got rip roaring disease, so they have a need to vaccinate as many people as fast as possible. Our situation is very different. That’s really important for us to recognise – we want to vaccinate, we want to get protection for our population, but there’s not that driven emergency to do it all at once. We will not be in that position unless we suddenly get lots of community transmission.”
Turner emphasises this repeatedly – our rollout will not look like the United States’ or the United Kingdom’s because we are trying to accomplish different things.
“It’ll be sequentially delivering from the highest needs first. Not trying to vaccinate the entire population all at once, which is essentially what the UK’s trying to do. I think that there’s a bit of confusion with people assuming we’re going to do what the UK and America are trying to do at the moment, but we will do a more planned, more sequential approach.”
She says there are a few different reasons to vaccinate an individual or target a particular community. The simplest is individual protection – the person who gets the vaccine is protected against the disease. The early components of our rollout will be based on individual protection, vaccinating people most likely to contract the virus (border-facing workers, health workers and staff in managed isolation) and those who would suffer the most if they caught it (older people and others who are more vulnerable to more severe illness).
Then there’s ring protection, where people around a vulnerable population are vaccinated.
“For example, in rest homes, you target the rest home individual people, but you’d also target everybody around them. So you ring protect everybody around vulnerable communities,” Turner said.
In a way, vaccinating border workers first is a form of ring protection for the rest of the country as well.
Finally, there’s vaccination of the general population in the pursuit of herd immunity.
“If these vaccines do show they have the potential to stop or reduce spread, then the better strategy for New Zealand would be widespread community vaccination. And I think, ultimately, that’s what we would aim towards,” Turner said.
“But there’s a couple of blocks. Firstly, we don’t know how effective the vaccines will be at that and secondly, at this stage, we don’t have any data on vaccine effectiveness and safety for children under 16 and pregnant women. We are waiting for that data because that will then support a broader community vaccination strategy.
“Depending on vaccine supplies, you do first your strategy of individual protection, secondly you try to ring protect the high risk and then, assuming the vaccines are going to work effectively, then you’d broaden it out to full community immunity.”
Potential supply and IT issues
The two major potential roadblocks are supply of the vaccine and the logistical challenges of distributing it from the ports to the arms of 70 percent of the country’s population.
On supply, New Zealand has arrangements to purchase enough vaccine to immunise the country twice over. However, not all of these vaccines will arrive in 2021 and they are not all guaranteed to receive Medsafe approval either.
The lead candidate, an mRNA vaccine developed by Pfizer and BioNTech, has been approved by much of Europe and North America. New Zealand has an agreement to purchase enough of the Pfizer/BioNTech to vaccinate 750,000 people. The Government has also secured enough of another leading vaccine, developed by Oxford and AstraZeneca, to immunise another 3.8 million people.
Alongside these, the Government has purchased 5.36 million courses of the Novavax vaccine and 5 million of the Janssen Pharmaceutica jab.
We won’t be receiving these all at once – Turner says it will come in stages. The Ministry of Health says, as long as Covid-19 is still eliminated, that border-facing workers and certain high risk health workers, as well as their household contacts, will be first in line. Then other vulnerable frontline health workers and public sector and emergency services staff will receive the jab. Vulnerable groups in the community and the rest of the health and social services workforce will be next in line.
The first vaccines will be delivered in the second quarter of the year (the Ministry of Health is aiming for April) and vaccination of the general population is likely to start in July or August.
New IT systems are also being developed to aid with the rollout. The 15-year-old National Immunisation Register, a database for all vaccinations given to children in New Zealand, as well as some adults, will be replaced with a new database accessible to all health workers. It will also enable members of the public to see their own vaccination records at any time.
A brand-new inventory management system will track volume, expiry date and temperature of Covid-19 vaccines around the country, allowing officials to distribute vaccines in such a way as to minimise waste.
Logistics a ‘mammoth undertaking’
“I’ve seen the plan as it’s being developed, it’s a mammoth undertaking and there’s a lot of people who are logistics experts working on it,” Helen Petousis-Harris told Newsroom.
Petousis-Harris is an associate professor in vaccinology at the University of Auckland and the chair of the World Health Organisation’s Global Advisory Committee on Vaccine Safety.
Turner was more optimistic, saying the staged rollout was more akin to engaging in multiple successive flu vaccine campaigns.
“Every year, we vaccinate 20 to 25 percent of the population with flu vaccine. And this vaccine’s going to come in a sequential fashion. So, yes it’s big, but we already have a lot of experience from doing the flu vaccine. It will be sequentially delivering from the highest needs first,” she said.
But Petousis-Harris said the rollout is unprecedented.
“The New Zealand MB programme, which was the meningococcal programme, was until now the biggest thing. That was until age 20. We did really well where it occurred in little ones in daily practices and in schools, so we hit those targets quite well,” she said.
“But once you started getting into those older age groups, the people who left school, they’re not necessarily captured anywhere. This is definitely going to be one of the challenges, which is how do you access people equitably, across the country?”
Turner says there are lessons to be learned from the latest flu campaign, which saw a record number of vaccines delivered – albeit with a few distribution hiccups.
“The New Zealand Government’s really committed to trying to really reach out and close the equity gap, and reach out to communities that traditionally don’t have such ease of access. There’s a lot of thinking going into how to improve ease of access to communities that miss out. We put a lot of extra effort in last year for the flu vaccination campaign and actually did get the highest coverage and got higher rates to older Māori communities and communities that miss out,” she said.
“You do your traditional approaches. So that’ll be general practices and pharmacy based delivery and occupational health delivery for frontline health sector and for border staff, and then there’s a range of other options dependent on the communities. You go out more, you do more outreach.”
Turner said the Covid-19 campaign could involve drive-through clinics, as happened with the 2020 flu vaccine rollout. It could also take place in marae – after consultation with iwi – in Pasifika churches, in the Community Base Assessment Centres that currently do Covid-19 testing.
“It’s about using local community sites that work for local communities,” she said.
Cold chain distribution
Petousis-Harris told Newsroom that the rollout will not be heavily reliant on distribution at first.
“The first ones will be centralised. Those vaccines will not go to primary care, they’ll be centralised for border workers. I don’t think there’s any intention of using our normal systems to administer those RNA vaccines because of the cold storage requirements,” she said. The mRNA vaccines like Pfizer’s – as well as the Moderna vaccine which New Zealand has yet to secure a purchase agreement for – must be stored at 70 degrees below freezing prior to administration.
These will be stored in nine large freezers capable of reaching -80 degrees, the Ministry of Health spokesperson told Newsroom. These freezers can store more than 1.5 million doses of vaccine – our entire Pfizer/BioNTech order – and “will become our central storage facility for vaccine that requires ultra-low temperatures”. Many will be installed in Auckland with a possible few in the South Island, but the details have yet to be confirmed, the spokesperson said.
Efforts to purchase more freezers are also underway.
Some of the mRNA vaccines can then be defrosted and stored at between 2 and 8 degrees for up to five days. The Ministry will roll out a cold storage chain to various regional centres, to which vaccines will be dispatched from the main nine freezers.
“We plan to distribute vaccines from our central storage facilities in a very controlled way to our cold chain network nationwide, which will ensure all New Zealanders have access to our immunisation programme,” the spokesperson said.
“This will require strict inventory management and tracking to ensure the vaccine is given to people within its short expiry time once out of ultra-low temperatures. It is very different to many vaccines, which typically can remain in cold chain fridges for months or years.”
“As you start rolling this out to the wider population, then you can start accessing people through their normal channels. But you also have to up your vaccinators – those people who have been trained to actually administer those drugs. That’s quite a hurdle, you can’t just throw the biggest mass vaccination campaign New Zealand’s ever seen at your already overburdened, overworked workforce,” Petousis-Harris added.
Turner’s Immunisation Advisory Centre is helping to train more vaccinators and the Ministry of Health says it is liaising with DHBs on workforce development.
That will include student nurses, student pharmacists, recently retired health professionals and other people in the health sector who hadn’t traditionally vaccinated, like paramedics and other people who have annual practising certificates within the health sector but weren’t traditionally vaccinators. Many of these people are on the list of health workers drawn up during lockdown who might be called into ICUs in the event of a surge of Covid-19 cases. Now, they’ll be called on to prevent a surge from ever threatening the country again.
The Ministry of Health says it plans to hire between 2000 and 3000 new full-time (or equivalent) staff to put needles in arms.