Jubilation over the imminent arrival of COVID-19 vaccines is justified, but must be tempered by the reality that a fast, safe, efficient rollout across a continent like Australia will be highly complex.
This makes last week’s release of a national COVID-19 vaccination policy an important development in how we will contain SARS-COV-2 in the future. Arrangements have been made with the developers of four promising candidates that, if successful, will begin arriving in 2021:
- Oxford/Astra Zeneca: doses to immunise 1.9 million people delivered, plus doses for 15 million immunisations manufactured in Australia
- University of Queensland/CSL: doses for 25.5 million immunisations manufactured here
- Novavax: doses for 20 million immunisations delivered
- Pfizer/BioNTech: doses for 5 million immunisations delivered.
The federal government has also signed a deal with COVAX, the global COVID-19 vaccine platform co-ordinated by the World Health Organization. The agreement secures enough doses of a successful vaccine to immunise half of the Australian population.
Just as well, because the frontrunner status of Pfizer/BioNTech is now challenged by Moderna, not on our short list but whose mRNA vaccine is showing high efficacy (although with some mild side-effects reported) without needing to be stored at ultra-cold temperatures.
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We are paying AU$123.2 million for our place in COVAX, with a further AU$80 million to support vaccine access in lower-income countries (LICs). That works out to be about AU$16 per immunisation excluding costs of storage, delivery and administering the vaccine on the ground (more on that later).
Pfizer has suggested that its product will be sold to the US government at US$39 (AU$53) per immunisation. Moderna suggests that its product will be priced at £38 to £45 (AU$68-81), with AstraZeneca and Oxford University indicating theirs will be £6 (AU$11).
All of these are excellent value for money. Consider that a successful programme would not only contribute to saving thousands, even tens of thousands, of lives, but also prevent another economic contraction approaching 10% of GDP.
The vaccines are most likely to arrive in batches, so there will not be enough doses to immunise everyone straight away. The national policy specifies three priority groups, comprised of people who:
- are at increased risk of exposure or with high transmission potential (e.g. health and aged care workers; quarantine workers)
- have an increased risk of developing severe disease or outcomes (e.g. Aboriginal and Torres Strait Islander people, older people and people with underlying select medical conditions.
- work in services “critical to societal functioning”.
Given the easing of restrictions and opening of internal borders, an additional group to consider may be so-called “super spreaders” — those individuals who come into close contact with a lot of people. Not easy to define, but certainly worth discussing if risk is to be managed.
Nevertheless, the initial supplies of the candidate vaccines listed should cover the priority groups.
Doses will be allocated across states and territories based on the number of individuals who qualify for prioritisation in each jurisdiction — far better than a per-capita allocation.
But competent implementation will be key. The vaccine will need to be rolled out quickly and efficiently, with minimal waste given the scarcity of the product. This will require an unprecedented level of co-ordination across jurisdictions, because all three levels of government will be directly involved in the rollout.
The immunisation sites listed fall under various jurisdictions, and include GP clinics, dedicated vaccination clinics, workplaces, in-reach teams to visit people’s homes and aged care facilities, Aboriginal and Torres Strait Islander Community Health clinics, pharmacies, and schools.
Storage, handing and logistics will be a particular challenge, especially for products like Pfizer’s that must be kept in ultra-cold temperatures. Such facilities are only be available in hospitals and regional centres meaning that people living in remote areas (a good proportion of the priority groups) will need to travel some distances to be immunised (most likely twice, given two doses of the vaccine will be needed).
Access to multiple vaccines with different storage and handling requirements will therefore be an advantage.
A big hurdle will be overcoming scepticism for vaccinations in general, and especially those seen to be rushed through. This fear is unfounded — Australia’s Therapeutic Goods Administration is among the world’s best regulatory bodies – but it exists, perpetuated and amplified on social media. A lot therefore hinges on government communication, which needs to be extremely clear and persuasive.
The whole exercise will also be a test for Australia’s digital health infrastructure, especially My Health Record (myHR). If there was ever a situation where a “one person one medical record” system is invaluable, this must be it. Those who will require immediate immunisation will need to be identified, contacted and encouraged to receive their jabs, then vigilantly monitored and followed up to assess effectiveness and spot any adverse effects as soon as they occur.
The current system for reporting adverse events following immunisation is paper-based. This must be addressed immediately to enable electronic linkage with relevant data sets such as myHR.
The need for two doses of the same vaccine is also a big challenge. It’s much harder to get people to show up for a jab twice within a specified timeframe. Given how scarce the doses will be, the fact that missing the second jab means that the first one is wasted is a big risk. In addition to good broad- and narrow-cast communication, Governments need to be smart about how they incentivise behaviour of both recipients and providers.
For recipients, it’s essential that the immunisation be free of charge. Co-payment and means testing will lead to a bad outcome. Financial rewards may be considered but are fraught with ethical questions. However, existing policies to encourage compliance, such as restrictions on accessing child care, can be used to guide the COVID-19 programme.
Incentivising providers will be similarly critical. As difficult as it may be to accept, remuneration plays a big part in health professionals’ decisions, with “normative pricing” often deployed to nudge activity towards more beneficial or efficient medical interventions.
The fee paid for administering the vaccine to the right recipient should be generous. Payment should be triggered when the second dose is administered to the individual or group. This will motivate providers, who hold a lot of sway with their patients, to follow up more vigorously than if they were paid per dose or paid up front.
The rollout will be complex, with costs exceeding those of the actual vaccines. We can expect immunising 70% of the population to carry a price tag of several hundred million dollars. But there’s no question it’s worth it, considering the suffering and economic destruction it may help to avoid.