The challenges of the vaccine rollout
After Australia’s pharmaceutical regulator, the Therapeutic Goods Administration, announced on Monday it had approved the Pfizer Covid-19 vaccine for domestic distribution, Prime Minister Scott Morrison and his health officials stepped out to reassure the public.
“We are ready to go,” Department of Health secretary Brendan Murphy declared.
But in sections of the health community that determination is tempered by confusion, anxiety and frustration. There is a creeping sense that despite its success tackling the virus, Australia is not as ready for this daunting next stage as it should be.
“I have [been] hearing concerns from particularly the GP community – who will be front line – that it’s not clear to them how this will all play out,” says Professor Catherine Bennett, chair in epidemiology at Deakin University. “This will be something that we’re learning as we go, so you just have to be careful about the promises you make.”
Doctors are not the only ones expressing concern. Some among the states and territories are also worried about a range of issues, not least supply, distribution logistics and cost-sharing.
Key officials say the next week will be crucial in determining whether the two levels of government – and the health networks – can be ready in the time proposed.
It is a mammoth task. Australia is preparing to join the largest-ever vaccination endeavour – a quest to inoculate against a virulent virus that has infected 100 million worldwide and taken almost 2.2 million lives.
Australia’s strategy will be divided into five phases, prioritising front-line health, border and hotel quarantine workers, disability and aged-care workers, and residents of care facilities and those with chronic underlying conditions.
This first group to be vaccinated is estimated to number 678,000. After that, the schedule ramps up dramatically to cover more than six million others, including those aged 70 and over, other health workers, senior Indigenous Australians, essential workers and younger adults with underlying medical conditions. The third group, of up to seven million people, includes those aged 50-69, younger Indigenous people and other high-risk workers. The rest of the adult population – another 6.6 million – is in the fourth group. Those aged 16-18 are last.
The Pfizer vaccine approval does not yet include children aged under 16. It is one of three vaccine candidates Australia has purchased and the only one approved so far. Most Australians will receive the AstraZeneca vaccine, which is still going through the TGA approval process.
While some doses of AstraZeneca will be imported initially, the bulk – some 50 million – will be produced onshore by CSL in Melbourne. The importance of this domestic production became clear earlier this week, on the same day the Pfizer vaccine was approved, when the import time line slipped, with Pfizer reporting it could not supply its initial doses until late – not mid – February with further slippage possible, into March.
The delay is the result of a supply shock overseas – the sheer volume of doses being required worldwide, due to the dire levels of infection in some countries.
Assuming the rollout may be delayed again to the beginning of March, the government will have, at most, 245 days to fulfil its promise to get the Australian population vaccinated by October 31.
Given each person needs two doses – with a three-week gap in between – a weekly vaccination rate of at least 1.43 million doses is needed to make the deadline.
The government anticipates it will start with 80,000 jabs a week. Scaling up from there will be a serious logistical challenge.
The government is proposing to establish up to 60 main hubs around the country for the first phase. This will involve the Pfizer vaccine, which needs to be transported and stored at a continuous minus 70 degrees Celsius.
Catherine Bennett warns that will be the easy bit. “The first phase with very targeted groups primarily defined by their residence or their workplace are, in some ways, more straightforward, because you’ve got an identifiable group who are most at risk and have the greatest investment themselves in wanting to have the vaccine and probably the highest uptake rates,” she says.
After that, it will get harder as the much bigger numbers also involve the need to persuade people to have what will be a voluntary injection.
The government has issued a call for GP practices to be involved in administering the vaccine in the tricky subsequent stages.
Australian Medical Association president Omar Khorshid expects many GPs will sign up. He is confident the government can reach the 1000 distribution sites it wants for the second half of the rollout’s first phase. But, as he told the senate Covid-19 committee on Thursday, that may not be enough.
“When you’re vaccinating 20 million people, if it’s only 1000 sites, that’s 20,000 per site – times two,” Khorshid said. “So that’s a huge burden for each of those sites and I suspect the rollout will need to be much larger than that.”
There will also be a cost burden, which GPs are seeking to have clarified.
“That whole issue about the cost base of this is going to be critical to that conversation because clearly the cost isn’t just the price of the vaccine,” says Catherine Bennett. “It’s the cost in someone’s time to actually administer the vaccine.”
Khorshid says many GPs will need to discuss issues with their patients – something requiring a proper, full consultation.
Melbourne-based emergency physician Stephen Parnis, a former AMA vice-president who has been at the front line of the Covid-19 fight, also believes using – and reassuring – GP networks is essential.
“From a science perspective, and as a doctor, I would not hesitate to have my family or myself vaccinated with this,” he says. “This now becomes a matter of logistics and politics.”
He advocates using pharmacies for vaccination – something he admits “might sound like heresy” to some doctors.
Health officials have confirmed that an official call to pharmacists is coming soon.
The government has also promised to design and build an online central booking system. The status of this project is not clear, although IT specialist Accenture has been contracted to provide it.
Work is also required to ensure those administering vaccines enter their patient details – and any evident side effects – on the Australian Immunisation Register. The record so far is not great. The government has been advised that the register of flu vaccinations is only 40 per cent up to date. The lack of baseline data for Covid-19 makes it imperative reporting rates are closer to 100 per cent.
While some of this vaccination infrastructure won’t be needed for the first half of phase one, buying the government some time, Omar Khorshid questions the government’s capacity to meet its current timetable, especially its first-month vaccination target.
“I do have some concern about whether that target of four million by March will be reached,” Khorshid told the senate’s Covid-19 committee, which held a hearing on the vaccine issue this week.
The government subsequently confirmed it probably won’t. International vaccine supply issues have forced a downward revision. “It will likely extend into the first half of April but that’s as good as we can say,” Brendan Murphy told the committee on Thursday.
Health administrator Jane Halton, who chairs the global Coalition for Epidemic Preparedness Innovations (CEPI) and is a former head of the federal Health Department, is “very confident” about Australia’s capacity to roll out the vaccine program.
“I think there will be bumps on the road and I think this early period will be difficult because we’re doing something we’ve never done before,” she tells The Saturday Paper. “And we are a bit hostage to global supply. But we have this huge advantage, which is domestic production.”
The global scrambling for access to vaccines has reignited the debate about equitable distribution and what is known as “vaccine nationalism”.
After the same behaviour led to poor countries missing out on vaccines against the H1N1 virus, CEPI – along with Gavi, the Vaccine Alliance – co-founded the COVAX facility to co-ordinate fairer vaccine access. This week, Norway’s Aftenposten newspaper reported that they had been nominated for the Nobel peace prize.
Halton is among those calling for wealthy countries not to trample over the poor. World Health Organization director-general Tedros Adhanom Ghebreyesus has made the same plea, as have the chairs of the independent panel examining pandemic readiness, former New Zealand prime minister Helen Clark and former Liberian president Ellen Johnson Sirleaf.
“Ultimately, we are relying on a combination of altruism and self-interest and goodwill,” Halton says of those appeals.
Europe’s threats to impose export bans unless its own countries have priority for the vaccine doses manufactured on their continent have done little to ease her concern.
“I continue to be worried when I hear language about export control,” she says. “I continue to be worried when I hear about countries who will vaccinate all of their populations before they even think about their neighbours or the vulnerable around the world. That does worry me.”
As the Australian government this week launches its $24 million educational advertising campaign about the vaccine, Halton advocates for better communication.
“Are we running behind? I don’t know what in front looks like in this world, because we’ve never been here before,” she says. “But I do think giving people as much detail as you have to give them a level of confidence [is vital]. I think that’s actually part of managing this.”
The Covid-19 vaccines are only confirmed to prevent illness, not the actual spread of infection. Work on that continues.
While surveys suggest 70 per cent of Australians are willing to be vaccinated, experts would like the number to be higher. That requires a detailed reassurance strategy to combat conspiracy theories and anti-vax sentiment spread online.
“The AMA is really keen to ensure that all Australians are adequately informed of … the benefits associated with the Covid-19 vaccine and it’s critical that we maintain public confidence in the vaccination process,” Omar Khorshid says.
Jane Halton insists nobody should panic about any initial slippage in the time line or any sense of tardiness in preparation. “We know that this will get sorted out,” she says. “Ultimately, we have an excellent health system and while we might want to speed this up and have it happen immediately, if it’s in another two or three weeks’ time, it’s not going to fundamentally cause us a problem.”
But Halton emphasises that is not an invitation to complacency.
“It is important because whilst we’ve done unbelievably well, we’re still running a risk all the time,” she says. “Whilst the virus is still running around, and it’s not going to go away, everyone is still vulnerable. And that is why pressing on the timetable continues to be important.”
This article was first published in the print edition of The Saturday Paper on Jan 30, 2021 as "‘Learning as we go’".
A free press is one you pay for. In the short term, the economic fallout from coronavirus has taken about a third of our revenue. We will survive this crisis, but we need the support of readers. Now is the time to subscribe.