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How has NZ performed on vaccines?

Late last year commentators generally recognised the public were appreciative of the effectiveness (despite some blips) of the government’s elimination of covid-19 community transmission strategy. New Zealand was one of a very small number of countries to have single-digit numbers for deaths per million people.

But perceptive commentators also noted that this appreciative goodwill would dissipate if the vaccine rollout failed in 2021. Now, with some impact, National and ACT are hammering a message that the government has badly mishandled the rollout pointing to our low ranking in OECD vaccination rates as evidence. This is a strong message but that doesn’t make it right.

The deeper one digs, the less the validity of this message. There were two main hurdles for the rollout to overcome – high complexity and a huge power imbalance. To begin with, there were many uncertainties to be navigated through starting with suitable safety and effectiveness, followed by who was developing and owned it and cost. There were further difficult requirements for transportation, storage and distribution. Of necessity, the government worked with a range of global coalitions and partners in its vaccine search. Flexibility was needed to handle all these uncertainties and cope with changes in direction as vaccine development further progressed. By the end of 2020, NZ had secured vaccines through advance purchase agreements with four pharmaceutical suppliers. These were Pfizer, Janssen, Novavax and AstraZeneca.

Janssen is a single dose vaccine while the other three require two doses. This was an impressive achievement. The Pfizer agreement alone was more than sufficient to fully vaccinate the whole country. However, this may have contributed to hubris, with covid-19 response minister Chris Hipkins’ confusing assertion prior to Christmas about the country being at the front of the queue. Perhaps correct in respect of advance purchase agreements but not in respect of supply. Critical decision The next critical government decision was to make Pfizer our primary vaccine provider. This might have seemed unwise; putting all our eggs in one basket and with Australia opting for both Pfizer and AstraZeneca (the only two of the four vaccines that had completed clinical trials at this point). But there was good logic behind the decision. Pfizer had an efficacy rate of around 95% against symptomatic covid-19 seven days after receiving two doses. AstraZeneca’s efficacy was high but a little less.

But AstraZeneca had rung some alarm bells including clotting. Although satisfactorily addressed, it was clear that Pfizer was better placed to achieve critical public trust and confidence with vaccine hesitancy such a serious risk. Logistically, as confirmed by the subsequent Australian experience, it was easier to commence full vaccination with one vaccine. Multiple vaccines would add further complexity to implementation because of multiple protocol requirements.

In July, Medsafe gave provisional approval to use the single-dose Janssen covid-19 vaccine for those 18 years and above. This will mean an additional two million doses are expected to arrive in October although it is unlikely to be needed for this year’s rollout. It does put the country in a stronger position next year for distant locations, returning residents, and immigrants as well as boosters. This vaccine has a 67% efficacy. What about our low OECD vaccination rate ranking? Perspective is required.

NZ is a small economy negotiating in a sea of sharks and facing a major power imbalance in its negotiating position. Vaccine supply is controlled by large overseas pharmaceutical companies who seek profit maximisation. A small economy like ours can’t compete with bigger economies, several of whom are also vaccine producers. A majority of OECD countries are in the European Union which was able to negotiate as a powerful block (27 countries and 447 million population) as were other larger economies providing far greater markets (populations), particularly the United States (331 million), United Kingdom (66 million) and Canada (38 million).

Outside the EU the only country of similar population size to NZ (5 million) was Costa Rica which recently became the newest OECD member (38th). As of September 9, 29% of NZ’s population was fully vaccinated whereas the much larger economy of Australia (25 million population) was 33% (September 11).

Costa Rica’s fully vaccinated rate was 29% (September 8). Delta rethink The government’s plan was to ensure that all eligible New Zealanders would have the opportunity to be fully vaccinated by the end of 2021. The country was on track to achieve this until the uncertainty created by delta’s arrival. However, the deal bringing 250,000 additional Pfizer doses following complicated negotiations with Spain, European Union and Pfizer (followed by the 500,000 extra Pfizer doses from Denmark in a separate deal) removes this uncertainty. Nevertheless, there are some operational questions about the government’s vaccine implementation.

There is a question mark over whether the government could have purchased more vaccines from Pfizer at the beginning if it had been prepared to pay a higher price. When the Pfizer agreement was reached the delta threat was not fully known so this assertion is more hindsight analysis although still worthy of investigation. Although, prior to the lockdown, the vaccine rollout was progressing according to plan overall, in part at least this was because of increasing numbers for the larger group four coming in earlier.

But, unfortunately, many Māori and Pasifika eligible for groups two and three were missing out. It might have been that being more dispersed they were difficult to access. Perhaps the focus should have been more economic deprivation focussed based on larger easier to identify communities where low incomes and overcrowding were prevalent. This would have picked up many Māori and Pasifika without requiring a specific ethnicity lens.

Once the greater severity of the delta variant became known planning should have commenced to ensure early vaccination for essential workers working outside border security, quarantine and the health system. Supermarkets, some of which became ‘places of interest’ are obvious examples. Unfortunately, supermarkets only became the focus after delta’s arrival.

A marathon, not a sprint The government would do well not to use altruism as a justification for the rollout schedule. Aotearoa is such a small market that our original Pfizer agreement would have made minimal difference to poor, low unvaccinated countries; these countries require an international supply solution. If the altruism argument was genuine, the government should have delayed the rollout a year and certainly not procured the additional 250,000 doses from Spain.

In assessing the government’s overall performance in the vaccine rollout, caution is required when comparing our vaccination rate with those of other countries as they can change quickly. At one stage the United Kingdom was well ahead of European countries. Now, these countries are catching up and some have passed it.

NZ is now ramping up and has one of the highest acceleration rates internationally. Even if NZ’s vaccination rates were higher when delta arrived we would still have had to go into lockdown. Singapore has one of the highest vaccination rates at 80% but is now having to consider imposing restrictions because of a delta outburst. NZ punched above its weight to achieve what it did both in the pre-delta period with its Pfizer supply and with the additional Pfizer supply given the enormous complexity and power imbalance it faced. We remain on track to ensure that all New Zealanders will have the opportunity to be fully vaccinated by the end of this year. This would be no mean feat.

ABOUT THE AUTHOR Ian Powell guest Ian Powell is a former executive director of the Association of Salaried Medical Specialists.

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