Part 2: The challenges of planning for a large-scale immunisation programme

Preparations for the nationwide roll-out of the Covid-19 vaccine.

2.1
The Covid-19 immunisation programme will be the largest ever carried out in New Zealand. It aims to vaccinate as many New Zealanders as possible, as well as provide vaccines to the Cook Islands, Niue, Tokelau, Samoa, Tonga, and Tuvalu.

2.2
For the immunisation programme to be successful, there are a substantial number of inter-related elements that need to come together at the right time. There is also a lot of uncertainty, for example, about the potential uptake of the vaccine. There is pressure on the Ministry to move at pace to roll out the vaccine, and there is a high level of public interest. The Ministry has also decided that ensuring that there is equitable access to the vaccine – that is access in a way that meets social, linguistic, and cultural needs – is important. All these factors make planning and managing the immunisation programme particularly complex.

2.3
In this Part, we describe some of these complexities, including:

Determining who will get vaccinated and in what sequence

2.4
For the immunisation programme to be successful, vaccines need to be administered to as many people as possible. The health and disability sector needs time to build capacity to manage vaccinations on a large scale.

2.5
The Government has decided to prioritise vaccinations based on need. The largest group of people to be vaccinated will be the general population. Vaccination of this group is scheduled to begin from July 2021. Decisions might still be required about whether it makes sense to further sequence the order that people are vaccinated in this group.

2.6
The sequence will affect the logistics of the roll-out. Some options will be simpler to implement – for example, fewer larger locations will make distribution easier. Focusing on one geographical area at a time could help if there are not enough trained vaccinators in all parts of the country. With each option there are likely to be trade-offs. Large vaccination centres, for example, might not be effective for certain communities.

2.7
It might make sense to depart from the sequence in some circumstances – such as to minimise vaccine wastage or allow health care providers in certain areas to move ahead of the sequence if they are well positioned to do so.

2.8
The Ministry wants to ensure that there is equitable access to the vaccine, with a particular focus on Māori and Pasifika communities and people with disabilities. Equitable access means ensuring that everyone can access the vaccine in a way that meets their social, linguistic, and cultural needs.

2.9
Parts of the roll-out, such as where vaccines will be administered and who will be administering them, will need to be tailored for different communities. Although this approach is likely to have better outcomes for these communities, it adds to the complexity of the immunisation programme. The Ministry can plan, co-ordinate, and monitor the programme, but district health boards and the wider health and disability sector have a significant role in its implementation.

2.10
District health boards are expected to work with other health care providers to understand their capacity and make decisions about how to get the vaccine to their communities.

The logistical challenges

2.11
One of the key decisions for the Ministry has been to decide where people will be vaccinated. Getting the vaccine to some communities will be a particular challenge, such as communities in rural or hard-to-reach locations, or communities that have less direct access to the health system or have less trust in health care providers. The Ministry and district health boards need to choose options that will help reach as many people as possible (and provide equitable access), while also keeping the roll-out as simple as possible so there are fewer variables to plan for.

2.12
The Pfizer vaccine has storage requirements that make transporting and storing it complicated. It must be stored at a temperature between -90˚C and -60˚C. It can also be stored at -20˚C for two weeks. However, after it has been thawed, it must be stored at a temperature between 2˚C and 8˚C and used within five days. Any thawed vaccine not used after five days will be wasted.

2.13
Booking systems are expected to provide sites with information that will allow them to forecast the amount of vaccine they need. However, not everyone will show up for their appointment and there will need to be provision for people without appointments (walk-ins). This makes it challenging for the Ministry to work out how to ensure that enough vaccine doses are available at vaccination centres when they are needed, while minimising wastage. This might require having a process in place to move vaccines between vaccination sites. The Ministry will need to consider what level of wastage is realistic in these circumstances and be open with the public about what is likely to occur.

Ensuring that there are enough vaccinators

2.14
The Ministry needs enough vaccinators to vaccinate about 4.23 million3 people by the end of 2021. The number of vaccinators and other staff required depends on the types of delivery model used. To estimate the required workforce, there needs to be clarity about how each district health board is planning to roll out the vaccine in its community.

2.15
There are currently about 12,000 health care practitioners authorised to vaccinate in New Zealand. The Ministry expects that most vaccinators for the Covid-19 vaccine will come from this group. However, these people are already working in the health system. If they are diverted to administer Covid-19 vaccinations, other health services and immunisation programmes, such as for influenza and measles, could be affected. Some of the health workforce are already involved in testing people, including border workers, for Covid-19 to support the wider Covid-19 response. Most of the health workforce will not be able to work full-time administering Covid-19 vaccinations, so there needs to be a wide pool of vaccinators to draw from.

2.16
If the Ministry and district health boards cannot source enough vaccinators from the “regulated workforce”,4 they will need to decide where to source additional vaccinators. Non-regulated groups will need extra training and support before they meet the requirements to administer vaccinations.

2.17
As well as vaccinators, district health boards will need to source staff to help run each vaccination site. This includes staff who can take people’s details and monitor them after they have received their vaccine.

Developing fit-for-purpose information systems

2.18
The Ministry needs to be able to identify the individuals to be vaccinated, and monitor and report on who is being vaccinated to ensure that the vaccine reaches all communities. This requires a range of capabilities, including having the right information technology systems in place.

2.19
A number of systems are needed to support the nationwide roll-out, for example, to record vaccine stock, identify where vaccines need to be delivered, and manage bookings for people to have vaccinations. These systems might also need to interact with each other and with other systems, such as patient management systems used by other health care providers.

2.20
The Ministry has decided that these need to be national systems so that vaccine distribution, uptake, and possible safety issues can be centrally monitored. Some of these systems are already in place. For example, there is a national immunisation register and a national system for recording adverse reactions.

2.21
However, systems are not currently equipped to manage the scale of the immunisation programme. The existing systems will need to be significantly upgraded and, in some cases, new systems will need to be built. All of these systems need to be ready as soon as possible, and before the roll-out to the general population. In the meantime, a range of workarounds are in place. The Ministry will need to work out if, when, and how it will transfer data collected in the early stages of the roll-out to the new systems when they come online.

2.22
The National Health Index contains some data about the New Zealand population, but there are gaps. Not all groups will be identifiable through the National Health Index’s data. The Ministry will need to decide whether, and how, it will supplement the National Health Index’s data so that it can identify certain communities to invite to be vaccinated and monitor uptake. This is important to understand whether any overall goal for vaccination, as well as specific equity objectives, are being achieved.

Contingency planning for multiple scenarios

2.23
The immunisation programme needs to be able to adapt to a range of changing circumstances.

2.24
The immunisation programme has been developed, and will be implemented, with an ongoing risk of a Covid-19 outbreak in the community. Depending on the extent of any community transmission, different parts of the country might need to go into different alert levels. This could significantly affect the immunisation programme. For example, people working on the immunisation programme might be diverted, reducing the availability of the health workforce to run both vaccination sites and carry out Covid-19 testing or provide care if there is a severe outbreak. Changes in alert levels might also reduce people’s willingness to attend vaccination centres.

2.25
Alongside the risk of community outbreak, there are a range of other challenges. New variants of the virus could diminish the effectiveness of the current vaccines or require them to be used differently. The immunisation programme will also need to keep up with the rapidly evolving science about who the vaccine is suitable for and how it should be delivered. For example, if it is determined that some or all people under 16 years can be vaccinated, the Ministry will need to decide whether and when to start vaccinating this group.

Building confidence with effective communication

2.26
The speed at which the immunisation programme is moving is likely to mean that members of the public have questions that the Ministry might not be able to answer yet.

2.27
Clear and transparent communication that is tailored to different audiences is essential so that people know what to expect and can plan accordingly. This will help to build confidence in the immunisation programme. It will also be important to provide assurance to the public that getting vaccinated is not just safe for themselves, but for all New Zealand.

2.28
With such a large immunisation programme, and one that is implemented in a context of considerable uncertainty, there will likely be problems. The Ministry will need to consider how to manage expectations about what can realistically be achieved, while at the same time building public confidence in the immunisation programme.

Progress so far

2.29
The first vaccines arrived in February 2021. The first vaccinations were administered to border workers on 20 February 2021. These first vaccinations were administered while the processes and systems needed for the wider nationwide roll-out were still being developed.

2.30
Early progress has relied largely on existing vaccination staff, a range of manual processes, and locally designed workarounds. Some of what is in place right now will not be sufficient when the immunisation programme is vaccinating much larger numbers.

2.31
The first group to receive the Pfizer vaccine was border workers and the people they live with. On 12 March 2021, the first person received their second dose of the vaccine. By 12 May 2021, 268,787 people had received their first dose of the vaccine and 120,090 people had received both their first and second dose.

2.32
The first vaccinations for border and managed isolation and quarantine staff occurred primarily at managed isolation and quarantine facilities in Auckland, Hamilton, Christchurch, and Wellington. The largest number of vaccinations administered was in Counties Manukau.

2.33
Vaccination sites were scaled up rapidly during February and March 2021. By 23 March 2021, more than 100 vaccination sites were in operation, including at hospitals, community pop-up centres, medical centres, and marae. By 7 April 2021, all 20 district health boards were administering vaccines.

2.34
District health boards have been responsible for identifying who needs to be vaccinated and inviting them for a vaccination. So far, district health boards have used their own booking systems and recorded information when people are vaccinated in the newly developed national Covid-19 Immunisation Register.

2.35
To manage the complicated storage and transport requirements of the Pfizer vaccine, district health boards have been estimating how much vaccine they will require and the Ministry has organised for the vaccine to be delivered when needed. This model works for the delivery of smaller amounts of the vaccine but, in our view, will not be sufficient as the amounts increase when the nationwide roll-out scales up.

2.36
The workforce needed for the nationwide roll-out includes vaccinators and staff who provide a range of support services. Training for vaccinators is under way. More than 4000 health care professionals have been trained so far to administer the Pfizer vaccine. Significantly more vaccinators will be required when the immunisation programme is fully scaled up.

3: This is the total number indicated in the vaccine roll-out plan. See Ministry of Health (2021), Our COVID-19 vaccine rollout plan at covid19.govt.nz. Each person will need two doses of the Pfizer vaccine.

4: The regulated workforce are those working for a health care profession regulated under the Health Practitioners Competence Assurance Act 2003, such as doctors, nurses, paramedics, and midwives.