The importance of equity in vaccination 

By Dr Maia Melbourne-Wilcox (FRNZCGP) and Professor Sue Crengle (FRNZCGP)

23 August 2021

The response of primary care in the coming weeks, will directly influence how severely our health system will be impacted by the current COVID-19 outbreak in Aotearoa. In addition to our usual BAU, we all have a crucial role to play with the vaccination roll out as well. 

The devastating effects of COVID-19 on countries, health systems and populations have been obvious internationally. We have all seen images and heard horror stories from all over the world, since this virus was first identified in December 2019. New Zealand has been relatively spared thus far, but the current COVID-19 outbreak, has the potential to change this since the confirmation that it has been linked to the infamous Delta variant of COVID-19.  

The science has been clear; public health measures like staying home in our ‘bubbles’, wearing masks, hand hygiene and physical distancing all have an important role to play in preventing transmission of the virus. This is one of the reasons we go into lockdown, to ‘flatten the curve’ to prevent overwhelm of our system with the sheer numbers. All of society has a crucial role to play in this and ensuring our communities are as protected as possible.

While vaccination against COVID-19 appears to help reduce transmission, it is also the best intervention to date to prevent serious illness, hospitalisation, severe complications and associated mortality. In Primary Care, we are well aware that it is in the prevention of severe COVID-19 infections and or other avoidable admissions that we will find our most significant contribution to reducing the burden on an already pressured health system. 

Vaccinating those who are at most risk of severe infections and worse outcomes from COVID-19, who are more likely to require hospitalisation, is one of the best tools we have in primary care to do this. 

Māori and Pasifika have experienced inequitable outcomes from all of New Zealand’s previous pandemics. Alas, COVID-19 appears to be no different. Analysis of New Zealand’s earlier COVID-19 outbreaks demonstrate clear and predictable inequities. Māori and Pasifika experienced a much greater burden of disease.  Māori were 2.5 times more likely to require hospitalisation for COVID-19 infection compared to non-Māori non-Pacific, even after adjusting for age and pre-existing conditions. The same study showed that the Pasifika population was 3 times more likely to be hospitalised [1]. 

Some of the reasons for this are well known and obvious. Māori and Pasifika are more likely to have a high risk of exposure to COVID-19 even at a level 4 lockdown, because of the demographics of our lower paid essential workers.  Māori and Pasifika are also more likely to be living intergenerationally, often in overcrowded situations and in sub-standard housing. These factors are all associated with increased transmission and worse outcomes from all respiratory illnesses [2], including COVID-19. 

Māori and Pasifika also have increased risks of adverse outcomes of COVID-19 due to a higher burden of long-term conditions like diabetes and cardiovascular disease. This increased burden is largely associated with inequitable access to determinants of health. The onset of these conditions also occurs at much younger ages in Māori and Pasifika populations.  

The current COVID-19 outbreak in Aotearoa which was only identified last week has the potential to be very severe, given that it has been confirmed that we are now dealing with the much more transmissible and deadlier Delta variant of COVID-19. 

This current outbreak also has the potential to be even more devastating and inequitable. This is in part because not all people who are at known to be at higher risk of complications from COVID-19 have been prioritised in the initial vaccine grouping system, and not all those who are in those groups have received either their first or second vaccinations. In the setting of community transmission which we are undoubtedly in, the vaccination roll-out plan is supposed to shift to focus on, where possible, ringfencing outbreaks, and then targeting those people who are most risk of severe infection, complications and hospitalisation. This would result in not only the protection of the populations who are at greatest risk, but will benefit of all of Aotearoa, by reducing the risk of overwhelming our health system, including hospitals, and limited number of ICU beds.

The urgent vaccination of these higher risk populations needs to be prioritised as a matter of national urgency. Primary Care has a unique opportunity to contribute meaningfully to reduce the impact of severe COVID -19 cases. While the analysis into the cause of the inequitable COVID vaccination rollout will be important for future planning, the role Primary Care has to be to focus on solutions to address the gaps and inequities that have resulted. The integrity of our entire health system may very well depend on it.

Because vaccine delivery is part of Primary Care’s bread and butter and with knowledge of and established connections with our patients, we are well placed to come up with solutions. We do however also have to acknowledge that even we, with our well-oiled systems, do not always do well in reaching and vaccinating all our populations equitably, even with the fully funded and routine vaccinations. It is likely that our standard methods of recall and or opportunistic vaccinations may not be effective enough to reach some of those who are at most risk from COVID-19.  Instead, specific and targeted measures will need to be taken and our endpoint needs to be the actual number COVID vaccinations given to these highest risk populations.   

Evidence from previous influenza vaccination programmes has shown that the strongest single factor influencing patient uptake of the influenza vaccine is a specific and personalised recommendation from a doctor or nurse [3].

What we can do

  • Decide to prioritise first dose vaccines for high risk populations including Māori and Pasifika over the age of 50, or those over the age of 12 with comorbidities and all hapū māmā (pregnant woman). Evidence suggests that this will save more lives at a population level and significantly reduce the burden of disease on the health system. This prioritisation of first doses in at-risk populations should be done over second doses, and first or second doses of the general public who are not at not at heightened risk.
  • Dedicate a non-contact staff member to call Māori and Pasifika patients to discuss the importance and potential benefits of the COVID-19 vaccine for them and their whānau (Ideally this would be by a qualified member of staff who is matched from both an ethnicity and or language perspective). This personal contact allows an opportunity to tailor information to them and their situation and provides an opportunity to allay any fears and or misinformation [3], maximising the chance of uptake.
  • Once this is done, follow up other at-risk populations in like manner.

Groups which require specific targeting in order to receive more equitable access to vaccinations have already been identified by Te Rōpū Whakakaupapa Urutā (the National Māori Pandemic Group) are [4]: 

  • kaumātua and elderly
  • people with long term health conditions
  • hapū māmā (pregnant women)
  • the unvaccinated whānau members of these three groups.

Once these groups have had their first dose, practices can then focus on other at-risk groups, including: 

  • Māori who are quintile 4 and 5 and those living in poor quality housing and overcrowded conditions
  • Homeless people, and those whose mental health may be impairing their ability to adequately care for themselves, isolate and follow public health advice. 

The focus should be on those who experience the most barriers to care AND those who are at highest risk of mortality and requiring medical attention in the future, if they were to contract COVID-19. 

Practices should maintain their systems that ensure people needing vaccination are kept separate from other unwell patients, to minimise risks and inadvertent exposure to COVID-19. 

We are confident that primary care is up for this important challenge, and again, has a vital role to play in reducing the impact of COVID-19 on whānau, communities, and our health system as a whole. 

We wish to acknowledge the work of Te Rōpū Whakakaupapa Urutā and give special thanks to Dr Jaclyn Aramoana-Arlidge for her insight, and to the RNZCGP, particularly the Equity team for their tautoko and contribution. 

References

[1] Steyn N, Binny RN, Hannah K, et al. Māori and Pacific people in New Zealand have a higher risk of hospitalisation for COVID-19. N Z Med J 2021; 134.
[2] Khieu,T et al. Modelled seasonal influenza mortality shows marked differences in risk by age, sex, ethnicity and socioeconomic position in New Zealand. Journal of Infection. 2017 75(3):225-233.
[3] Burns VE, Ring C, Carroll D. Factors influencing influenza vaccination uptake in an elderly, community-based sample. Vaccine 2005 20;23(27):3604–8
[4] Te Rōpū Whakakaupapa Urutā, 19 August 2021. https://www.uruta.maori.nz/unvaccinated-m%C4%81ori-and-pasifika-must-be-prioritised