Dr Tarun Weeramanthri, President, Public Health Association of Australia
Vaccination is a key element of Australia’s COVID-19 strategy for 2021. At the moment, there is a heated public debate about the mix of vaccines that should be used in Australia. But let’s step back a bit. On the surface, this is a debate between experts about technical issues (relative efficacy, prevention of disease vs. prevention of infection etc.). All the things that epidemiologists, trained and armchair, have been grappling with for some time. But on a deeper level, the issues are about who should decide, what criteria should be used, and the role of experts and expertise in the process.
My view is that the current Australian government approach is reasonable. And that the success of the vaccination strategy from a public health point of view will depend not so much on the precise choice of which safe and effective vaccines to use in the early months, but on the distribution and communication strategy over the coming year, both in Australia and globally. Fairness is the key principle that needs to be kept front of mind.
No one doubts that Australia has responded to COVID-19 very effectively, compared to other countries. Our political response has been based on sound public health principles, and a health system and regulatory infrastructure consistent with our status as an economically privileged nation. Public trust in government has risen as a result. This does not mean that everything from now on must be accepted uncritically, but it should count for something when we consider the vaccination strategy announced.
The Australian government acted last year to secure vaccines from potential international suppliers, and to promote vaccine research, development and manufacture in Australia. It also entered into a multilateral agreement to join the global vaccine initiative, COVAX. There was no way of knowing which vaccines would get through the development phase, so a range of pre-purchase agreements were made.
With a high proportion of the vaccines having demonstrated their efficacy in phase 3 trials, we are now in an incredibly fortunate position as a country, with a sound proven regulatory agency in the Therapeutic Goods Administration (TGA) looking through the data in detail. They will grant full approvals when they deem it appropriate. I remember the debate in 2009 about the novel pandemic H1N1 vaccine – it was vital for public trust that it got full approval, not emergency approval. We need to act as fast as possible, but as Australia has very few COVID-19 cases, we don’t need to take any shortcuts. The public will know that all COVID-19 vaccines approved are safe, effective and have been through the same thorough vetting as other vaccines. This is a good basis for promoting vaccine uptake, and a necessary defence against vaccine scepticism.
Once approved, Australia will have enough vaccines to help protect those potentially most exposed (quarantine and border workers, health staff etc.) and those most at risk (aged and disability care, and other populations) from serious COVID-19 disease and death in the first months of 2021. As, over the year, we move on to vaccinating other groups in a staged manner, it seems more than reasonable to use the vaccines already purchased, even if we cannot be sure of the total population effect in terms of prevention of further transmission. Further trials may provide data on that transmission effect, or on dosing that further increases efficacy of particular vaccines. The TGA will tell us, and the Australian Government will also be able to use information, as it comes in, to guide future purchasing decisions.
As Australian citizens, we are, truth be told, already privileged. If a single vaccine was to be distributed globally and you were compiling a priority list of countries to receive it on the basis of need, Australia would be down the bottom because of our success in controlling COVID-19. The COVAX initiative, which Australia is a signatory to, has the principle that all countries should receive enough vaccine to cover 20% of their population before any one country receives more. Even if all vaccine suppliers completely meet their most optimistic manufacturing projections, there will still be a global shortfall of many billions of doses by the end of 2021. From a global equity point of view, we cannot afford to waste vaccines.
Experts also need to be given some credit for their expertise. Epidemiology and vaccine expertise is tough to attain, and the members of our expert advisory committees (e.g. Australian Technical Advisory Group on Immunisation or ATAGI) and regulatory authorities (such as the TGA) have been appointed for a reason, usually based on decades of work. As a generalist public health physician, I would never second-guess such advice, and would always want to read their detailed analysis and hear their thinking, how consensus was achieved, and whether there were any outlying or minority views. The strengths in such expert systems need to be recognised as we weigh up other opinions. Transparency and explanation of reasoning are critical, as the evidence (and hence advice) may change as new data comes in. Such expert advice is separate to decision making (which is often, rightly, the province of elected politicians), and expert commentary (academics, professional bodies and the like in the media) which has its own value and limitations.
In summary, the national vaccination strategy – as currently announced – seems fair, and sound public health practice, as it is based on expert advice and systems, and seeks to protect the most exposed and most vulnerable. It therefore represents a good use of a scarce resource and decent value for money. It is also appropriately cautious and likely to engender public trust. Let’s use the vaccines we’ve got, derive the evident benefits they bring, and think about future purchasing and distribution, aligning our national goals with our regional and international commitments.
Dr Tarun Weeramanthri is the President of the Public Health Association of Australia, and is an independent consultant in public health. He is an Adjunct Professor in the School of Population and Global Health at the University of Western Australia. He has served as Chief Health Officer in two Australian jurisdictions (Northern Territory 2004-2007, and Western Australia 2008-2018) and was a member of the Australian Health Protection Principal Committee from 2004-2018.