Health workers are at higher risk of COVID infection and illness. They can also act as extremely efficient transmitters of viruses to others in medical and aged care facilities.
That’s why health workers have been prioritised to get a COVID vaccine when it becomes available in Australia.
But just because health workers are among those first in line to receive a COVID vaccine, it doesn’t necessarily mean they all will.
Our health systems represent a microcosm of the community. Just like in the broader community, there will be health workers highly motivated to get the COVID-19 vaccine, driven by concern about risk to themselves, their family, and their patients. There will also be those who have medical conditions, those that may not be able to get vaccinated, and staff who are hesitant.
There will also be health workers with questions about the vaccine, who perhaps need further support to help them decide.
Reports from the US track vaccine hesitancy among health workers at around 29%. However, it’s important to note different groups have different reasons for COVID-19 vaccine hesitancy; rates and reasons can vary across and within countries.
Protecting health workers is critical. Achieving high COVID-19 vaccine uptake among health workers will not only protect these critical staff members, it will also support high levels of uptake among the general public.
Personal health workers are the most trusted source of information on the COVID-19 vaccine.
Decision-making around vaccination can be a complex mix of psychosocial, cultural, political and other factors.
Health workers, just like the broader public, may perceive they are at low risk of acquiring a vaccine-preventable disease. They may have concerns about the safety and effectiveness of a vaccine and/or may find it challenging to get vaccinated.
While most health workers understand how vaccines work generally, they may not necessarily be experts across all vaccine types. If we want to ensure they feel comfortable to receive it and advocate for it, then we must address any misunderstanding and concerns health workers may have. This may be focused on the vaccine itself (how it was developed, effectiveness and so on), or the necessity of vaccination.
One strategy that may assist will be to work with middle managers, as they are influential, trusted and can act as vaccine advocates and agents of change. They may also play a role addressing questions or concerns where they arise. If a COVID vaccine becomes an occupational requirement for health workers, hospitals and other organisations need to include middle managers in the development and roll-out of programs. They can then help ensure staff members understand the rationale for the mandate, which staff members are targeted and why.
Investing in the staff responsible for delivering vaccines in the workplace, as well as other potential vaccine allies such as managers, can help reduce COVID vaccine hesitancy among health workers. That will benefit all of us.
In July 1921, a French infant became the first person to receive an experimental vaccine against tuberculosis (TB), after the mother had died from the disease. The vaccine, known as Bacille Calmette-Guérin (BCG), is the same one still used today.
This first dose of BCG was the culmination of 13 years of research and development.
BCG remains the only licensed vaccine against TB and 2021 marks its 100th anniversary.
Today, all eyes are on the rollout of the COVID-19 vaccine. But while the number of people who died from COVID-19 in the last year is shocking, TB kills about the same number of people — about 1.5-2 million — each year, and has done so for many decades.
In fact, it’s estimated that over the last 200 years, more than 1 billion people have died from TB, far more than from any other infectious disease.
Tuberculosis is caused by the bacterium Mycobacterium tuberculosis. It’s transmitted when a person with active TB coughs up aerosol droplets, which are then inhaled by someone else.
There are about 10 million cases of active TB annually, and it’s estimated up to 2 billion people are what’s known as “latently infected”. That means they are not sick and do not transmit the disease, but in about 10% of these people the disease reactivates.
In most TB endemic regions of the world, BCG is given to infants shortly after birth. The vaccination prevents childhood versions of TB and saves thousands of children’s lives annually.
However, the efficacy of BCG wanes over time. In other words, it stops working. Protection against TB is often lost by adolescence or early adulthood.
Importantly, BCG doesn’t prevent active lung TB in adults, the most important driver of ongoing transmission and cause of death.
The World Health Organization has a goal of TB elimination. To do that, we need to find a TB vaccine that also works in adults.
Over the last decades only about 15 new TB vaccine candidates have entered clinical trials (versus 63 for COVID-19 in one year).
Worryingly, many of the most advanced TB vaccine candidates work no better than BCG.
Because the current TB vaccine candidate pipeline is relatively small, these setbacks and trial “failures” mean BCG may remain the gold standard for many years to come.
Despite being 100 years old, exactly how BCG vaccine works is largely unknown. It’s unclear why BCG usually only confers protection against childhood versions of TB or why protection wanes in adolescence.
Given those uncertainties, we can count ourselves lucky the bureaucratic hurdles for vaccine development were significantly lower in the 1920s.
If BCG were developed today, it would probably never be used; the current complex regulatory framework for vaccine development and licensing would likely not allow the use of a vaccine for which nothing or little is known about how it works.
The reasons BCG hasn’t been replaced with a more effective TB vaccine include:
the decline of TB in many Western countries in the 20th century
limited interest from pharmaceutical companies to invest in TB vaccine development
the fact TB research and pre-clinical vaccine development is logistically challenging and requires special biological containment facilities
the short-term and fiercely competitive environment for government and philanthropic research funding makes it difficult for academics to commit to TB vaccine research as a career path.
The pace of COVID-19 vaccine development shows what’s possible when the political will, pharmaceutical interest and funding is there.
While TB is no longer widespread in Australia, it is an issue in remote Indigenous communities.
Papua New Guinea, Australia’s closest neighbour, has high rates of multi-drug resistant TB and low BCG coverage rates. TB has been introduced into Australia via the Torres Strait, with a high proportion of cross-border diagnoses in North Queensland and over-representation of Indigenous children.
Resistance to current TB treatments increases steadily. Treatment of multi drug-resistant TB is hugely expensive and can take up to two years, requiring multiple antibiotics and close monitoring.
Now is the time to put financial and political will into finding a more effective TB vaccine.
2020 taught us pathogens can cause enormous harm to societies and economies. Investment into infectious disease research and vaccine development represents a fraction of the economic cost of a pandemic.
Tuberculosis is a global threat and a public health concern on a scale similar to COVID-19. The development of a new and effective TB vaccine is crucial if TB is to be significantly reduced, let alone eradicated.
Although the anniversary of BCG is cause for celebration, it should also serve as a reminder more needs to be done to combat this deadly disease.
On Sunday, federal Chief Medical Officer Professor Paul Kelly said most Australians will be offered a vaccine from Oxford-AstraZeneca.
Australia currently has agreements in place to receive 53.8 million doses of the AstraZeneca shot, and 10 million doses from Pfizer-BioNTech.
So how do these two vaccines compare, how will they be used in Australia, and what can we learn from other vaccines?
Both the Pfizer and AstraZeneca vaccines induce immunity but in different ways. They both deliver the instructions for how to make a target on the virus for our immune system to recognise the spike protein.
The Pfizer vaccine packages the instructions up in a droplet of fat, while the AstraZeneca vaccine packages the instructions up in the shell of a virus, the adenovirus.
Clinical trials for both vaccines have shown they’re broadly safe.
In terms of efficacy, the Pfizer vaccine protects 94.5% of people from developing COVID.
The AstraZeneca shot protects 70% of people on average — still pretty good and on par with the protection given by a flu vaccine in a good year.
However, the optimal dose and timing of AstraZeneca’s shots is still unclear. One trial reported 62% efficacy, and another 90%, with a low dose for the first shot and/or longer break between doses possibly improving protection. More studies are underway to define this and the Therapeutic Goods Administration, Australia’s regulatory body, will evaluate new data as it comes through.
In any scenario, the AstraZeneca vaccine will still protect the majority of people that receive the vaccine from disease.
While the Pfizer vaccine was more protective in clinical trials, the AstraZeneca vaccine has other advantages that could make it more appropriate for use outside of clinical trials:
we can make the vaccine here in Australia, so we’re not dependent on a supply-chain from overseas
we can ship and store it easily at normal refrigeration temperatures, while the Pfizer vaccine requires temperatures below -70˚C
we can administer it more easily, potentially in GP offices.
From a logistical perspective, the AstraZeneca vaccine has a major advantage. The ability to distribute vaccines can be almost as important as the vaccine’s effectiveness.
The effect of these advantages on the impact of this vaccine shouldn’t be underestimated. We have lots of people to vaccinate, a low disease burden currently, are far away from the rest of the world in terms of shipping, and Australia is a pretty big country, so distribution to rural and remote communities is a massive hurdle.
It can be helpful to look at the flu vaccine as a contrast. The flu vaccine is far from perfect — it provides moderate protection, with effectiveness varying between different groups of people and from season to season. For example, in the 2015/16 season in the United States, the quadrivalent influenza vaccine (which covers four strains) was about 54% effective against laboratory-confirmed influenza.
People know it’s not perfect, but people don’t generally judge whether they’ll receive a vaccine based on its effectiveness alone. We know from talking to the community that many factors influence motivation, especially perceived risk and severity of infection, and confidence in the safety of the vaccine.
Every year, access to flu vaccines is prioritised to those at most risk, such as people with medical conditions, Aboriginal and Torres Strait Islanders and those aged 65 years and older. The public has confidence in this approach. We need to protect those most at-risk first, and we don’t have an issue doing this day-to-day. We now have a similar challenge with the new COVID vaccines.
The best approach for protecting everyone’s health amid the pandemic is to provide different vaccines to different people according to need and availability, at least in the short term. The best vaccine is always the one you can get to the communities that need it before they urgently need it.
Because Australia is essentially COVID-free at present, it means we’re in a unique situation that permits a “combination” vaccine strategy.
The Pfizer vaccine is perfect for preventing the most extreme outcomes for people at very high risk of infection or disease: people on the frontlines of the fight against COVID and older people or people with high-risk health conditions.
The AstraZeneca vaccine has the ability to protect a large number of people against disease quickly, because we can make it easily and distribute it quickly.
As a result, Pfizer is likely to be prioritised for people with higher risk and AstraZeneca is likely to be prioritised for everyone else.
We won’t all be able to get the Pfizer vaccine straight away, so for many of us the choice in the short term will be between a 70% efficacious vaccine or no vaccine.
We all stand to benefit from a strategy that protects extremely vulnerable groups from severe disease and aims to rapidly generate immunity in the rest of our community.
There may also be other vaccines that become available. Australia is part of COVAX which can distribute a variety of vaccines, and it also has an agreement for a vaccine made by Novavax, pending the outcome of phase 3 clinical trials. There could be other vaccines that emerge or other agreements developed, and Australia’s strategy will no doubt respond to that.
Nevertheless, both the Pfizer and AstraZeneca vaccines are essential tools in our public health toolkit, with vital roles to play in protecting the entire Australian population. We’ll also need to continue to use other public health tools like testing and contact tracing.
Factoring in effectiveness, availability and distribution challenges, a strategy that uses a combination of the two vaccines for Australia is the best of both worlds.
Shane Huntington co-authored this article. He is Deputy Director, Strategy and Partnerships, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne.
Kylie Quinn, Vice-Chancellor’s Research Fellow, School of Health and Biomedical Sciences, RMIT University; Holly Seale, Associate professor, UNSW, and Margie Danchin, Associate Professor, University of Melbourne, Murdoch Children’s Research Institute