Q&A Covid roll out eve 280421

Q&A from the COVID-19 vaccine roll out evening 28 April 2021

126 Eleventh Avenue, Tauranga 3110 PO Box 13225, Tauranga 3141 P: (07) 577 3190 | wboppho.org.nz

Q & As from the night Can people who have anaphylaxis to egg the receive the vaccine?

Yes The list of biologicals, is this complete? For example, rheumatology patients, are they okay to go?

The rheumatologists have been actively involved in writing to their patients to guide them on what needs to be done. There is also the option for patients with higher risk to attend an acute location such as the DHB where specialist care is on hand if needed.

The decision on the management of Checkpoint inhibitors has been reviewed. It is no longer necessary to ask patients to seek Specialist advice. Patients on nivolumab (Opdivo), pembrolizumab (Keytruda), atezolizumab (Tecentriq) or ipilimumab (Yervoy) can receive this vaccine. There will be a delay in updating the consent form to reflect this change.

Is there evidence that paracetamol reduces the immune response?

Not that we are aware of.

What about other sites outside of Whakatane and Tauranga?

Are there going to be centres closer to Waihi Beach - there is no way our patients will drive 90 mins to get to Tauranga. I think there will be more uptake if the vaccines are being delivered locally by practice staff who the patients know.

While Tier Two vaccinations are being managed by fixed sites in Tauranga and Whakatane, in the Bay of Plenty a mixed model approach will be used for Tier 3 vaccine delivery onwards: •

fixed sites

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temporary locality sites with sufficient population to fill clinics for approx. 8 weeks, enabling the delivery of the two vaccines. These will be manned by local primary care providers if there is capacity, otherwise support will be brought in as needed.

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mobile services delivered by a variety of teams

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primary care and pharmacy delivered vaccination

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primary care supported options (provider hubs)

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and other methods that may be developed - there is room to be flexible and innovate.

We want to get the vaccine out to the people where we can, so the population has that choice.

Information to general practices will be communicated via the PHO and our mutual communication channels; we will use the Practice News, further events like this, Zoom meetings, whatever it takes.

Response from Joe Bourne via Zoom: We need to get the right balance between bringing people to the vaccine and taking the vaccine to people - each DHB will need to assess the right balance depending on available resources - particularly workforce.

Will services be going to schools for the 16 to 18 years old vaccinations?

This is currently being scoped and is an option under consideration for the Tier 4 vaccinations.

Will universities be offering vaccines nationally?

Response from Joe Bourne via Zoom: It is being investigated.

Why were the Covid Vaccinations not put on to the National Immunisation Register? Because I can see that we will have a major conflict with the flu vaccines and there is not one source of information.

NIR had already been identified as needing an upgrade, it was not fit for purpose for this large scale rapid vaccine roll out. Developing CIR was needed, there was always going to be a new vaccination register and the Covid vaccines are the first one to be added to the new system. I agree there will be some confusion and working out the timings is adding more complexity. We are hoping that CIR will be integrated into the PMSs so it will be easier to compare, but there will be some interchange between the two systems to work out the sequencing.

The Ministry have now revised their guidance. That is, where possible do not plan to do the flu and Covid vaccinations within the same two weeks. However, if a person presents who has had their flu vaccination within the last two weeks but this is your only opportunity to provide their Covid

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vaccination, deliver it. Don’t deny a person access to their Covid vaccine if they had their flu vaccine in the past two weeks.

The official advice regarding spacing between vaccines (taken from the IMAC website) is included below. https://www.immune.org.nz/covid-19-vaccination-general-info-faq

Can other vaccines be administered with a COVID-19 vaccine?

Currently Medsafe advice is only available for the mRNA vaccine, Comirnaty™ (Pfizer/BioNTech). A twoweek gap is recommended between any non-live vaccine, including influenza vaccine, and the COVID19 vaccine and a four-week gap is recommended for MMR or any other live vaccines. Please note that two doses of the mRNA vaccine are required, given at least 21-days apart. However, based on first principles of how these vaccines work, adverse impacts on immunogenicity or safety are unlikely with a shorter gap between vaccines, so if it is clinically important to deliver in a shorter time, do not delay. These recommendations are likely to be reviewed.

Do we have confidence that all these sites that are going to be delivering the vaccines safely where there is not a PMS with medical history information etc?

Yes, the contraindications for this vaccine make up a very small list. We have had a small number of adverse reactions from the 5000 delivered within the Bay of Plenty to date, which is within your normal expected adverse reaction rate. My understanding is that was one anaphylaxis (in someone with a history of allergy) but I don’t have details on the other events. The most common side effects are dose one, sore arm, and dose two, flu like symptoms with some waking with sweats and shivers overnight.

Dr Farrell, GP in attendance, reported one patient who lost their taste post vaccination.

Our older population can sometimes genuinely forget when and what vaccines they have had.

The nominated General Practice will receive notification that their vaccine has been done. Once you have access to CIR you will be able to go in and see when COVID vaccines were delivered.

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Also, there is minimal risk if a patient does happen to have their vaccines close together. The Ministry recommendations are cautious, but it is not a clinical risk. It’s not a contraindication, it is more of a precaution.

What if we have a situation where we have a patient who does receive their flu and covid vaccine within the two week period and something goes terribly wrong, who will stand behind that clinician medico legally? Also there may be some non-medical people who are trained to deliver the vaccine, what will their medico legal backup be?

We are working from operating guidelines that are coming from the Ministry of Health. As long as we work within these rules, this is our safety net. And this guidance changes, often week on week, so it is important to stay updated. The source of truth is the Ministry of Health website.

A lot of the restrictions in the guidelines are based on caution, rather than actual clinical risk. Already the newer versions of the guidelines are removing restrictions that make it easier for us to deliver the vaccines in primary care.

CIR and Claiming Comment: There is strong push-back from the software vendors over this - quite likely we won’t have to use the CIR and can just enter the Covid imm in our PMS. Response from Joe Bourne via Zoom: I was meeting with the IT team this evening. Integration with PMS is hard for a number of reasons but they are working towards it as fast as they can. It will be a couple of months away. We will need a system for payments also.

So if we started with CIR how would we invoice?

Response from Joe Bourne via Zoom: The details for payments are being worked through but it could be linked to the vaccinator and the site that they are vaccinating at which are recorded in CIR. It is complicated and they are working with the Ministry team that do other payments.

We are working through the options for claiming if it is not incorporated into the CIR. Halcyon is an option that is being explored.

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Will there be the option to bring in CIR-trained staff to the practice to assist?

Potentially, this will be part of the work with individual practices to identify what you might need for vaccine delivery.

Is the GP IMAC COVID course the one GPs need to do or is there another one, and retired doctors and nurse what do they need to do?

Response from Joe Bourne via Zoom: Retired doctors and nurses can sign up to be part of the surge workforce and then they should be guided through the training process.

CIR training for GPs is through the RNZCGP website (www.rnzcgp.org.nz/covid19). This is different to the IMAC training for administrators and nurses (https://covid.immune.org.nz)

How far away is the unrelated vaccinator technician role nationally?

Response from Joe Bourne via Zoom: The course for unregulated workforce is starting mid-May, that is a trial though.

The extent we utilise this workforce will depend on what our local response is. If we meet capacity through our primary care workforce, fixed sites, and iwi partners, we may find that we don’t have to train up a huge unregulated workforce. It will depend on the capacity and planning we put in place for the Bay of Plenty.

Is there any talk of compensating practices that may not be able to deliver the vaccine, but may be able to assist the vaccine delivery process?

Yes, there is the potential locally to develop a further funding model to recognise this additional work, but this has not yet been scoped. DHBs have been given a pool of money to support vaccine roll out for their population. All contributions need to be recognised.

Comment: It’s also the phone calls that practices will have to field when the roll out starts.

Absolutely need to be compensated for the extra phone calls/admin.

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When is our region anticipating going to Tier 3 vaccinations, and how will this be publicised? We really want to be giving this group their flu vaccinations now. There is a timeframe issue. If the level three people come in and they haven’t had their flu vaccination yet, it will push flu vaccinations to July and we will miss the window. We can do our 65+ years now, but I think the national date is May 17 for Tier 3 when under 65s with health conditions can get their vaccines and that makes the timing difficult. When we know that level three is likely to be coming regionally, will there be public messages going out saying “you are likely to be able to get your covid vaccine from this date, please get your flu jab now”?

It will be a challenge, because the flu and Covid vaccination roll outs for these groups are happening at the same time. We have been going out to the 75 plus group, which will assist somewhat. There is also messaging going out to Māori and Pacific whanau, which will help vaccinate some of the elders in that group earlier, but it will be a challenge.

One of the processes at the moment for Tier 2 is they have an 0800 number to contact to book for their vaccine, this service checks whether they have had their flu vaccination. 0800 numbers will probably not be viable when we get to the larger groups for vaccination, so we will need another solution going forward.

UPDATE: we have now opened the criteria to all over 65 as well as Maori/Pacific kaumatua. There is going to be a regular alert coming out to practices to advise them of any updates and there is a local media campaign which will be starting next week (first week of May).

(Comment) At the moment it is quite difficult to contact the 0800 number for staff vaccination booking. A National Booking system would need to be robust.

With the big sites are patients going to make their own appointments?

Hopefully by the end of May patients will be able to book their own appointments via the CIR, and choose their location for the vaccination. The 0800 number and booking centre through the hospital is purely an interim service while we wait for the national booking service. These will be used for the big sites. Practices don’t have to use this central service, you will have the option of managing bookings through your PMS if you like.

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Response from Joe Bourne via Zoom: the plan for the {national} booking system is for it to be ready around 27th May.

Does a doctor need to be onsite for the vaccination clinics?

No, the expectation is you have an appropriately trained team.

How many other staff are needed per one vaccinator. How many vaccines is one vaccinator expected to manage per hour?

It will depend on the size of the site. In a smaller practice, it could be one person doing all the tasks to deliver the vaccine. At the moment First Ave is vaccinating about 8 an hour, we are working towards 10 people per hour. It takes about 7 minutes to do the actual vaccination, but you also need to have sufficient capacity for people to be registered and support the 20 minute wait at the end.

Is the cost of collecting the vaccine from the distribution centre to get out to the practice which may be 30km plus away paid to the practice or will it be couriered out by the DHB? Currently the vaccines must be delivered by an approved pharmacist to sites. This will be a limiting factor as the sites increase. If this delivery process becomes more flexible and practices are able to pick up vaccines we will need to look at time and costs involved, but this is not finalised. We want the practices to be focused on delivering the vaccines, not spending time on delivery.

Response from Joe Bourne via Zoom: We are exploring direct delivery to general practice and community pharmacy from HCL. No cost to general practice for vaccine delivery.

Comment: That makes me nervous as the history of flu vaccine delivery has been disastrous over last couple years.

Response from Joe Bourne via Zoom: The distribution of vaccine is a major constraint and the challenges are recognised.

Due to the advance planning involved we would need absolute certainty we would get the vaccine. It was very difficult when the flu shots did not arrive last year.

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There is a very robust and detailed ordering and delivery system with a dedicated team of people coordinating this working out of the DHB Pharmacy team. There were some initial problems when the vaccine was first rolled out but these appear to have settled. Once we can store vaccine at -20 degrees locally this will be part of the backup process to ensure certainty with vaccine supply.

I suspect giving the vaccines will be the easy part, it will be the co-ordination of bringing people in and then bringing them back for their second vaccination that will be timing consuming.

What’s your experience with this for the Tier Two vaccinations currently and have you developed any tools we can use?

In the same way that we supported the swabbing roll out, we will do the same thing for practices this time. We will have a central point for resources and strategies to support practices. We may also look to set up a regular COVID alert.

Is there a formal process for declining vaccines?

There is an option to log a decline in CIR. Currently with Tier 2 we are not logging this as people have already called to book to have their vaccine. The consent process can now be verbal. It no longer needs to be written but with a few exceptions, which are those with diminished capacity, those with power of attorney, or tier one workers, or any one else where it would be in all parties best interests to gain written consent.

How many general practices would you envisage opening for this, and what timeframe are you looking at?

I think that any practice who wants to be able to deliver vaccines to their patients can be enabled to do this. We did it for COVID testing and I think we can do it for vaccines. I appreciate we are busy and we still have to do all our other work. There will be times when other activity has to wait, it’s a big ask. But if a practice wants to vaccinate, we should be able to make this happen. The first practices who are willing and fully capable may be able to start within the next month and I anticipate there may be a number of roll outs as practices develop their capability.

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“Some work has to pause while this is being done”. What primary care work can be paused for the many months this roll out would take? I cannot imagine what we can safely back off on, to be able to provide this?

I think this will depend on the practice and their priorities. Perhaps we will have to get creative about how we deliver some of the work that is being paused.

Comment: You could consider running the clinics in ‘out of hours’ so it does not compete with BAU. Yes, but of course you need to assure staff welfare and that there is capacity for this. The DHB can help with resourcing as needed.

Response from Joe Bourne via Zoom: Out of hours is 8pm to 8am Monday to Thursday and then from Friday 5pm through to 8am Monday morning. That's the definition in the funding paper.

We have quite a large unenrolled population, how will it work for this group?

I think there will communication through the media, through ED etc (the places where unenrolled people tend to go). It’s hard to arrange for drop-in clinics with Covid given the nature of the vaccine storage but we could look at this. Perhaps making spare slots available for these people. There will also be mobile / outreach vaccinators, and we will be working with the iwi partners and other community providers to get in touch with as many people as possible.

There will be some Tier 3/4 people who might get the vaccine alongside the Tier 2/3 in these more remote locations because we need to take the opportunity.

Is the thinking that this will become an annual vaccine programme?

I suspect there will be some sort of rolling vaccination programme and will become part of what we do alongside our current vaccine programme.

Are the public health nurses doing the vaccinations currently?

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Currently they are doing the majority of the vaccinations. As more people are registered with the CIR they will pull back to provide more of an supervisory/expert role and return to their core work.

Unfortunately currently given our limited workforce they have had to put some of their BAU on hold, we are looking to get them back to this as soon as possible.

What is the vaccination coverage rate required to be effective for the community, and what rate are we expecting in the Bay? We are hoping for as high as possible, but we don’t know what the public response will be. Overseas there is high uptake but they are in the midst of a pandemic, where as it’s contained here. We are hoping for 75 to 80 percent uptake but so far there has been mixed feedback from people so it’s hard to know. Currently national thought is that the vaccination programme may be effective with a 70 to 80 percent coverage rate. However, if other strains come to New Zealand we may need a higher vaccination rate to cope with this, so the target coverage is not currently know.

Often patients may initially decline, or are unsure, but with a conversation people often become ready, or may come back later to get the vaccine.

There is a risk that we will lose our primary care nurses to secondary services if the DHB offer a higher rate for vaccinators.

Thank you for raising this.

How can we commit to providing a service if we have so many physical restrictions (Ministry of Health) in Primary Care? And how long is it expected to take for these sorts of restrictions to be removed (more realistic)?

The Operating Guidelines are reviewed regularly and updated (weekly at the moment) and there is a specific resource for Primary Care in development which will address a lot of these issues and I would anticipate being available within the next few weeks. I am confident that a lot of the current restrictions will be revised.

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Will the PHO be providing some gear to the primary health care workers to wear to promote the vaccine such as badges and t-shirts?

There is no plan for this at present but we can explore this – there are a number of resources available through the MOH including posters, leaflets, stickers which will be shared with practices to use as they need.

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