Nikki Turner: Let's keep our eyes on the ball

News that the Government has options to buy Covid-19 vaccines has raised hopes of a better 2021 than 2020.

The agreement is to purchase 1.5 million doses of one vaccine, once it has successfully completed clinical trials and been fully approved.

But is a Covid-19 vaccine the holy grail? Will life ever return to normal?

Dr Nikki Turner, director of the Immunisation Advisory Centre (IMAC) and Associate Professor in General Practice and Primary Healthcare at the University, says we need to keep our expectations of any return to normality in check.

“A vaccine is not the magic bullet people would love to have,” she says. “Vaccines alone are not going to stop Covid-19 getting into the community.

“First, it depends how effective it is. No vaccine is 100 percent effective. A vaccine that is 60-80 percent effective would be fantastic but it still leaves a lot of people unprotected … vaccines won’t protect all people against the disease.

“Secondly, we won’t know for a while whether the vaccine will actually stop the spread of the virus. Some vaccines have the ability to stop the transfer and some don’t.

“The third problem is that even if we did have a vaccine that could stop the transfer, we’re unlikely to get enough vaccine for the whole community when the first batch of vaccines arrive. It will likely be directed to high-risk populations and to frontline healthcare and border control personnel. So, it’s personal protection in the first instance.

“When we do open the borders, the virus will still enter. A vaccine can mitigate spread, but not fully prevent the virus circulating.”

Nikki says the key is to continue to actively monitor, through traditional public health measures and track and trace, just as we do with measles and other infectious diseases. “We’ve at least learned just how important it is to stay home when you’re sick, and to wash your hands.”

She says ultimately we’d hope to get degrees of herd immmunity. “But if we think that we can instantly achieve herd immunity for all of the New Zealand population, well it’s not going to happen.

“In the long term, the ideal is to have at least one effective vaccine, to have the disease not spreading and to have enough of the population immune. That would be great, but would still seem to be a way off.”

She says what’s likely next year is Covid-19 vaccines that have pretty good effectiveness as individual protection for high-risk groups, frontline healthcare professionals and other frontline staff.

While much attention has been on a Covid-19 vaccine, Nikki has been equally concerned about a slip from the public mindset of the importance of other vaccines.

Nikki, who is also a GP in Wellington, represents the RNZCGP (College of General Practitioners) in child health interests and is a health spokesperson for the Child Poverty Action Group. She was a member of the World Health Organisation (WHO) Strategic Advisory Group of Experts (SAGE) on immunisation and chair of the measles and rubella elimination sub-committee until the end of 2019. She is chair of the NZ measles verification committee and an adviser to the Ministry of Health and Pharmac on New Zealand’s national schedule of vaccines.

“Let’s not lose sight of the immunisation programme we have and the importance of that programme for infants, children and adults. There are really scary signs of immunisation programmes falling apart around the world with the stress over Covid. It’s so important not to let our gains slip.”

She says the Child Poverty Action Group is very worried about the rise in issues of inequity.

“My concerns are for young infants, kids not getting their vaccines on time, especially from communities of high deprivation, particularly Māori and Pacific whānau and also refugees and migrants. We need to recognise the importance of looking after those who are struggling the most in our world. We need to make sure they receive vaccines for preventable diseases.

“I’m particularly interested in hearing the stories of those who may be missing out.”

Recently, the tragedy of under-immunisation took a deadly toll in Samoa. The 2019 outbreak began in September and by January 2020, 83 had died, mostly children. The cause of the outbreak was low vaccination rates, which went from 74 percent in 2017 to 34 percent in 2018. That was largely attributed to mistrust in health authorities after an error in the administration of a vaccine caused the death of two babies.

“What happened in Samoa was a tragedy, but internationally there have been other big measles outbreaks,” says Nikki. “The WHO has been warning about the situation since 2017. There’s a serious concern that we may end up having bigger problems with children dying from measles, and the damage from measles, than Covid.”

Nikki says she’s concerned not just for Samoa but for all of the Pacific, New Zealand included.

“We need to make sure the measles coverage rate is up and we sustain high coverage rates. You don’t need to take your eye off the ball much for childhood infectious diseases to return.”

But there have been other diseases that have dramatically reduced in New Zealand this year.

“We have had hardly any ’flu and hardly any respiratory syncytial virus (RSV) that causes wheezy bronchitis in babies,” says Nikki.

“They are two big, nasty respiratory illnesses and we had a more than 95 percent reduction of those this winter. If you talk to any of the paediatric registrars in the hospitals, they were really quiet, as were general practices because of this reduction in childhood respiratory cases.”

She says colds from rhinovirus were still around because “they’re robust little buggers” but also much-reduced thanks to social distancing, washing hands and not taking bugs to work.

“That, alongside high ’flu vaccination rates, resulted in a dramatic reduction in respiratory illnesses and overall deaths here. Accident rates were lower too, with the lockdown.

“It’s a matter of getting the balance right when returning to mixing and mingling. I think people got used to ’flu and RSV in the community and they didn’t realise how much damage it actually causes each winter. It makes a huge difference if we stay at home when sick.”

Looking to the future and the expected arrival of a Covid-19 vaccine, she says we need to prepare ourselves emotionally, physically and strategically.

“It’s important for public health officials, and politicians for that matter, not to over-promise or under-promise; just to communicate clearly what the gains and limitations of a vaccine would be.”

She says people shouldn’t make statements without knowledge of how a vaccine is created and delivered effectively and safely. “You can’t just say, ‘oh, we need a vaccine to solve all our problems. Let’s just bring it in’.

“If you don’t walk through community-appropriate concerns at all levels, such as with vaccine safety, the community will appropriately say, ‘I won’t have this vaccine’. I, personally, wouldn’t trust just any vaccine. It needs to have been peer-reviewed with published data to reassure me.”

The race to develop a Covid-19 vaccine has sparked some concerns over safety, but Nikki says what appears to be an expedited process is no less rigorous.

“Science has come a huge long way in the past few years. We learned a lot, most recently with Ebola vaccines.

“There are several reasons we can potentially create this vaccine in less than the traditional 15-20 years it may normally take. The first reason is we have a basic understanding of coronaviruses and early vaccine research from SARS and MERS which are a similar sort of coronavirus, so we already had the platform.

“The next thing is this is a huge international emergency and there’s a lot of money going into it on many different levels. What the world is now trying to do is not speed up the steps, but to run the steps consecutively. So, for people worried we are speeding everything up, that’s not the case. Things are just being done alongside each other.”

She says traditionally there are phases one, two and three studies and, after you release the vaccine into the community, phase four.

“Now, what they’re doing is running animal studies in phase one and two alongside each other and then as soon as early studies suggest the vaccine looks safe and has some effectiveness, you go straight into the large phase-three trials.”

She says the bottleneck is likely to come after phase-three trials.

“That’s the manufacturing of the vaccine. But the other amazing thing the world is doing is taking a risk and saying ‘will this type of vaccine work? I think so, so we’ll need a large, extremely expensive manufacturing plant’. They are actually developing manufacturing plants before they know for sure if the vaccines will work.”

Some will lose money on that gamble, but the benefit is that you don’t have a delay at that end of the trial process.

“Once you know your phase-three trials are working, you apply for a licence and then you manufacture. That’s what I mean when I say all this is running in parallel. They’re not speeding up the regulatory authorities’ processes. They’re certainly not dropping any safety steps.”

There is of course the anti-vax brigade, and Nikki has thought about the possible psychology of its members.

“The issue with conspiracy theories, and people’s anti-vaccination fears, is whether you trust the health authorities and the science behind how you offer public health in a country. New Zealand has done really well on that level, but what we’re seeing internationally, and dare I mention the disaster in the United States, is that if politics gets in the way, science doesn’t feel safe. It feels like it’s been interfered with.

“So, it’s no surprise that you get a rise in conspiracy theories and paranoia. Unfortunately, social media allows a very loud voice to what is still a minority and it creates a lot of dissonance.”

She says even though New Zealand is doing well with its public health communication, we are part of an international community. “There are dissonant voices out there, it makes us nervous and it certainly accentuates the anti-science voice. It’s a very challenging environment.”

She says the introduction of any Covid-19 vaccine would need to involve a transparent system, well-communicated to the public.

“The only reason we maintain high immunisation coverage is because the system works effectively and the community is confident in it. We don’t diminish people’s concerns, we address them.”

As New Zealand looks towards a future in which the borders might be open to certain parts of the world, Nikki says there’s much to think about and assess as to how we keep as many people as we can safe, but also protect the economy.

“We can’t maintain really tightly locked-down borders and wait for vaccines forever. Hopefully there will also be medication available that mitigates the effects of Covid – that would help.

“We need an ongoing conversation about what the next type of protection would look like. What would track and tracing look like and how can we try and prevent Covid’s spread? These are really difficult decisions and there’s no simple answer.

“If we suddenly allowed it in the community, our hospitals would take a huge hit and people would die or get severely ill. Ethically we’re not prepared to do that or to try for herd immunity by just letting it rock through the community. I don’t believe New Zealand would tolerate or want that.

“Recently we’ve seen community transmission in Auckland, and we will probably see community transmission in the future. What we need to do is minimise it so it has as little effect as possible on New Zealanders’ health, while also recognising we are part of an international community and we will need to have our borders open to some extent.”

Denise Montgomery

Dr Nikki Turner also took part in a University of Auckland expert panel discussion on the future of a Covid-19 vaccine, in association with Newsroom and RNZ. Watch the video below.