A position paper from the Immunisation Advisory Centre:
Professor (Hon) Nikki Turner, Professor Peter McIntyre, Dr Joan Ingram, Dr Emma Best, Dr Edwin Reynolds, Dr Liz Wilson.

COVID-19 is with us for good and we are now learning to live with it. The SARS-CoV-2 virus that causes it, continues to evolve into new variants, which have so far become more infectious but not more severe. We now need to manage it in our community with all the tools and evidence we have available, adapting our methods as needed in the long term.

The public health measures used to control COVID-19 have also significantly reduced the circulation of other respiratory viruses, in particular influenza (flu) and respiratory syncytial virus (RSV). These infectious diseases are a significant burden on our community, with a disproportionately higher burden among Māori and Pasifika people.

The good news is that our experiences over the last two years have taught us that we have a broad suite of public health measures available to both support obtaining high vaccination rates and prevent community spread. These measures need to be included in building a strategy to reduce the burden on our communities from all respiratory infections.

Lifting our COVID-19 vaccination rates has involved community-based engagement, vaccination sites, mobile health teams; and reducing transmission of respiratory viruses involved mask wearing in indoor areas, improving ventilation in houses, schools and workplaces, and avoiding crowding especially if ventilation is not adequate. To these it is important to add adequate financial and social supports to allow those with respiratory symptoms to stay at home, which needs to become part of our work culture.

For COVID-19 and flu, it is the oldest and frailest in the community who are most at risk of severe illness and death. Other Inequities are also a major problem, with the burden falling more heavily on Māori and Pasifika peoples.  As a rough example, around 800,000 New Zealanders access free flu vaccine because of their health risk. That’s about one in every six people in our communities who are at high risk from respiratory viruses, and benefit most from our shared public health measures, including vaccination.

Vaccine effectiveness

We have effective vaccines for both COVID-19 and flu, especially against severe illness. For omicron, a third dose (a booster) is needed to retain protection for adults. We should also remember that the travel restrictions which helped keep flu out in 2021 are no longer in place. Flu is now here while flu vaccination rates for those over 65 years were only around 70 percent in 2020. There is good work underway to lift this, in 2021 we increased flu vaccinations to 1.5 million and there is a strong focus on lifting it again this year.

Fortunately, the COVID-19 vaccines are even more effective than flu vaccines. It is estimated through both delta and omicron waves in the United States that among people over 5 years old, unvaccinated people were 10 times more likely to die from COVID-19 than people who had received two doses of vaccine, and 20 times more likely to die than people over 12 years old who had received a booster dose (https://COVID-19.cdc.gov/COVID-19-data-tracker/#rates-by-vaccine-status). New evidence shows that in people over 60 years a second booster dose given at least 4-6 months after the first restores protection. The second booster can be given with or after influenza vaccine and is not associated with any increase in side effects.

If omicron infection occurs despite optimum vaccine protection, people at risk of severe disease can also have this risk very substantially reduced by early use of therapeutics. We now have a number of COVID-19 treatments approved by MedSafe.

Both flu and RSV are particularly severe on our youngest and oldest people, often causing higher rates of severe disease, and substantially more severe disease than COVID-19 in our youngest children. We can vaccinate for flu, but not RSV yet, although important work is underway on RSV vaccines.

Vaccination coverage

While overall vaccination uptake has been good for COVID-19, equity gaps remain, and uptake is disappointingly lower for boosters and for children. Vaccination isn’t as high for flu, which like COVID-19 has significant equity gaps. Māori and Pasifika health providers and their communities have worked tirelessly and innovatively to address this during the COVID-19 pandemic by lifting community acceptance and prioritising high-risk groups. Supporting them in this work is essential to ensure all can easily access advice and vaccination from people they trust.

The initiative and new leadership to be provided by the Māori Health Authority will be a key path forward along with embedding community vaccination in all healthcare. Genuine engagement with communities is essential to gain and maintain trust in public health programmes. Services need to be designed with communities that can be sustainable, equitable and integrated with immunisation programmes.

Flexible vaccination strategies are needed that are responsive to disease patterns. For COVID-19, a second booster will be useful for higher risk groups. These groups are similar to those at higher risk of flu and include those over 65 years, those with medical conditions and/or significant social risk, such as poor housing or nutrition, and Māori and Pasifika ethnicity from 50 years. Ensuring flu vaccines are available to Māori and Pasifika peoples from a younger age is a good example of this responsive approach.  

Respiratory vaccines are already part of our childhood and maternal health vaccination – infants can be protected from pneumonia with the vaccines in the first years of life; from complications from measles, whooping cough and by women being vaccinated against whooping cough and flu in pregnancy. The momentum and techniques used to bring Aotearoa/NZ to over 90 percent COVID-19 vaccination needs to be replicated for other vaccines to protect children. Let’s not forget that measles is only a plane ride away.

What about the future?

Vaccination strategies need to sit within broader community health plans. We need to maintain our focus on the best approaches to protect all in our community, especially the one in 6 of us who are at higher risk. This includes staying home and social distancing when you have respiratory symptoms. Let’s limit the risk of spreading to others.

New vaccines are being developed for flu, COVID-19 and RSV, along with combined vaccines eg flu+COVID-19 which would be ideal for high-risk groups. We continue to watch for new variants of COVID-19 as we do with flu, with annually updated vaccines likely to be needed.

Extra measures are needed for our more vulnerable people, most of whom who are active members of our communities. Here there is an important place both for repeated vaccine boosting and targeted therapeutics. Healthy younger people are not at great risk as once they’ve had a full vaccination course, most have only mild disease if infected. We need to focus on the burden from flu in children, especially infants. It is time to consider a free flu vaccination strategy in this age group.

We need to maintain our community focus, supporting vaccination outreach for at risk groups, ensuring we are reducing equity gaps all the time, and encouraging everyone to use all the tools we have to keep each other safe.

Finally, we need to walk with the unknowns and have plans for new scenarios, including potentially new severe variants across all respiratory diseases so we are ready to rapidly and easily step up our public health plan to an appropriate pandemic response if it’s needed again.

ENDS