The jab: The full, inside story of New Zealand's vaccine rollout

Last year New Zealand won the first battle against Covid, but today it seems to be struggling in the war against the pandemic. Vaccines emerged as the single most-effective tool, but our own access seems to have lagged behind international peers. Matt Nippert digs into thousands of pages of Cabinet documents and talks to scientists at the front lines about the reality of the campaign's stumbles and successes.

'The opposite of a perfect storm'

In May 2020, New Zealand was gingerly feeling its way out of its first lockdown when there were warnings that our apparent success against Covid that year had served to complicate the next.

As the virus established itself around the world, the previous few months had seen a retreat to selfish national competition worthy of Squid Game. Countries were diverting flights full of PPE destined for neighbours and allies, and export restrictions were being imposed on the likes of testing swabs to try to satisfy desperate domestic demand.

On May 7 last year, Officials told Cabinet that any path to vaccination would be a bumpy one. There were nearly 200 vaccine trials underway, with a handful that might later show promise: "Our past experiences … suggest that there will be strong incentives on manufacturing countries to restrict the export of vaccines until they have ensured sufficient supply for their own need."

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The stakes were high. A back-of-an-envelope calculation by officials on the costs of even a three-month delay in access to hypothetical vaccines was estimated to range between $3 billion and $15b, based on the economic drain from border and social restrictions.

This was, officials say, "before we even consider the serious loss of life that would occur in a major outbreak".

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At this moment the hoped-for promised land of vaccinations was still thought to be the better part of two years away. Epidemiologist and Auckland University professor Rod Jackson speaks for many of his colleagues when recalling his thoughts about how far off in the distance deliverance lay.

"I think most of us thought 18 months would be great - it was the most optimistic out of the forecasts at the time," he says.

Then, in early May, pharmaceutical companies Pfizer and BioNTech published early findings from its work on an mRNA vaccine that showed genuine promise in stopping Covid. They had suddenly overcome long-term problems over compounds produced by the technology becoming quickly inert.

Jackson positively fizzes at the progress made in 2020 into Covid vaccines, with Pfizer merely the first of many.

A healthcare worker fills a syringe with the Pfizer Covid-19 vaccine. Photo / AP

"What people hadn't appreciated is that this was the opposite of a perfect storm, it was like all the ducks got lined up at once. You had this major pandemic, making it much easier to conduct trials, and you had governments pulling billions into vaccine research to make that final step so much easier."

If there is criticism from hindsight on the early days of the Government's race to procure the vaccine, it is that New Zealand, seeing itself as a small non-pharmaceutical manufacturer facing likely market triage, hoped that multilateralism could provide access to vaccines through facilities like Covax and offer a lever to end the pandemic.

A briefing in early July still clung to hopes that our risks of an outbreak could be managed by the world beating the virus and making local vaccination irrelevant: "We need to consider the interests for New Zealand between control of Covid-19 outside our borders, given that our border poses the greatest risk of the disease re-emerging in the country, and our wider domestic needs."

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As it turns out, our international peers quickly turned to negotiating individual advance purchase agreements - effectively nonrefundable downpayments to secure early access to unproven medicines - as their main tool for vaccine delivery. And Covid was not eradicated - instead setting up shop in every corner of the globe, including Auckland.

That briefing also foreshadowed one of the most crucial calls to be made as the world rapidly moved from having no vaccine options to many: to prioritise speed or effectiveness.

"We may need to consider the trade-offs between getting a vaccine quickly and its longer-term effectiveness," the briefing said.

'Fierce competition'

A week later that July, another briefing to Cabinet showed New Zealand's approach was evolving to look more like its peers, as first-movers like the United States and United Kingdom kickstarted what would become panic buying on a global scale by inking deals for hundred of millions of doses of vaccines that weren't yet shown to work.

The briefing was even more stark about the international environment.

"Even when a successful vaccine is developed (provided it can be), the global demand for doses of that vaccine will be fierce. There is no guarantee that New Zealand will be among the first to receive the doses we seek, especially if there is some prioritisation based on assessment of need," officials wrote.

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"Other countries are already entering into [Advanced Purchase Agreements] with pharmaceutical companies and we will quickly fall to the bottom of the queue if we do not pursue our own arrangements."

National Party Covid response spokesperson Chris Bishop acknowledges that judging from the rear-view mirror comes with advantages, but that this pivot didn't come soon enough.

"One of the problems with all this is looking back with the benefit of 18 months of hindsight: but the biggest criticism is the slowness, generally, in relation to getting a vaccine strategy going. And that slowness continued and it's had an impact in terms of rollout speed in early 2021," he says.

That second July briefing advised gambling on multiple vaccine candidates, spending up to $1.2b in advance payments to pharmaceutical companies covering 20 potential drugs to hedge the risk that most would be duds.

"There is a real possibility that none of the supported candidates will be successful. However, the value of earlier access to a vaccine is enormous, in terms of lives protected and economic damage avoided. This makes the risk worth taking."

Within weeks a vaccine taskforce was established by MBIE and what is likely to be hundreds of millions of dollars (the exact figure is redacted) was set aside for us to try to fill our medicine cabinet.

By September, the Government was in talks with a handful of pharmaceutical companies, including Pfizer. The number of simultaneous negotiations would peak in October at eight. Low-temperate fridges to store the Pfizer vaccine were acquired in bulk before contracts with the drugmaker had been signed.

250,000 doses of Pfizer-Biontech Covid-19 vaccine are unloaded at Auckland Airport in September after arriving from Spain. Photo / Supplied

These talks proved tough going, according to updates on progress obtained under the Official Information Act. "The tempo of negotiations is not being limited by our resourcing and process, but rather the fact that we are dependent on the response times of pharma companies that are themselves managing multiple parallel negotiations in different jurisdictions," one official said.

University of Auckland vaccinologist Helen Petousis-Harris, who has advised the Government on vaccine strategy, says for most of 2020 we had no firm idea about what we might be buying. "Until the . . . big reveal from the phase III trials. Before that you are pretty much flying blind."

On October 12, Pfizer released the results of its phase III trials, which showed its vaccine was both safe and effective. That same day, Prime Minister Jacinda Ardern announced the first stages of a deal with Pfizer that would see 1.5 million doses bought, enough to cover one-fifth of New Zealand's population. Delivery was flagged for the first three quarters of 2021, but reality would see the bulk land at Auckland Airport in May and June.

At this point New Zealand wanted more, but with international demand dramatically outstripping supply, the market was now effectively subject to rationing.

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The Office of the Auditor-General looked into this deal in its probe of the rollout and reported: "The Taskforce wanted to purchase more doses of the Pfizer vaccine but, at the time the agreement was signed, Pfizer was in negotiations with other potential purchasers and could not commit to supplying more doses of the vaccine to New Zealand."

Looking wider, it is telling that of advance orders placed with Pfizer by December 2020, no country - not even the United States or the European Union where the vaccine was to be manufactured - had been able to secure delivery contracts large enough to cover even half their populations.

The hedging policy of multiple options was now well in-train, and more viable candidates started clearing more hurdles. By year's end New Zealand had secured advance orders for doses of AstraZeneca, Janssen and Novavax and committed to buy enough vaccines to cover our population many times over.

There was now just the small matter of waiting for them to be delivered, and figuring out what to do with them when they arrived.

The 'sequencing framework'

The Ministry of Health had started working on how to roll out vaccines - if and when they were delivered - in the second half of 2020. The sector had some experience in delivering hundreds of thousands of vaccinations annually - whether measles or the flu - but the challenge ahead was a huge step up.

By November, as the vaccine portfolio was taking shape, Cabinet was told the scale of proceedings was coming into focus: "The programme will be the biggest immunisation programme undertaken in New Zealand, as it seeks to immunise as many people as possible. It is a highly complex and challenging initiative that is at a much larger scale compared with other immunisation programmes."

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Expecting shortages in supply, at least initially, considerable work was spent working out who in the population to jab first. Rather than describing it as a priority list or queue, officials preferred to describe this process as a "sequencing framework".

The result broke the population into four group categorisation, largely based on age bands with older cohorts first. Advisers and community feedback regularly recommended Māori and Pacific populations be given some priority, given their expected likely higher mortality rates, but this suggestion did not make the final announcement.

Pfizer, which had ended up on New Zealand's order book largely because it was the first candidate out of the blocks and the first to successfully navigate the gauntlet of trials and regulatory approvals, began arriving in very limited numbers in February and was immediately used to fortify workers at the border.

Then one of the biggest calls of the pandemic was made that would have significant effects on both the course of the rollout and New Zealand's medium-term prospects. In March the portfolio approach was largely sidelined and instead we were to go all-in on Pfizer. On the horizon, supplies were again available, and an order was placed with the drugmaker for another 8.5 million doses.

With equal measures of good luck and good management, the drug had turned out to be one of the most effective vaccines available. Studies show it drops the chance of catching Covid, and the possibility an infection will progress to hospitalisation or death, by more than 90 per cent.

The decision to switch to Pfizer early in 2021 "was a bold decision, but not a risky one," says Epidemiologist Sir David Skegg. Photo / Mark Mitchell

Epidemiologist Sir David Skegg, who has been tasked by the Government with trying to steer a course through the pandemic, acknowledges this decision likely involved a slower rollout than simply jabbing whatever could be brought to hand.

"The decision to switch to Pfizer early in 2021 was on the advice of many specialists, including myself. It was a bold decision, but not a risky one – because we still had several other vaccines on order," he says.

Professor Jackson, still fizzing, wasn't involved in the decision but is still wildly supportive over Pfizer: "It really is the Champagne of vaccines."

Petousis-Harris, says there were also practical concerns: "The simplicity of teaching the vaccinators about one product, and doing the same thing over and over as opposed to juggling products has some merit. When things start getting complex, you're more likely to make mistakes."

A vial of Pfizer vaccine at an Auckland pop up vaccination clinic. Photo / Sylvie Whinray

Meanwhile, Australia opted for a dual Pfizer-AstraZeneca rollout. A domestically-developed vaccine from the University of Queensland had flopped in trials. Australia found some supplies of the AstraZeneca drug expiring after its citizens preferred the former over concerns about efficacy and adverse reactions.

The New Zealand vaccination programme chugged along through the middle of the year, with speed largely dictated by deliveries from Pfizer (the country's stockpile ran perilously close to running out - down to 20,000 doses on hand - in late June).

Analysis of international comparative data shows New Zealand's deliberate approach saw it around four months behind Canada, the US and the UK- and one month behind Australia - in reaching the milestone of having jabbed 20 per cent of the population.

But developments outside our borders would see this effort both turbocharged and depowered. As Jackson put it: "We're in a situation now where we have vaccines that are much, much better than we thought they'd be - but we also have Delta."

'I was so scared'

The Delta variant first evolved in India in late 2020, and within six months had become the dominant strain worldwide. Almost overnight, in July it became the only strain being detected in MIQ.

Mutations made the variant both faster (with a halved incubation period) and more transmissible (each case infecting twice as many people) than its predecessor virus which had managed to bring the world to its knees in early 2020.

These adaptations made contact-tracing vastly more difficult - with now only two days to test and identify contacts of cases before the infection cycle would repeat - and dashed hopes early on in the pandemic that vaccinations alone would be able stamp out the virus.

Even a world-leading vaccination rate of 90 per cent will leave large pools of unvaccinated people in New Zealand - including children under 12. The 10 per cent of adults who opt against the vaccine amounts to hundreds of thousands of people - providing a reservoir of potential cases that modelling shows will allow Delta to maintain a stubborn, long-term presence.

Delta's arrival into New Zealand in mid-August caused justified alarm in both public and scientific communities. When the outbreak was first seeded, only 17 per cent of our population had been fully vaccinated.

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Professor Graham Le Gros, director of the country's leading immune system research group, the Malaghan Institute, doesn't mince words about his reaction when he heard the variant was circulating in the community.

"If I'm honest, I was screaming. I was so scared. I thought 'f***,' and thought I had to get off my arse and get vaccines moving," he recalls.

Within weeks Le Gros found himself conscripted by the Ministry of Health to attend a hui answering questions about the vaccine from an unusual audience: the Mongrel Mob. It's not a crowd the scientist is used to fronting, but says he found the experience invigorating.

"Can I tell you an irony? I've got a whole lot of white, woke, Taranaki midwives who hate my science - but I've got the Mongrel Mob who want to talk to a scientist before taking the vaccine. Who are the smart ones here?"

While the outbreak triggered a nationwide lockdown, it also spurred a dramatic increase in vaccine uptake. After lagging behind international peers by four months in the middle of the year, like a tortoise chasing the hare, the gap has since shrunk to an average of two. New Zealand has now, compared with Britain and the US, even taken the lead.

Auckland University vaccinologist Helen Petousis-Harris. Photo / Supplied

Of the lag, Petousis-Harris says the first member of the public to get vaccinated against Covid anywhere in the world was in December 2020, and New Zealand started doing the same in its population from February.

"The difference is not as extreme as people seem to think. One might argue: Did we order enough early along? You can argue around that. But you're doing the best with the information you have at the time," she says.

By now the brakes were off, and the vaccination drive began to operate at maximum possible speed without rationing supply, despite concerns in September that stockpiles were again close to running out.

As the pandemic rolled on, vaccine supplies began to free up a little after the panic-buying of 2020. Many countries found their own stockpiles, enough to vaccinate their populations many times over, now far exceeded remaining domestic demand.

The modern chemical miracle that prevents the medical compound in the Pfizer vaccine from falling apart almost instantaneously does not convey immortality: Even if stored in special sub-zero freezers it is given only a six-month shelf-life. It is these conditions that allowed New Zealand last month to buy more Pfizer doses directly from Denmark and Spain and keep the vaccination drive going.

And in a time of modern plagues and miracles, it was a jarring throwback to the '80s that seems to capture the spirit of the pandemic in New Zealand in 2021. "Super Saturday," a cross-platform vaxathon extravaganza on October 17 harking back to the glory days of free-to-air television, was intended to spur flagging vaccination efforts.

By the end of the day, more than 130,000 people had lined up for jabs - more than three times the daily average achieved the previous week. New Zealand's effort on Super Saturday, putting to one side heroic efforts by tiny Iceland, appears to have achieved the highest day of vaccinations achieved per capita by any member of the OECD.

"We are heading to achieve vaccination coverage that will be very impressive by world standards," Skegg says.

"We have already passed the USA, Germany . . . and the United Kingdom. But I hope we can make a lot more progress yet."

Vaccine life

As well as being the most significant health measure in the fight against Covid, the vaccine will also determine how we live with the virus in the months ahead.

The Government has announced restrictions on how we live will be loosened in the Covid Protection Framework traffic light system, but only when 90 per cent of every district health board population has been double-jabbed.

Staff from South Seas Healthcare working at the Covid-19 vaccination Centre in Otara. Photo / Dean Purcell

Additionally, many sectors of the community now have a no-jab, no-job policy, including health workers, teachers and staff within industries where vaccine passports are required such as hospitality, gyms and hairdressers.

The vaccine will also dictate how and where we can travel - Air NZ is considering requiring domestic passengers to be double jabbed to travel and has already announced anyone travelling on its international network will need to be vaccinated.

And it will also dictate what restaurants, bars, hairdressers and summer festivals we can attend with proof of vaccinations needed to attend events such as concerts.

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