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Feature

Overcoming distance and other challenges to support vaccination in the Pacific

18 March 2022
The Immunisation Advisory Centre is transporting a cold-storage Covid-19 vaccine to the Pacific islands and supporting vaccinator training there.

Safely transporting a cold-storage Covid-19 vaccine within New Zealand is hard enough.

Getting it to Tokelau is a whole other level.

Typically, travel to Tokelau starts with a four- to six-hour flight from Ƶto Apia, Samoa.

From there, the fortnightly boat takes 24 hours to arrive at the nearest atoll, Fakaofo.

It’s a further three and a half hours to Nukunonu and then a further six hours to Atafu, the northernmost atoll.

Image
Ellaine Ete-Rasch, third from left, with vaccinators in Samoa

Not only is maintaining the cold chain a logistical challenge, there’s also the issue of ensuring, without entering the country, that local healthcare professionals know how to properly store, prepare and administer the vaccine, as well as know what to do if someone has an adverse reaction.

 (IMAC), based at the University of Ƶand run by UniServices, has taken on this challenge not only for Tokelau but also for Tonga, Samoa, Niue, Cook Islands and Fiji. 

The project is part of the Polynesian Health Corridors programme led by the New Zealand Ministry of Health and Ministry of Foreign Affairs and Trade to support better health outcomes in the Pacific.

IMAC’s part of the programme focuses on delivering vaccination education, training and support, including cold chain administration for the storage and management of vaccines. 

Keeping vaccines cold

Image
Bernadette Heaphy with a container freezer on board ship

 

Typically, vaccines need to be stored between +2 and +8 degrees Celsius, a range that corresponds to the average refrigerator. The Pfizer-BioNTech vaccine, which New Zealand and many Pacific countries use as their primary Covid-19 vaccine, is different. 

For longer-term storage, the Pfizer vaccine must be kept at the ultra-low temperature of -70 degrees. It can be transported at -20, attainable in a standard freezer, for up to two weeks, and then returned to ultra-cold storage – but only once. Once warmed up to fridge temperature, it must be used within a month. Diluted, it can be stored at room temperature and used within six hours.

Keeping vaccines at the correct temperature at all times is even more challenging where the climate is warm, clinics are often remote, electricity isn’t always reliable and equipment such as temperature data loggers and even chilly bins can be in short supply.

IMAC has helped ensure all the necessary equipment is available and people know how to use it correctly.

“Being able to get it there in the ultra-cold state is a huge gain for the Pacific Islands in terms of having more transport time to their outreach centres. It’s pretty cool, literally.”
Bernadette Heaphy

For Tokelau, which presented the biggest logistical challenge, vaccines were initially transported on a chartered naval ship, in a freezer at -20. That was a pretty-good solution that required IMAC to work closely with the New Zealand Defence Force and Ministry of Health on the logistics for safely maintaining the cold chain at that temperature. 

Subsequently, a process to transport vaccines by flight and then chartered boat to Tokelau was found to be possible with the vaccine stored at -70.

“Being able to get it there in the ultra-cold state is a huge gain for the Pacific Islands in terms of having more transport time to their outreach centres,” says Bernadette Heaphy, who is IMAC’s cold chain lead as well as programme manager – education and quality. “It’s pretty cool, literally.”

Training from afar

As the Cook Islands prepared for the Covid-19 vaccine rollout in May 2021, some members of the IMAC team flew to Rarotonga to help set up vaccination clinics, standard operating procedures and cold chain management, as well as work with healthcare workers to prepare for the delivery and administration of the vaccine and manage adverse events.

However, with other Pacific countries’ strict border rules and New Zealand going into lockdown in August 2021, Programme Manager Moelagi Leilani Jackson and Nurse Educator Ellaine Ete-Rasch, with the support of IMAC colleagues Jude Young and Catherine Tobin, had to figure out how to effectively educate vaccinators in the five other countries from afar.

IMAC had already developed an online training platform for New Zealand vaccinators but had supplemented online learning with face-to-face training and support. This wasn’t possible in most of the Pacific.

The team was able to mitigate some of the challenges of teaching over Zoom through means such as shipping over equipment in advance to ensure learners had access to the items being demonstrated so they could use it at the same time.

“That was a first and very effective,” says Loretta Roberts, national manager of IMAC.

Image
Loretta Roberts (middle) with Cook Islands vaccinators

 

Technological and linguistic challenges

There were still challenges that weren’t as easily addressed from New Zealand.

“The internet connections on some of the islands did not permit everyone to use Zoom or in some cases to access the online learning platform at all,” says Jackson. “We used a train-the-trainer approach where countries would select their leads, we’d train them, and they’d train the nurses who didn’t have access to the internet.”

For those who didn’t have reliable internet access, IMAC provided materials designed for PowerPoint in PDF form so they could be printed out along with other support materials. These resources were also useful where data costs were a barrier.

In some places, technology access issues meant that people congregated for Zoom sessions, so Jackson and Ete-Rasch had to train as many as 20 people clustered around a single laptop.

“That’s another reason we always sent through written material to support, because we were aware that looking at this little screen would not provide the best-quality learning experience,” says Jackson.

Another barrier for some was linguistic.

While English is widely spoken in the countries IMAC is working with, it’s not the first language for most people. All the training materials were developed in English and sessions are conducted in English. However, Jackson and Rasch did use techniques such as allowing time for talanoa (discussion) to go over the information. Some materials were also translated.

The challenges of distance, technology and language have recently been overcome for Samoa, because Ete-Rasch (top photo, third from left) had to temporarily return to her homeland for family reasons. While she’s working remotely from a New Zealand perspective, it has given her the opportunity to conduct in-person training for about 100 nurses.

“IMAC is using my presence here in Samoa for the best,” says Ete-Rasch. “It’s really good to have that face-to-face interaction with the nurses and vaccinators.”

Promoting health equity and accessibility

For Jackson, who grew up on a smaller Samoan island a two-hour boat ride from the mainland, healthcare accessibility has always been an important issue. Her sister died of rheumatic heart disease when she was young, largely due to poor follow-up. This was a large part of what motivated her to become a nurse and more recently to take the job at IMAC. 

Although some health equity and accessibility challenges have been exacerbated by the pandemic – for example, patients can’t fly to New Zealand or Australia for advanced care – IMAC and the New Zealand government are working to overcome them.

New Zealand doctors are supporting Pacific doctors via Zoom and New Zealand has donated enough Covid vaccines to inoculate all eligible people. IMAC has provided the cold chain training and support for nearly 300,000 vaccine doses that have been sent over.

“It’s been very satisfying to look at the number of nurses applying the knowledge they have gained from the training to increase Covid-19 vaccination coverage in Pacific countries. There has been a lot of learning both ways and it has been a pleasure helping nurses in the Pacific build on their strengths to support people in their respective countries during this pandemic.”

Ellaine Ete-Rasch

To date, IMAC has registered 360 vaccinators from the Pacific onto the online learning management system in addition to the face-to-face training conducted in Samoa and the Cook Islands. While it has been harder to evaluate success remotely, only one vaccination error has been reported and training evaluations have been overwhelmingly positive, say Jackson and Rasch.

“We have delivered the best we can, given the resources we have and the circumstances we’re under,” says Jackson. 

IMAC is currently conducting education on the paediatric Covid vaccine, which will increase the number of people protected. 

Over the next year, it will move into supporting Pacific healthcare professionals with other vaccination programmes, such as for measles and standard childhood immunisations.

“It’s been very satisfying to look at the number of nurses applying the knowledge they have gained from the training to increase Covid-19 vaccination coverage in Pacific countries,” says Ete-Rasch.

“There has been a lot of learning both ways and it has been a pleasure helping nurses in the Pacific build on their strengths to support people in their respective countries during this pandemic.”

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