How to close the vaccination gap

Each year, vaccines save thousands of lives. But in the wake of the pandemic, Australians are sick of hearing about vaccination. Amidst the misinformation on the internet and fatigue from government messaging, many of us have become complacent.

New Grattan research shows that millions of older Australians at high risk of serious illness are missing out on essential vaccines, and certain groups of people are more likely to miss out than others.

Listen to Peter Breadon, Health Program Director, and Ingrid Burfurd, Senior Associate, discuss their new report with host Kat Clay.

Read the report

Transcript

Kat Clay: Each year, vaccines save thousands of lives, but in the wake of the pandemic, Australians are sick of hearing about vaccination. Do we even need to get vaccinated anymore? Amidst the misinformation on the internet and fatigue from government messaging, many of us have become complacent.

Getting COVID or flu might just mean a couple of days off work. No big deal, right? But new Grattan research shows that millions of older Australians at high risk of serious illness are missing out on essential vaccines, and certain groups of people are more likely to miss out than others.

I’m Kat Clay, and you are listening to the Grattan Podcast. With me, are health program director, Peter Breadon, and senior associate Ingrid Burfurd, to talk about their new report, A fair shot: How to close the vaccination gap. So Australia has rigorous childhood vaccination policies, but we seem to have dropped the ball when it comes to adults.

This report looks specifically at adult vaccination rates among high risk groups. Ingrid, what vaccinations does this include?

Ingrid Burfurd: In the report, we look at four vaccinations. We look at vaccinations for flu, for COVID, for pneumococcal disease and for shingles. So pneumococcal disease is a bacteria that can cause pneumonia and meningitis.

There are two reasons we’ve, we’ve done a report on these diseases and vaccines. The first is that they’re all, very dangerous diseases. So since the start of the year alone, COVID has caused 3000 deaths in Australia. In the average year, flu is responsible for about 600 deaths. But, in a bad flu season, like 2017, for example, flu can be responsible for several thousand deaths. Pneumococcal, is estimated to be responsible for several hundred deaths a year, and shingles is rarely fatal, but it is very painful and debilitating. And about one in 10 people go on to have long-term symptoms. So that’s the bad news about the diseases that are the focus of our report. But the good news is that vaccines are extremely effective against these diseases and they often slash the risk of illness, hospitalization, and death by more than half.

Kat Clay: So the report limits it scope to people who are at high risk. Who are these people?

Ingrid Burfurd: When we talk about people who are at high risk, what we mean is that these are the people who have the greatest sort of absolute risk of, the most severe symptoms of these diseases. So that can look like hospitalization time in ICU death.

Broadly there are two factors that drive up people’s, risk profile. the first is age. So as we get older, our immune systems get progressively weaker and less able to fight off the kinds of viruses and bacteria that we’re looking at in this report. The second, factor that can drive up people’s risk profile is whether or not they have any high risk conditions that might predispose them to those particularly severe symptoms. These are. the people who get the most benefit from vaccines, which is why they’re the focus of our report. And in the report we specifically look at, for covid and flu people who are aged 65 and older, or people who have two or more of those high risk medical conditions.

So things like, stroke or having dementia or a heart condition. For shingles and pneumococcal, our focus is on people who are aged 70 to 79 because that’s the, the age bracket when people have, until very recently, actually been recommended to get the vaccine. There’s a brand new vaccine available, for shingles, which is now recommended is on the National Immunization Program from 65 years of age.

Kat Clay: And I think that’s one of the things we’ll discuss a little bit later in the podcast is, you know, knowing what vaccine to get, when. Because that’s part of the confusion of the vaccination program. But I wanna track back a little bit because I feel like the mentality around vaccines has changed. Uh, we saw a huge surge of people getting vaccinated in the pandemic.

You know, I still remember vividly lining up at Sunshine Hospital for a couple of hours to get, you know, my covid jab. But Peter, what’s happened to vaccination rates since then?

Peter Breadon: Well, Kat, you’re right. Australia achieved a really high rate of COVID vaccination not that long ago. It was well over 90% of people who were eligible had a COVID vaccination, since then, understandably, it’s crashed because perhaps people have lost sight of the risks of Covid. reached a low of only about 10% of this high risk group that Ingrid talked about being vaccinated. Government gave it a bit of a push and it’s bounced up a bit since then, but it’s still less than, four in 10 high risk people currently up to date with their COVID vaccinations, which is having had one in the last six months or so.

We’ve also got problems with the uptake of other vaccines for this older age group. For flu, the best of the four, it’s often around two thirds, but that varies year to year. And even on a good year, about a third of older adults are missing out. For shingles, about half of the recommended people in their seventies that have had a shingles vaccine. Pneumococcal’s the worst. Only one in five people in their seventies have had that vaccination. So we’ve got problems with the uptake of all four of these really important vaccines for older people.

Kat Clay: Ingrid, one of the biggest pieces of research in this report is around who’s missing out, and there are some pretty shocking statistics in this report, I have to say. Can you take us through what you found?

Ingrid Burfurd: What we found in this report is that people’s likelihood of being vaccinated, differs a lot. And it depends on their cultural background. It depends on their income, and it depends on where people live. In our report, the way we measure these disparities is by comparing the average vaccination rate for all high risk Australians, to the high risk Australians in these specific groups. It’s about 60% less for people who aren’t proficient in English, less half for people who don’t speak English at home, and Aboriginal and Torres Strait Islander people are about a third less likely to be vaccinated in that high risk group.

Income plays a role as well. And so we can compare the vaccination rates from people in the bottom 10% weekly income compared to the top 10%, for example. And people in the bottom 10% vaccination rate less than 30%.

People in the top 10% have a vaccination rate above 50%. So it’s about a 60% difference from the, the bottom to the top of that income distribution. And of course these factors are also reflected in where people live and so are vaccination rates. So if you live in a remote or very remote part of Australia, you are less likely to be vaccinated. But even within capital cities, there’s big variation.

Kat Clay: That was really interesting to me because I, I would assume that people in regional areas would probably be less vaccinated due to lack of access to medical facilities and things like that. But the, the really shocking one here was, the fact that the disparities in, within major cities themselves, I mean just across the board for suburbs or for for particular, uh, local government areas, you know, was huge.

Ingrid Burfurd: So for example, if you, live in Mosman, you have an average vaccination rate above 50%. But if you live in Fairfield, still within Sydney, you have an average vaccination rate below 17%. those are huge differences even within our capital city areas. And those are big areas too. Kat, there’s about a hundred thousand people in each of those areas. And so if we dug further, we’d find even bigger differences.

Kat Clay: Peter, did you have anything to add to that, I mean, how does this make you feel thinking about these kind of health disparities here?

Peter Breadon: It is pretty disturbing, Kat. I honestly went into this project knowing we would find differences, in vaccination rates according to wealth and where people live, and their cultural background. I think the differences were bigger than I expected, particularly these differences between language groups. We like to often pride ourselves in Australia on our multicultural model, which performs in so many ways better than some other countries. But these really stark disparities. It’s pretty huge and it’s frankly unacceptable. The other thing we found is that you can look at all these different dimensions of barriers to access to vaccination individually, but they compound for individuals. So we looked at how they can stack up. And if people have just, uh, one of these risk factors like living in a small town or being low income, or not speaking English at home, they will have a lower rate than the average.

But as you add those together, it goes down and down and down. So we really see that some people have extremely low vaccination rates based on a whole range of characteristics. That block them from getting access to the healthcare that they need.

Importantly, those same groups are the ones that miss out on all kinds of other healthcare. They’re also more likely to be exposed to other kinds of health risk factors ranging from, in many cases, exposure to tobacco, smoke or obesity, or stress. And, and we know racism is a contributor to illness as well, so it really does paint a picture of some people who are being left out, left behind, and troublingly those people are the ones at greatest risk these conditions that vaccines protect people from.

Kat Clay: I mean, one of the things I, I do think about reading this report about the flu vaccine. It’s one of the best communicated vaccinations, I think out of, out of the four that you’ve identified here, because people do know that, you know, in that kind of may period you should go and get your flu vaccination.

But I’m really interested in what else is preventing people from getting vaccinated, especially around, these other vaccines.

Ingrid Burfurd: People have different barriers to vaccination and it’s useful to think about, barriers existing along the spectrum. So some people have low barriers to vaccination, so this might be things as simple as, forgetting to put an appointment with your GP or pharmacist, a bit confused about what vaccines you need when. Some people have moderate barriers.

 These are people who are happy to use mainstream healthcare services like GPs pharmacists, but there are either practical or cultural barriers to them, making best use of them. And then there are people with much higher and more entrenched barriers vaccination. So these are people who, typically visit GPs and pharmacists and they might need more intensive, um, engaged outreach work to reach them and get them vaccinated.

Peter Breadon: And these different levels of barriers that, you know, that range from just, you know, things like convenience through to things like really deep skepticism and suspicion or distrust of the health system, or believing in misinformation about, vaccinations. There is that whole spectrum that Ingrid talked about, but across that whole spectrum, many of these things are not about people’s individual willingness to get vaccinated.

Some of them are, but a lot of them are about things like awareness, cost, convenience, and even when it is about people’s attitudes to vaccination, those attitudes can be changed with the right solutions.

Kat Clay: So moving on then, because we are a think tank about solutions, not just ideas, what do you think should be done?

Ingrid Burfurd: For people with low barriers, need to use universal policies to really lift the vaccination rate across the board. And in our report, What we recommend is using, vaccination campaigns, which is sometimes called surges to do that. So that’s a a period where we really basically throw a lot the vaccination, uptake drive. We do that with things like, very clear communication about who is being targeted and using SMS reminders people,and then the other thing that we think should be explored is, shorter and more flexible, periods between The most people’s most recent infection or vaccination a vaccination during that surge period. So that’s to give people, opportunity to sort of get, on board with a routine surge based, vaccination schedule to make it much easier for everyone to do. what they’re doing in Europe. And so far it looks like that’s been a reasonably successful strategy particular for reaching those high risk people. For people with moderate barriers to vaccination, we need actions that make it easier to access mainstream healthcare services. So that’s things like, better access to translators, and more frequent use of inReach services to nursing homes and people living in disabled, accommodation. Cultural awareness training for GPs and pharmacists so that they can make sure that their vaccination services are accessible to the widest possible range of people.

Peter Breadon: And that leaves those people who have really high barriers. But what we’ve learned through the pandemic is there are a lot of great programs that can overcome even those really high barriers. So we’ve seen these programs that have been designed with those communities and often delivered with those different communities. have some success. So examples, and there are case studies in the report are models where there are champions that come from those communities and share, um, information about vaccination within that community from their position of high trust and authority. Um, and maybe in that language and understanding that culture, there are models like providing vaccination outside mainstream health services, but in community settings, again, where people can, be in a high trust environment, and in a place where they can get information in a way that’s culturally sensitive and safe.

Ingrid Burfurd: So a really good example of that actually came up while we were doing the research for this report. We were looking in particular at, uh, Yarrabah, which is one of Australia’s largest, uh, discreet indigenous communities.

There’s over 4,000 people who live there. it’s an area with extremely high burden of chronic disease so that at-Risk Group that we are particularly worried about, we looking in particular at the work that was done by the Gurriny Yealamucka Health Services, in order to make sure that their community was vaccinated.

So at a point in time you know, vaccination rates were really taking off in Sydney and around Australia, they were really lagging in a number of these indigenous communities and in Yarrabah as well. The doctors at the health service there were really concerned about what would happen if COVID swept through the community. Getting people vaccinated was a question of going door to door, having many cups of tea so that they were sitting down with people and reassuring people who had often quite deep of sort of centralized government-led medical services. There were people who were concerned that the vaccines might harm them. There was rampant misinformation in the community. And so, the doctors there, Aboriginal healthcare workers and Aboriginal healthcare practitioners were going door to door with an esky of vaccines, convincing people to get vaccinated against COVID, and their efforts were extraordinarily. demanding, but were rewarded.

So by the time COVID reached Yarrabah, over 83% of the community had been vaccinated, which is an extraordinary effort, the health service there, which is very deeply embedded in the community. It’s an Aboriginal community controlled health organization. actually one of the recommendations in our report is that Aboriginal controlled um, healthcare organizations, which are called Achos, get ongoing additional funding, separate to any vaccination agreements so that they can continue this work that’s so deeply embedded in their communities and which provides an alternative to the mainstream health services people might not be comfortable using.

Kat Clay: National Vaccination Strategy lapses next year. There’s a lot of work to be done in this space and also a lot of reform, as you’ve pointed out.

Who should be responsible for these policies and actions?

Ingrid Burfurd: Well, federal and state governments both play a role in vaccination. That’s because the federal government’s largely responsible for primary health, and states are largely responsible for public health. And vaccination sits at the intersection. We will see a role for both levels of, of government and that will need to be formalized. We recommend that there’s a new framework, adult vaccines, that sets targets for adult vaccination. as we already have for childhood and adolescent vaccines, and because those universal and targeted are largely led through the, primary health system, we recommend that the federal government should be responsible for lifting vaccination rates, essentially across the board.

What we recommend is that there are targets for coverage for all four of the vaccines that we’ve been talking about today. targets should be based on advice ATAGI, which is Australia’s technical advisory group on immunization. But in addition to those, broad-based targets, we also would like to see, states responsible for equity-based targets. So in particular, we recommend that there’s $10 million a year over five years for primary health networks to drive those universal and targeted policies. But that states and the federal government co-fund those tailored initiatives with $20 million a year over five years.

Kat Clay: Peter, do you have anything to add about just the urgency of why this is important?

Peter Breadon: It is urgent because are talking about thousands of deaths every year, many of which are avoidable, hundreds of thousands of days in hospital. The reason it’s a great time to strike right now is because we’ve actually got a lot of the building blocks that have been built up in just the last few years through a lot of hard work by governments and by healthcare workers. Since the late nineties, vaccination has surged, it reached. Targets the government set showing us that targets worked so we can learn from that. And they had equity targets, which really meant that we got fairer vaccinations of kids. So we’ve learned some lessons from that. Since 2021 we’ve got new data to track and understand adult vaccination, which we never had before. So we can set those targets for adult vaccination and we can understand who’s missing out. During the pandemic we had wave after wave of hard won innovation, out to those people who really need the most help. But we’re in danger of letting some of those lessons go as those programs and those resources up. So it really is a great time to strike.

Kat Clay: Thank you so much, Peter and Ingrid for talking through vaccination and why it is so important, especially for these high risk communities. If you’d like to read this report, it’s available for free on our website at grattan.edu.au. And if you’d like to talk to us more about this, you can find us on social media at Grattan Institute.

As always, take care and thanks for listening.