Did Australia get its vaccine strategy right?

As the long pandemic year drew to an end, and people started stringing up lights and decorating Christmas trees, Australians could be forgiven a small glimmer of hope that the worst of COVID-19 was behind us.

By mid-December, the country had secured more vaccine doses per person than any nation other than Canada. Early data from clinical trials suggested we’d nailed our four vaccine picks.

Prime Minister Scott Morrison receives his second Pfizer vaccination at Castle Hill Medical Centre in March.Credit:Edwina Pickles

“We aren’t putting all our eggs in one basket,” said Prime Minister Scott Morrison in November.

“There are no guarantees that these vaccines will prove successful, however our strategy puts Australia at the front of the queue.”

Just a few months later, Australia’s once-blooming bouquet of vaccines now looks rather wilted.

The University of Queensland’s vaccine failed, Novavax’s has been stalled by production issues, and AstraZeneca’s has just been quasi-restricted to people over 50. Pfizer is the only unqualified success – but until last Friday we only had enough to vaccinate less than half the country.

Meanwhile, Britain has managed to give a first dose of vaccine to almost half its population, and Israel almost two-thirds. Countries as large as Turkey and as small as Uruguay are racing out ahead of us.

What happened? Could we have chosen different vaccines? Hindsight is 20:20 – but was it clear early last year we should have selected different jabs?

Our vaccine choices were rational, experts say. And we got unlucky: mRNA vaccines worked out better than anyone could have forseen, and AstraZeneca’s vaccine ran into safety issues.

But we may have placed too much faith in the University of Queensland’s vaccine – and economists and decision-theorists are united in their criticism the government spent too little on vaccines, and took on too much risk.

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Making decisions in times of risk and uncertainty

Typically, when a government orders vaccines it knows how many doses it can get, how safe and effective they are, and when they will be delivered. “And then it just turns up on your doorstep,” says Dr Bonny Parkinson, a Macquarie University health economist who helps assess drug costs and benefits for the federal government.

But when the federal government began talks with vaccine developers in March and April, it did not know any of those things. Scientists weren’t even sure they could make a vaccine.

Dozens were being developed. Governments could not tell with certainty which would succeed.

The longer they waited, the more data they had to make a decision with – but countries that ordered earlier were also likely to get doses first.

“When you learn Pfizer is wonderful, you might not be able to buy any,” says Professor Tom Kompas, chief investigator at the Centre of Excellence for Biosecurity Risk Analysis.Credit:AP

“When you learn Pfizer is wonderful, you might not be able to buy any,” says Professor Tom Kompas, chief investigator at the Centre of Excellence for Biosecurity Risk Analysis at the University of Melbourne.

How do you solve this problem? There are no true wrong answers, says Kompas’s colleague Professor Andrew Robinson, the centre’s director. Just different “risk profiles”.

Britain and Canada opted to spend more money to cut their risk, both signing contracts with eight different vaccine developers.

That came at a huge cost. Britain spent more than $21 billion on its vaccine purchases; the US spent $23.4 billion. In exchange, they secured a guarantee their citizens would get the vaccines first.

Australia opted to spend less money, meaning we took on higher risk, says Professor Robinson.

We signed deals with four vaccine manufacturers at a total price of more than $3.3 billion, as well as signing up to COVAX, a global agreement aiming to guarantee fair and equal access to COVID-19 vaccines.

To put that figure in context, Victoria’s airport rail link is forecast to cost $10 billion. Our new fleet of 12 attack submarines will cost at least $80 billion to build.

Was this the right decision?

“The ideal strategy, to my mind, was to order all of the leading contenders,” says Steven Hamilton, an assistant professor of economics at George Washington University and a persistent critic of Australia’s vaccine strategy.

Britain’s Prime Minister Boris Johnson visits a laboratory in Livingston, Scotland.Credit:AP

Buying different vaccines reduces risk. Buying more doses increases the speed at which those doses are supplied, Professor Hamilton argues.

“We should clearly have ordered 50 million doses up front of each of the leading contenders,” he says. “The only basis on which to defend our strategy is budget.”

The economy benefits enormously from early vaccination, says Grattan Institute health program director Dr Stephen Duckett. “The costs of not opening up the economy are really, really high and the benefits of a speedy vaccine rollout are extraordinarily high.”

This is an example, says Professor Tom Kompas, of an “asymmetric risk”. The risks of overspending on vaccines are vastly outweighed by the risks of underspending and not having enough to vaccinate a population.

“The loss is so asymmetric. It’s incredible. The cost of a lockdown is about $1 billion a day,” he says. He would have purchased tens of millions of extra doses of Pfizer’s vaccine in December, when it started to become clear it was likely to be highly effective (the government opted against this as they were confident they had enough supply of AstraZeneca, and knew it would take months for extra Pfizer supply to arrive, The Age understands).

Risk is not the full picture, though, says Professor Andrew Robinson.

Countries with uncontrolled outbreaks, like the USA, knew they faced high losses if they did not get an effective vaccine. With an under-control outbreak, Australia’s potential losses were far lower.

“What they’ve done is not unreasonable. It’s just not optimal.”

Could we have purchased different vaccines?

It’s easy to say we should have bought more vaccines, or chosen differently. But a vaccine that is safe and effective is not enough. Governments knew that there likely would not be enough jabs to go around, and the fight for supply would be fierce.

Take Moderna’s mRNA vaccine. The Age understands the government viewed it as very likely that he American government – under then-president Donald Trump – would block exports of the vaccine for many months, as ended up happening.

Britain won’t get its first doses of Moderna until April – and then only 500,000 of them.

Minister for Health and Aged Care Greg Hunt and Chief Medical Officer Professor Paul Kelly.Credit:Alex Ellinghausen

The other leading candidate was an adenovirus vaccine made by Johnson & Johnson. The Age understands the government viewed it as less advanced than AstraZeneca’s adenovirus vaccine, and less likely to be available early in large doses; it also emerged this week Johnson & Johnson was refusing to sell the vaccine to Australia due to our lack of a no-fault compensation scheme.

Given the likely supply issues, Australia’s government prioritised onshore production. The Age understands it pressured British-Swedish pharmaceutical company AstraZeneca to allow CSL to produce its vaccine at its Victorian plant – despite the company’s assurances it could make and supply it overseas. It also explains the decision to invest in the University of Queensland’s vaccine.

To hedge against failure, the government included clauses in all four vaccine contracts allowing them to be expanded as needed, The Age understands – as happened for Pfizer’s vaccine after AstraZeneca’s fell through.

Did we pick the right ones?

By opting against a whatever-the-cost strategy of purchasing every vaccine, Australia put itself under more pressure to nail its choices. Did we get them right?

Australia opted for a portfolio approach: one of every type of vaccine technology. This is the strategy espoused by the Coalition for Epidemic Preparedness Innovations. By buying different types of vaccine, you minimise the risk they will fail for the same reason.

That exact risk is imperilling Johnson & Johnson’s adenovirus vaccine right now, as fears mount it may cause the same rare blood-clotting syndrome as AstraZeneca’s adenovirus jab.

Australia purchased an mRNA vaccine from Pfizer, an established global pharmaceutical manufacturer, over biotech start-up Moderna.

We bought an adenovirus vaccine, a type of viral vector vaccine, from AstraZeneca, which we could make on-shore. This vaccine was considered the overall scientific and production leader by the government, The Age understands. And we bought a protein-based vaccine from Novavax. This choice is globally unusual; our 51 million-dose purchase makes us the fourth biggest buyer worldwide.

This vaccine technology is “conventional and old-fashioned” compared to the cutting edge but at-the-time-untested mRNA vaccines, says Professor Kim Mulholland, a member of the WHO’s Strategic Advisory Group of Experts on Immunisation.

“I think it was the rational choice.” (Professor Mulholland is a member of the safety monitoring board for Novavax’s clinical trials.)

Protein vaccines like Novavax’s also have proven “booster” capacity, allowing them to be used repeatedly to keep immunity high – a key factor in the government’s decision, The Age and the Herald understand. It remains unproven if mRNA and adenovirus vaccines can be used in the same way.

CSL’s Broadmeadows laboratory, where AstraZeneca’s vaccine is being made.Credit:Chris Hopkins

Another option was an inactivated-virus vaccine – the type now being exported around the world by Chinese companies Sinovac and Sinopharm.

“That’s really old-school technology,” says Professor Mulholland.

Five of the top 10 countries leading the world on vaccine rollout are using one of China’s vaccines.

But that technology has had very serious side effect issues in the past. “They created nervousness among a lot of us,” says Professor Mulholland.

Five of the top 10 countries leading the world on vaccine rollout are using one of China’s vaccines.Credit:Bloomberg

There would also likely have been issues getting a Chinese-made vaccine registered in Australia due to that country’s less-stringent regulations.

“The government’s choice was rational,” says Professor Mulholland. “But they had placed quite a bit of faith in the University of Queensland. Which clearly was a mistake. And to be honest, it was probably a foreseeable mistake.”

The University of Queensland vaccine

It is sometimes forgotten now, but in September the Australian government signed a deal for 51 million doses of the molecular clamp vaccine being developed by the University of Queensland and CSL. The doses were due in the second half of the year, with the government considering it (and Novavax) a back-up to Pfizer and AstraZeneca, The Age and the Herald understand.

The University of Queensland’s vaccine relied on a small protein similar to one used by the HIV virus.

But in December, it was discovered that HIV-like protein caused people who were vaccinated to test positive to standard HIV tests.

“To be honest, knowing it had an HIV protein stuck to it, we should have been able to tell that was going to be a problem,” says Professor Mulholland.

But vaccines often fail clinical trials. And the University of Queensland’s vaccine had the impressive backing of the Coalition for Epidemic Preparedness Innovations.

“We hit every target – creating a promising, stable vaccine able to be produced at scale,” the University of Queensland team said in an emailed statement. “Years of work had gone into the underlying molecular clamp technology.”

“In December, multiple vaccines were showing promise, and the team understood the decision to shift the focus and financial support to other candidates.”

Professor Sharon Lewin, the director of the Peter Doherty Institute for Infection and Immunity, dismisses criticisms of the UQ vaccine.

Prime Minister Scott Morrison during a tour of the University of Queensland Vaccine Lab in October, before the government ended its collaboration.Credit:AAP

In fact, she argues Australia should have been investing earlier and more deeply in home-grown vaccines.

“I think we moved a lot slower than other countries did with other vaccine candidates. It would have been nice to have more in the war chest. We have one of the best vaccine manufacturers in the world, and fabulous immunologists. A much more significant investment in the basic science of vaccines would have put us in a different position.”

Health Minister Greg Hunt said the government had made the decision to double the Pfizer purchases from 10 to 20 million in December once the University of Queensland molecular clamp was no longer considered viable. “This was done on the basis of strong clinical trials and need for additional supply in mind, with options we had built into the contract,” he said.

“The medical advice from the Scientific and Technical industry Advisory Group chaired by Professor Murphy was to contract for four vaccines across three platforms: one MRNA vaccine, Pfizer and one viral vector vaccine, Astra Zeneca (AZ). In addition, the onshore manufacturing capacity at CSL made the AZ a choice that would bring mass vaccine supply forwards in Australia by at least six months.”

‘I think we have just been unlucky’

Beyond choosing to spend more to cut our risk, and perhaps a misplaced confidence in the University of Queensland’s project, the experts who spoke to the Herald and The Age were fairly unanimous: Australia made reasonable calls but got unlucky.

Professor Lewin has closely followed mRNA vaccines for years. “As recently as November, we had absolutely no idea that mRNA was going to be as good as it turned out to be.”

If Professor Kim Mulholland were put in charge of Australia’s vaccine strategy back in March last year, he would have done almost exactly what we did.

“I was not that happy with the UQ thing but the choice of an mRNA vaccine, an adenovirus vaccine, and a conventional protein vaccine – it was logical to pick one of each.

“All the candidates they chose were credible … I think we have just been unlucky.”

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