Theme 1: Equity

Equity is the absence of avoidable or unjust differences between population groups. ^{Reference Signal, Martin and Cram31} Across all categories of the influenza and measles case-studies, and for COVID-19, inequity in disease and immunization rates and inequitable roll-out of the immunization programs are concerning. As with the influenza and measles programs, the COVID-19 immunization roll-out has been criticized in the media and by public health experts for using a non-targeted approach. ^{Reference King, Cormack and McLeod32} Like measles, COVID-19 is considered a “magnifying glass,” the transmissibility and immunization data highlighting inequities in the immunization response. ^{Reference Kvalsvig and Baker33,Reference Williams and Dawson34}

A commitment to equity in public policy goes beyond recognizing and prioritizing vulnerable groups and requires intentional actions to target priority groups and achieve equitable outcomes. ^{Reference King, Cormack and McLeod32} The need for action to achieve equity is emphasized by King and colleagues: “saying, ‘equity is important’ is different from actually making equity important by means of intentional actions to achieve it.” ^{Reference King, Cormack and McLeod32} While vulnerable groups are often mentioned in the influenza and measles case-study documents, few official documents incorporated the value of equity, and of those that did, only a few explained how the goal of equity was to be practically achieved. Although the COVID-19 immunization response claims to be predominantly driven by equity, the COVID-19 immunization programs organized by the MoH and District Health Boards (DHB) did not reach their targeted audiences. ³⁵ For example, despite the Manakau DHB having a high Māori and Pacific population (38%), less than one-fifth of people immunized at a mass immunization event in August 2021 were Māori or Pacific. ^{Reference Mayron and Tokalau36} In comparison, a mass immunization event organized by Pacific providers in Auckland in October 2021 saw 7000 Pasifika immunized over 3 d. ^{Reference Foon37}

There is often a tension in public health between achieving equity by prioritizing a specific group of the population and maximizing benefits across the whole population. A one-size-fits-all strategy can be beneficial at the population level—reaching an 80% immunization rate in the whole population, for example—but will likely perform poorly in achieving equitable rates for all population groups. A maximizing strategy can result in a failure to distribute benefits fairly, violating a core tenet of justice. This is evident in NZ, where population COVID-19 immunization levels were high, but lower among Māori. Thus, paying attention to how the benefits of an immunization program are distributed is an important ethical constraint on a maximizing strategy.

However, the “cost” of achieving equitable outcomes might involve sacrificing some benefits for 1 group to prioritize benefits for another. ^{Reference Williams and Cooper38} For instance, equitable rates of immunization might necessitate the prioritization of subgroups of the population at the expense of a slower rise in immunization rates in the whole population. The ethical trade-off between equity and utility was evident in a few documents compared with the public debate over immunization strategies for measles, influenza, and COVID-19 tended to emphasize 1 value over the other. ^{Reference Jacobs39} While some degree of trade-off between these values may be necessary, prioritizing equity in immunization contributes to overall utility due to the promotion of herd immunity and reduces direct and societal costs. ^{Reference Williams and Cooper38}

The major difference between COVID-19, and influenza and measles, was the public, political, and economic pressure to re-open borders to international travel and trade. ^{Reference Malpass40} Achieving equity in immunization rates across the population has subsequently become increasingly important as NZ no longer seeks COVID-19 elimination. ^{Reference Tahana41} As well as incurring these direct impacts, more vulnerable groups will be disproportionately affected as the health-care system becomes over-burdened, and the opportunity cost of treating COVID-19 patients in place of patients with other health problems increases. ^{Reference Tahana41}

A commitment to equity in health policy must, therefore, include and go beyond prioritization in principle and directly incorporate vulnerable groups in immunization planning and delivery. Multimodal, culturally acceptable programs that understand the unique challenges faced by each population group are most effective when the affected communities are involved in decision-making. Funding must be allocated fairly, to support underserved populations and to avoid HCW burnout. ^{Reference Stewart and Gardner42}

Theme 2: Te Tiriti O Waitangi

In NZ, equity is underpinned by the Crown’s obligations under Te Tiriti and the goal of equitable health outcomes for Māori. ^{Reference Came, O’Sullivan and Kidd43} Past immunization approaches have not led to equitable outcomes due to a failure to incorporate Māori in the planning and response of immunization strategies. ³⁰ Similar to influenza and measles programs, the COVID-19 immunization strategy has been criticized for largely ignoring advice from Māori health experts. ^{Reference Jacobs39} The principles that underpin Te Tiriti are rangatiratanga (self-determination), partnership, active protection, equity, and options. ³⁰ While active protection and equity are often goals of more recent immunization programs (since 2019), without active incorporation of the other principles, immunization will continue to be delivered inequitably due to the one-size-fits-all model. ^{Reference Came, O’Sullivan and Kidd43} To uphold the rights of Māori in NZ, policy-makers need to work directly with Māori to lead, co-design, implement, and evaluate programs. These principles of partnership and co-governance could be applied in contexts other than NZ to uphold equity and justice.

In the traditional Māori context, tikanga (values and standards) guide Māori and help to promote and advance health. ^{Reference Gallagher44} The Māori worldview gives a holistic view of health, which goes beyond the individual to consider the interconnectedness of relationships. A holistic view of health is encapsulated in Māori models of health such as Te Whare Tapa Wha and Te Pae Mahutonga. ^{Reference Durie45,Reference Rochford46} Other countries have developed similar models which similarly incorporate indigenous values. ^{Reference Chino and Debruyn47} The effects of COVID-19 extend beyond an individual’s health, rippling into all aspects of the health-care system, the economy, and collective society. Therefore, the fundamental values of tikanga can help guide an immunization approach. Incorporating Te Tiriti alongside tikanga values may provide solutions to increasing herd immunity among the whole population. As noted earlier, influenza, measles, and COVID-19 immunization strategies designed by Māori, such as outreach programs and drive-in immunization services that offer incentives such as kai (food), held in community gathering places such as marae and churches (emphasizing community wellbeing over individual wellbeing), have increased immunization rates among both Māori and non-Māori. ^{Reference Wehipeihana, Sebire and Spee48}

Theme 3: Immunization Mandates

Measles, influenza, and COVID-19 immunization strategies are dependent on education and awareness. Both influenza and measles documents included discussion of immunization mandates, particularly among certain high-risk professions or during an outbreak. However, the response to COVID-19 is unique in its introduction of population-wide immunization mandates and certificates (discussed below). COVID-19 immunization mandates and certificates highlight the tension between maximizing benefits and individual autonomy. ^{Reference Gostin and Salmon49} The public debate on the ethical principle of maximizing benefits and minimizing harms intensifies in the setting of pandemic influenza, measles outbreaks, and COVID-19.

Vaccination certificates are 1 means by which the Government and businesses can attempt to increase immunization rates and minimize disease outbreaks. ⁵⁰ Vaccination certificates for COVID-19 could be considered analogous to the measles and childhood immunization certificates required by schools in NZ. This approach has been described as “compulsory choice” because it requires people to reveal their immunization status, which may contribute to increased immunization rates. ^{Reference Dare51} However, there are no clear consequences for children who are not immunized against measles, although they are recommended to stay home from school during an outbreak. The immunization certificates for COVID-19 (still in the proposal stage at the time of this study) enact consequences of social exclusion for those who are not immunized, providing an incentive to become immunized. A policy of requiring certificates demands that everyone has equal access to the vaccine. Consequently, certificates could compound existing inequities and lead to a mistrust in the government. ^{Reference Haire, Komesaroff and Leontini52} The potential harms can be justified on the grounds of widespread benefits to society, such as increasing herd immunity and economic growth. However, these justifications must be balanced against other ethical principles with the values and justifications outlined and communicated in advance. ^{Reference Gostin, Salmon and Larson53}

In 2020, the NZ government introduced immunization mandates to groups such as border workers, HCWs, and educational workers. ^5,54 These mandates were similar (although on a much larger scale and more punitive) to strategies used in measles outbreaks in which unimmunized teachers are required to stay home during an outbreak. The increased risk of morbidity and mortality of COVID-19 further emphasizes the “duty of care” of HCWs, an aspect that is evident in the influenza documentation. ^{Reference Dini, Toletone and Sticchi55} The key ethical justification for mandates is minimizing harm by keeping the community safe while promoting the benefits of herd immunity and other important social goals, such as ensuring children have access to education. ^{Reference Gostin, Salmon and Larson53}

Poorly implemented and unjustified mandates can increase distrust among the community. ^{Reference Haire, Komesaroff and Leontini52} The urgency of the pandemic and COVID-19 “fatigue” from lockdowns and restrictions, as well as the adverse economic impact, meant that people were perhaps more accepting of an immunization mandate for COVID-19 than for other diseases, such as influenza and measles. ^{Reference Williams56} A further risk, however, is that wider community mandates can divert resources away from other immunization campaigns and result in a decrease and reluctance to get immunized for other diseases. ^{Reference Gostin, Salmon and Larson53} Considering the impact of the COVID-19 pandemic on the decreasing immunization rates for diseases such as measles, it will be important to consider additional focus and resources for other immunization programs, to prevent further disease outbreaks. ^{Reference Witton57}

Theme 4: Planning and Preparedness

Planning and public health workforce preparedness for disease outbreaks is imperative to ensuring a cohesive immunization program that targets priority groups, ensures adequate vaccine supply, and builds trust. This study found that, although being prepared for a disease outbreak is considered highly important, disease outbreaks in NZ rely primarily on the NZIPAP, ¹⁶ which urgently needs updating. Moreover, there are no detailed publicly available immunization plans for use during an infectious disease outbreak. ^{Reference Kvalsvig and Baker33} This lack of preparedness results in immunization programs being reactive, rather than preventative to outbreaks. The lack of planning and foresight results in a perpetual cycle of under-funding of the public health system, a system designed primarily for prevention, until there is an emergency or crisis such as the COVID-19 pandemic.

The lack of planning also results in a “crisis mindset,” whereby the immediate threat of disease takes precedence over the long-term approach needed to prevent future outbreaks. ^{Reference Fenton and Chillag58} This is evidenced by the decrease in immunization rates for other diseases such as measles, during the COVID-19 pandemic. ⁵⁹ There are many uncertainties with the COVID-19 pandemic, and immunization plans are constantly changing and evolving as new evidence emerges. ^{Reference Manch60} Using information from modeling and expert advice, which has been successfully used during COVID-19, can help to decrease the severity of an outbreak. ^{Reference Steyn, Plank and Hendy61}

Ethical preparedness is fundamental to an effective public health response. ^{Reference Saxena, Horby and Amuasi62} While documents in this study were coded for foundational ethical principles, few NZ documents other than NEAC’s Getting Through Together (2007), explicitly note the ethical values that should guide decision-making during a public health emergency. ²³ Public health operates in a political context, and in an emergency, political considerations can influence how and when particular measures are implemented or publicly accepted. ^{Reference Fenton and Chillag58}

Ensuring that ethical values and commitments are transparent is important to the success of public deliberation, trust, and willingness to comply with necessary public health measures. ^{Reference Gray, MacDonald and Mackie63} This is especially important when rapid action is required in the midst of the fear, uncertainty, and urgency of infectious disease outbreaks. ^{Reference Fenton and Chillag58} There are several ethical frameworks that can be used in combination with Te Tiriti and other policy recommendation documents (such as WAI2575 in NZ), to assess and justify policy change, to avoid reactive policy changes, and to ensure equity. ^{Reference Kass64,Reference Upshur65} Using health promotion to communicate mandates and the underlying values is best practice (as evidenced in other vaccination programs). Clearly articulating the values and justifications behind policies, such as immunization mandates, is important to maintain public trust and transparency, and ensure processes are guided by core values.

Limitations

While this study highlighted some key findings that will be useful for future immunization planning, there were several limitations. The document analysis was not triangulated with other data such as interviews with key stakeholders, including the MoH and community groups, which would have enhanced the study. Moreover, to fit within the scope of this study, only 2 case-studies were used and not all documents were able to be collected pertaining to the case-studies.

Due to the fast-moving nature of the COVID-19 pandemic, updates to the NZ COVID-19 immunization strategy after October 15, 2021, were not included in the analysis. Policy changes and new information after this date are not discussed.

The analysis used NZ documents and data, and as such, the findings may not be applicable to other countries or for immunization programs that do not require herd immunity.