Evaluation of the Implementation of the Varicella Vaccine Introduction

This report presents the findings of an evaluation of New Zealand Ministry of Health's (the Ministry's) processes to support the introduction of the varicella vaccine to the National Immunisation Schedule (NIS). The vaccine was introduced to the NIS on July 1 2017, offering 1 dose for primary vaccination in children at 15 months old and 1 dose for unvaccinated 11-year-old children who have not previously had chickenpox. In accordance with the World Health Organization (WHO) recommendations, the Ministry commissioned Allen + Clarke to undertake this assessment of the impacts, successes, and challenges associated with the vaccine implementation and to provide recommendations for the future implementation of new vaccines.

The evaluation drew on qualitative data from a vaccinator survey and interviews with representatives of stakeholder organisations, including District Health Board (DHB) and Primary Health Organisation (PHO) representatives, immunisation coordinators, vaccinators, and parents/whanau (a Maori-language word for extended family) of children eligible for the vaccine. This was supported by a review of key documents provided by the Ministry and analysis of quantitative data related to immunisation coverage.

The evaluation found that the varicella vaccine introduction exceeded expectations in informing and training vaccinators to administer the vaccine. Key findings include:

• The health sector was well informed about the introduction of the varicella vaccine to the NIS. The most common communication mechanisms seen or used by the vaccinator workforce were the Ministry's immunisation monthly update, the hardcopy version of the Immunisation Handbook, and the NIS changes fact sheet.
• All modes of information and communication were rated as "adequate" or higher by over 90% of survey respondents for their effectiveness in providing information about the varicella vaccine introduction to the NIS. The information and communication methods that rated the highest were the hardcopy Immunisation Handbook, the Immunisation Advisory Centre (IMAC) website, the NIS Reference Card, and Ministry and IMAC fact sheets.
• The information and key messages were consistent across the resources provided by the Ministry, the Pharmaceutical Management Agency (PHARMAC), IMAC, and GlaxoSmithKline (GSK).
• All the training mechanisms were rated as "adequate" or higher by at least 93% of survey respondents. In particular, the "train the trainer" model was seen as an effective and efficient way to train the workforce, enabling vaccinators to feel prepared and confident to administer the varicella vaccine.

The varicella vaccine introduction exceeded expectations in the communications and resources intended for parents/whanau. Key findings include:

• Vaccinators considered that the Immunise Against Chickenpox brochure and the Childhood Immunisation booklet were highly effective resources to aid their conversations with parents/whanau.
• Parents/whanau perceived that the resources were easy to understand, used simple language and provided relevant information. Maori and Pasifika parents/whanau considered the resources to be culturally appropriate.
• Nearly all parents/whanau stated that they were given enough information to make an informed decision about the vaccine.

The varicella vaccine introduction met expectations regarding its acceptability to vaccinators and parents/whanau. Some of the key findings include:

• The varicella vaccine is highly acceptable to the vaccinator workforce, with nearly 90% of survey respondents stating that they "fully accept" the vaccine.
• Most parents/whanau engaged with during the evaluation were confident about their children receiving the varicella vaccine. Decisions to split the vaccines are primarily driven by a perception that 4 injections at once (varicella alongside the measles, mumps, rubella vaccine (MMR), Haemophilus influenzae type b vaccine (Hib), and pneumococcal disease vaccinations) is too much for the child's immune system.

The varicella vaccine introduction met expectations regarding its impact on information management systems. Some of the key findings include:

• Practice management systems (PMS) were updated to record varicella vaccine events, but not all vaccinators accessed the PMS release notes because they did not see it as part of their role or considered that the release notes were written from an information technology (IT) perspective and did not meet the needs of the nursing workforce.
• Most vaccinators reported that they were confident in entering the varicella vaccine information into their PMS. However, some vaccinators discussed issues with entering rotavirus vaccine information into the MedTech system which in turn caused some general confusion in entering immunisation data related to the July 2017 NIS changes.

The varicella vaccine introduction also met expectations in terms of its impact on cold chain management and regarding uptake and coverage. For example, 79% of children who turned 18 months of age between October 2017 and February 2018 received the varicella vaccine, compared to 83% of children who received the other three 15-month vaccines. This is comparable to the difference in coverage rates between the existing and new vaccine when rotavirus vaccine was introduced in 2014.

The findings will contribute to the body of evidence that can be drawn on to inform future vaccine introductions. Based on the findings, the evaluation makes several recommendations, including these communication-related ones. The Ministry should:

• Continue its current approach to informing and training the vaccinator workforce for future NIS changes. This should include: employing multiple communication channels and releasing a suite of information resources with varying degrees of detail; retaining the current processes for ensuring information consistency; and continuing to use the "train the trainer" model.
• Together with the Health Promotion Agency (HPA), continue to develop resources to support future vaccine introductions. Resources should use plain language, provide the rationale for the vaccine, and detail potential harms if the disease is contracted.
• Communicate with immunisation providers to ensure they are aware of the requirement to update their cold chain policy in response to NIS changes, even if these occur between annually scheduled updates.
• Implement more frequent communication with PMS providers as they develop updates in response to future NIS changes, to reduce the likelihood of errors.

The Ministry is incorporating these recommendations in its planning for future changes to the NIS.