COVID-19: Vaccine information for health professionals

The last primary community care webinar for 2021 and I'll just catch up with the back end and talk about the potential for 2022. Thanks, everyone. Just to remind everybody, this is being recorded. If you do have any questions, we just like you to drop those into the chat. Some of our presenters will be able to answer those on the fly otherwise we'll pick those up, someone will pick up at the end of the meeting. For those people who got really full agenda I'm sorry I haven't got my Sergeant and arms Sandy with me, so I'm not prepared to fumble my way through a karakia. But if there's anyone online who would wish to start us with a karakia that would be really appreciated otherwise.

OK, so no takers, let's just move straight into today's webinar. So firstly I'd like to introduce Professor Nikki Turner who will be no stranger to any of us I anticipate. And it's starting off a conversation about the 5 to 11-year-olds, and immunization for that group. And we followed up with John Harvey from the program talking about some of the practical operational implications of the work that we'll be starting next year. So agenda's type, Nikki the floor is yours.

Oh, kia ora, thanks. Actually, maybe I'll just start with a very brief karakia just since I'm the first speaker. So just a brief one, Kia hora te marino Kia whakapapa pounamu te moana Hei huarahi mā tātou i te rangi nei Aroha atu Aroha mai Tātou i ā tātou katoa May peace be widespread. The sea be like greenstone, a pathway for us all this day. Give love, receive love, and let us show respect for each other pure. Kia ora Tatou and thanks for the invitation, nice to be here with you all. So look I'm just briefly going to run through some of the science around the 5 to 11-year-olds. Now, I think what we've all got to be clear is that it's not yet a done deal. We are waiting for Medsafe licensure. And we cannot move without Medsafe licensure we're expecting to hear within a week or two. I think it's likely that Medsafe will approve it, but it's not clear yet. And then after that the technical advisory group also has to feel comfortable.

So these decisions should be through within the next week or two. If the decisions do go through and they feel that the effectiveness and safety is appropriate for this group then my understanding is that we're all gearing up for a rollout potentially from the third week of January for 5 to 11-year-olds. There is still data coming for children under five and that's a completely different conversation. So a few quick comments from me around the science just to help us all. Why would we vaccinate 5 to 11-year-olds? These children, the disease is overall more mild. They're are more asymptomatic. When you look at adults about 35% of them may be asymptomatic with COVID, and kids it's more like nearly 50%.

Overall more than 90% are mild or asymptomatic, and less than 1% overall are hospitalized. Of interest is that hospitalization rates are higher for Delta than for beta variants. So of course, we do not yet know about Omicron and its effect. Now, so yes the disease is overall mild, but it's not negligible. And I think this is the important issue for New Zealand, is that kids who are at higher risk remain Maori children, Pasifika children and children with significant medical issues. Now amongst that as obesity, which is a real issue for New Zealand population, and chronic respiratory disease. So we've got quite a sizable group of our kids who are at higher risk despite being a more mild disease.

There's a rare condition called multi-inflammatory syndrome, which does affect this group more than others, and it may be around 1 in 3,000. Now if you think about the fact that when we get COVID into the New Zealand community most children are going to end up being exposed to it even though the numbers could seem low, the absolute numbers could be quite high. So that's an argument to consider it even though the overall burden is lower in this group, particularly for Maori and Pasifika children. The community put so the first argument is individual protection, OK. The second argument is community protection. So would this be useful to reduce community transmission?

Now, this is where it's a bit weaker. I think that we know that transmission is important within household with big large crowded households. So vaccinating children as well will help and will reduce transmission, but not nearly as much as continuing to vaccinate the older age groups and probably now boosters in the older age groups. So there is an argument to help community transmission but it is not as strong, but it's there. But of course, that argument is more important for large households, overcrowding, generally poor housing conditions. And once again, the drivers behind poverty, socioeconomic deprivation are really important there. So even though it's a weaker argument about community transmission, it's still there.

The vaccine, we've only got a randomized controlled trial to date on just over 2000 children, 2/3 of which you were given the vaccine. It shows the vaccine used in kids is one third the RNA dose amount of the vaccine used in adults. It's shown that immune response is really good. It's the same as teenagers, young adults, in fact slightly stronger but equivalent really. So that's the data on it. At this stage, of course, it's reasonably small numbers so it hasn't yet translated into big community data. The safety profile to date is side effects for this vaccine for kids are overall about 10%. Injection site pain is higher in children other reactions are lower than adults. So you tend to see less fevers although you're still seeing about 3% getting fever.

Lymphadenopathy, swelling of the lymph nodes is a little higher in this age group. Now that's worth remembering because that gives kids tummy pains, can mistake it with appendicitis. So just remembering it's an inflammatory vaccine. But overall safety profiles looking good in this age group. Now what I want to stress is that the clinical data to date coming out of America and Canada they've already vaccinated more than two million kids. We are wanting to see the safety data on big numbers in America and Canada. We should see that very soon because it's coming out so fast. But we'll only see data on the first dose. So I would also caution us about what the interval from the first to the second dose should be. It is absolutely not a given that it should be a three week interval and there may be reasons why it might be better at a longer interval.

So my quick summary for everybody the reasons for vaccinating 5 to 11-year-olds would be particularly for individual protection, but recognizing there's important groups in the New Zealand population who are at higher risk. And that would be Maori and Pacifika kids, kids with co-morbidities, and remembering our problem with obesity and our problem with asthma and respiratory conditions. So I think it's really important for high risk groups that if you try just the highest targeted program you usually miss those who are most vulnerable. So that's why universal programs are better. For community protection, it will probably add a bit for our communities but not significant. And the effective Omicron may actually make that worse, because Omicron is looking like the vaccines are less effective for mild disease. So it'll help a bit for community protection but it's not a magic bullet.

I think the other important issues are less school disruption. Social distancing, other public health measures are important in schools when you get COVID outbreaks. They make a difference. But I think if you do have a vaccinated population then you hopefully have less disruption for community life, family life, school life. You know kids getting sent home, quarantined, working parents can't look after the kids, you've got a huge amount of social disruption within this population. So I think that's a significant aspect. And then I think the other potential is our Maori communities are telling us that this is a general community issue, and that if kids also are vaccinated it supports the general wider Maori fono to come forward and vaccinate. And it normalizes it more for everyone.

And my final point is that if we do go ahead with vaccinating 5 to 11-year-olds we must consider it alongside the childhood immunization program. I particularly want to highlight MMR and our deep concerns about not having good MMR uptake. We're at high risk of measles coming back to New Zealand. So I really want to see that we don't miss the opportunity to tie this in together with other aspects of the immunization program. And then my final point around the safety issues is I think we'll have good safety data soon for first dose, but I remain cautious around the second dose particularly around the issue of myocarditis. We've had some safety signals in teenagers. This is a lower dose. This is an age group that's at lower risk of myocarditis, but we still need to take it seriously. So those are my cautions. And otherwise, those are my supports around the program.

So I hope that's useful. I've run through it as fast as we can being aware you've got loads and loads of other things to go through. So kia ora koutou and I'll leave it back to you.

Nikki, thanks very much for that. I thought that was loaded with information. And really appreciate the clarity of thinking so far, certainly in an environment that's swirling with lots of evidence piling around. And I think lots of speculation certainly as we head into Christmas and that sort of era we've got boosters on. So I really do appreciate for that real clarity you've given us. You're welcome to stay on because we're going to have John Harvey talking to us now a little bit about some of the possible practical implications operationally and what's being talked about at the moment in terms of preparation for the most likely tick from our regulators in the next sort of week or two. So again, Nikki, thank you very much. Take this opportunity to wish you a Meri kirihimete and to you and Tony and thank you for an extraordinary year of information support to the sector with your knowledge and skills.

Thank you kia ora tatou.

OK, thank you everyone. So there's no questions in the chat. So John Harvey I'm sure you're around the place wanting to step on up.

Hi, everybody. Yeah, my name is John Harvey. I've been working in the civic program since March this year. And it's I'll just give you a brief rundown on our thinking on the 5 to 11-year-olds from an operational perspective. Clearly the jury's out, the decisions are being made. There's evidence to be considered by the regulators and CV TAG who are advisory group on how we should go forward as a program. However, we are doing a number of things in preparation for a decision to vaccinate just to ensure there isn't a I guess a gap between a decision being made and our ability to safely start to implement the program. So in support of that objective we've been working with Pfizer around the supply of the vaccine to New Zealand in the pediatric dose. Obviously, it's a different pharmaceuticals so it's a discretely different supplier perspective.

And the good news, the good news is that the dose, the pediatric product will be available to us in New Zealand from really Q1, very early in Q1. And we will be able to get in our first drop enough to vaccinate the whole cohort. So if you cast your mind back to earlier in the rollout where we had the sequencing framework in part to target those most at need, but also to help us manage to constrain supply situation, we don't have that constraint with the pediatric product. So that allows us to design our program around need, but not have to try and effectively in building a rationing type of objective amongst that. So that is helpful.

In terms of other planning, we obviously have Medsafe going through their process at the moment. And that's obvious they're independent and they're working. We've heard good reports in terms of responsiveness and lived with that they've been requiring. So that's positive. We've also CV TAG have been meeting and extending their membership to ensure that this is debated thoroughly from a number of perspectives. That ensuring that pediatric specialists who possibly aren't quite as heavily represented get their chance to bring their thinking to this debate. So that's Dr. Ian Towne is managing that. And they are targeting to come back with some advice prior to Christmas, so that's progressing.

We've been working with the IMAC team around preparing the necessary updates to the collateral that you're familiar with in terms of the training modules, the immunization handbook and so forth. Caveat is in all of this is that we are effectively using overseas data, and until we have our regulatory approval through, this is just simply when and if we get that approval we will do a an impact assessment and adjust that accordingly. But really it's about making sure we're as far ahead in that sort of work as we can be prior to prevent that lag as I mentioned. We're working through our policy activities, which includes wide engagement both through the sector through DHB and how all providers and et cetera, as well as a number of government agencies like the Ministry of Education, Ministry of the Children's Commission and DPMC and so forth. So we're in a sort of a wide consultation phase outside of the I guess the direct clinical decisions.

And finally, yeah, we're obviously working up our communications and messaging information and ensuring we have campaigning and aligning to Nikki's point where we can ensuring we are gaining alignment with other immunizations for this age group. So really quickly because I know we've packed. I guess the summary is we're doing as many of the-- as much as the planning as we can so that we can go forth and come through with a rollout process early in the new year and subject to approval. So I'll just--

That's fantastic. I don't see anything in the chat. And I apologize because I just switched off a bit while I was trying to write some stuff down. I don't do too well at doing two things at once. But one of the questions I think that will be evident will be the sites for delivery. People of course think that this group of people are young schoolchildren heading into sort of early secondary, and yet there's primary care and there's pharmacy and big community sites-- any sense about I suspect all those sites would be available, but any sense of the planning that's going on. I know you talked about talking with education. But I wonder if you could help with the detail there.

Yeah, look at this stage from a training perspective we'll be enabling the authorized and provisionally authorized workforce, and that will include yourselves of course, to be able to deliver the vaccine. We're slightly fortunate from with regarding the pharmacy setting, which has been very, very widely used and received well through the rollout because of its proximity. We don't have those-- we don't have the constraint around the age which we do with other immunizations. So the COVID vaccination authorization allows us to then immunize these children. So that's actually a constraint we don't have. Look, the school based-- the use of school it does appear to be something that initially that people tend to because they're school aged children. But at this stage we're really open to whether that as an appropriate mechanism partially through timing. Because if we start in January obviously schools aren't back. But also we don't currently immunize widely this age group at school in school-based settings or-- sorry nationally run school programs. So schools could well be vaccination sites as in community sites, but we're not seeing-- we're not really going forward saying this will be a school-based rollout at this stage. So really hoping that the local DHBs and provider networks will enable the sites that they believe will most best suit their communities. That's the intent, so not really constrained.

Yeah, thanks John. Yeah, of course there will be that potential clash around MMR catch ups and all these sorts of things going on as well. So as much as we are talking about 5% to 11-year-olds in the COVID vaccine then we are going to be thinking about that concomitant-- yeah, yeah.

Opportunity, which might cause some issues for our pharmacy community who have been front and center of a lot of this work. So they've been great.

Hey, John. Look, there's nothing more on the chat. I just really want to appreciate again if we come to the end of the year your leadership and your work bringing some sort of operational sense to the swirl of information and the instructions that are given to us. So thank you very much. And I hope you get the opportunity of having a well-deserved break although I'm suspicious with everything on the horizon that it's going to be very short for you.

Yeah, well you know.

Make it short, make it short but deep Johnny.

Yeah, that's we'll aim for that. OK, look there are a couple of questions in the chat, we'll respond to those. But I'll let you get on with your agenda. Thanks Vince, good luck with your holiday too. So thank you.

Yeah, thanks man. All the best, thank you.

Cheers.

OK, thank you John. So I'm going to invite now-- take a I think a slight diversion into talking about the disability strategy. So Rawa Karetai would bodily and I think probably Casey and Carrie, I think I see both of them in the audience there are going to talk to us about the-- here we go. We'll leave it up to you Rawa.

Vince, thank you for having me here. And Kia ora everybody my name is Rāwā Mahu Karetai, I'm the CVIP at Disability Lead. And I just wanted to quickly go through the program where we've come from but where we're with hitting but what we've also achieved. So as you know disabled people were identified as a priority group in the vaccination program, recognizing vulnerability to COVID-19 for some disabled people in the historic poor health outcomes. Disabled people who provided support and care were included in Group 3 of the sequencing framework with social model of disability. The program has put an emphasis on ensuring that the program is inclusive by raising awareness, accessibility, and accommodating for disabled people in the fono across the vaccination journey. This has included providing information on alternative formats. Enablers, like these that are accessible like BookMyVaccine website and the disability team at Whakarongorau via Healthline.

We've also provisioned support around transport, staff education, and also promoting accessible sites. So as you know we've got a various range of options for disabled people to be able to get vaccinated, either in the community through high clinical oversights spaces, through trusted providers, and also within their home bubble or through mobile units. There often is additional considerations with the disability community that we do need to make sure that we accommodate. And so what we've done is made sure that all staff are well versed in disability issues and rights and are inclusive and responsive to clients. We've allowed extra time and space for support that is appropriate for the individual and provided that environment. But we've also provided an environment where fono and support people are welcome throughout the process.

Information around vaccines has been available in various range of formats most notably you're probably seeing New Zealand sign language interpreters used quite regularly, but we do have other alternate formats as well, including Braille, large prints, easy read, and audio. Whanau and support people are encouraged to use supported decision making tools and other social stories to help with providing decision making options. And we've also provided some low-sensory your options around the country as well, including visits with pre-vaccination during the vaccination and also post vaccination. We've also made sure that vaccinators understand the right to supported decision making and are well versed and rights even.

Now supported decision making for a lot of you might be new, but it is another way of looking at informed consent. We have supported decision making, which is a tool for making or helping people to make their own decisions based on their will and preferences so that they have control over their life. Ensures that the person who needs support is at the center of all of the decisions that concern them. But particularly for people who might need support to make decisions like some people with dementia, acquired brain injuries, neuro-diverse disabilities, mental health issues and other kinds of cognitive, physical, or conditions or communication challenges. You can find this on the website pretty easily if you have a look at the COVID-19 section. Under easy read you'll find this tool here with making a decision about having the COVID-19 vaccine.

The Ministry has also disseminated the tool through disability channels encouraging families, whanau, and support providers to work through this tool with disabled people, and that they support and also IMAC have a module available to introduce the two and an overview of the concepts within the tool to the workforce. With a major public health campaign like this we know that there will be increased inequalities and access for disabled people with varied and complex needs. And we have to ensure that specialized services for meeting these needs are available to support access. These access requirements are a key difference when thinking about saving the disability community and one that is fundamentally necessary and meeting the needs of this community, and ensuring the right to consent for those with communication challenges is supported through the decision making tools and training.

And we do have a various range of feedback and sentiment mechanisms. We have Tatou Whaikaha which is a disability persons CVIP advisory group. These people are people who have lived experience with disability. We've also got two disabled persons engagement group, which has representation from across the sector. We do a bit of research through Horizon's research. And also we've managed to get our social well-being agency to help us with the ITI data from Stats NZ and the data that we're collecting with those who have been vaccinated.

What the feedback and sentiments told us is that there's an overwhelming appreciation of flexibility and accommodations staff helping to ensure that people's vaccination experience is inclusive. Many people wish to attend services that are familiar to them where they have had previous experiences and they are comfortable with those people that they've already met such as GPs or their pharmacists. Access to information in an appropriate format is a challenge. So sometimes the volume of information is overwhelming and people switch off. But also because they don't believe that the information is for them sometimes they miss some of their content. It's also not generally accessible for them. So our accessible and alternative formats process does take a lot longer than some of the information that's been released on a daily basis. And people do not know how to find it.

So we have created a website, for example on the COVID-19 website where you go covid19.govt.nz/disability and that will pull together all of the disability related information. We also know that parents and whanau are concerned about impacts of their vaccination on young people, and may be a bit hesitant to allow young people to get vaccinated. In the Horizon's research when disabled people were asked if their disability or impairment was taken into account during the process, there has been a reduction as we've moved away from mass vaccination sites of indicating that their needs are definitely met. So that's from 69% in August to 56% in October. And also we've noticed that their vaccination certificate requirements are particularly challenging for people with intense need of phobias.

And we are also doing a bit of monitoring and uptake around how many people are being vaccinated. So the social well-being index has been built as an indicator of disability from administrative data sets and the integrated data infrastructure that has identified $1.2 million-- sorry 1.2 million disabled people. The primary data sources include the 2018 census using the Washington Group short set and the InterRAI data, while the indicator of analysis is one of the first times that we've actually had a full population level view of disability in this context. Key insights include disabled people are vaccinated at a higher rate of the general population. Trends in the vaccination rates for disabled people generally follow population trends. People with at least one very high impairment type are slightly less likely 2% to 3% percentage points to be vaccinated compared to people with at least one high impairment type.

Across all ethnicities disabled people are more likely to be vaccinated than non-disabled counterparts. And there are still some subgroups who need support. Those from 12 to 24-year-old with severe communication, hearing, and memory challenges are a particular area that we have noticed that we need to provide some extra assistance. And also tāngata whaikaha or Maori disabled people as well as specific disabled people and this affects an older than the general population. We are expecting to be able to publish the full report early next week. So hopefully we'll have the prime minister talked a bit on Monday.

As we look ahead, we are looking towards the rollout for 5 to 11-year-olds to ensure that the range of options are available to ensure equitable outcomes supporting to disabled whanau and the whanau and their families to have conversations about their children's vaccination and encouraging participation in health care decision making. And we have also set up a accessible regional communications collective, which is a new strategy for [INAUDIBLE] risk engagement in mobilization qualitative research with young people and parents of disabled people and children into barriers in their motivations to vaccination will also be undertaken. And any questions?

So I'm just having a look at the chat there Rawa so-- hey, firstly, thanks very much for the information. I think all three presentations today have given a load of really good clear and concise information. So I'm assuming that's why the chat hasn't got a lot of chatter. But I just want to acknowledge that uptake rate for this group of people and congratulate everybody out there and provide a land all the communities that are connecting and the leadership certainly has shown by yourself and the team. It's brought us a pretty pleasing result if uptake is the measure that we were looking at the start of this program. But it's more than that, isn't it? And I think what you've talked to us about today is the connections that communities have made and was always an opportunity for this program to build platforms that would allow us to attend to a whole lot of other tasks for communities that were otherwise be disadvantaged about getting access to health services.

So I don't see it in the chat. So I would like to thank you very much for your leadership in the space and, it wouldn't be appropriate, also, to leave this conversation without acknowledging the work of [? Kirsten ?] [? Currie, ?] who, with you, has actually done a tireless amount of work in bringing together that sector. And I think it's been a great value to the both of you, the teamwork that's gone on. So thank you very much. I hope to you had go away and leave and have a fantastic break. I know you've got a large and well-deserved break coming up over this period of time. And joining the most sensible people on the call and coming back to Canterbury, it's not a bad place. I know many of our customers call it the village of the damned but for us who are down there it's paradise. So hey, all the best. Thank you very much for your work and we look forward to seeing you again next year.

Hey, look I just want to introduce a dear friend to us. I was going to say an old and dear friend, but it's only a slip of a man, and welcome back Doctor Joe Bourne, who was telling me last night that he felt like the sievert program itself wasn't providing enough of a challenge for him. So he thought he would exit stage left into the world of care of Covid and the community. And he's going to give us a bit of a rundown on what's going on in their space. So Joe the floor is yours.

So kia ora koutou and it's a pleasure to be back on this forum again. Vince doesn't have his computer set up so I can see anybody's pictures. So our apologies I can't see your smiling faces, but I just want to acknowledge that it's been a few months, a couple of months since I've been on these calls and we've seen during that time us move up to pretty close to 90% of people fully vaccinated across the country, which is a figure that we only dreamed about back in January. So that's an awesome effort. And it has been a delight for me to see how community-based providers have really been at the center of how we've delivered the vaccine to communities, particularly to our priority populations. So fantastic work.

Yeah, as Vince has indicated there just simply wasn't enough going on in the vaccination space anymore. So I've moved across into Covid Care into the community providing some leadership for that program. Fortunately and probably due to some degree to the successful vaccination program whilst we do have increasing numbers-- well we have cases in the community the numbers aren't actually increasing as fast as some of our modeling suggested that they would. So that is whilst we still have considerable challenges in providing both the health care and menarche support that people need while they're self-isolating and dealing with the medical consequences of catching COVID-19.

The system is able to develop and to build some capacity and establish our systems so that if and when we do have larger numbers of cases coming through it we will be able to respond and meet our community's needs. That's not to detract from those of you who are working in the metro Auckland area where there are decent numbers of cases. And I know that there have been providers working-- excuse me-- working at all levels who are doing a huge amount of additional work supporting those people in the community. So this forum-- and I'm looking at the numbers attending today this forum appears to be meeting a need amongst community-based providers in terms of an opportunity to share information about the vaccination program.

And therefore, we are considering using it as vaccinations shifts into a sort of a new part of that process using a forum like this to support Covid Care in the community. A number of people on this call may have been on a webinar that we held yesterday. I was just bragging to Vince that we had 250 people plus attending our webinar yesterday. And Vince's down closer to 60. But so many, many of you may have attended that webinar yesterday and one of my actions after this will be to make sure that Simone has access to the letter that we're sending out to all the participants, which includes a link to the content that was provided yesterday as a video. It does take it's just about spot on an hour and that content will only be available to be watched online for the next week because of where it sits. It can't stay any longer than that. But that's probably a good thing because the environment is changing so quickly that it probably would be out of date in a week.

But what that webinar will tell you is some of the framework that we're using to support Covid Care in the community, the roles and responsibilities that are currently being allocated, how we're approaching equity so we can make sure that Covid Care and community is very much able to respond to those who have the highest needs particularly people living with disabilities, people with mental health and addiction issues, Maori and Pasifika who are disproportionately affected by COVID infection. So that's covered off. There's a brief part about funding which there'll be more between now and Christmas. There are discussion on clinical governance arrangements and also directing people who need clinical information on treating COVID in the community to the health pathways website, which is where all the clinical information sets.

We also touch upon how we're meeting people's menarche needs, and explaining how the government has constructed the funding that funding for health care needs of people is coming through ministry of health and then out through DHB to commission providers. But those menarche needs are now being funded out of the Ministry of Social Development and working through their regions, which don't map to our health regions, but working through their regions and having input from them into local care coordination hubs. Anyway, there's quite a lot of complexity and I wasn't planning to go through all of that now. But if people want to know more then they can access that webinar. I'm noticing that David's just popped a couple of things in the chat about how general practice is being linked into providing this care. And I probably just will quickly answer that David.

So for the past 20 months I guess it is public health units have essentially been assuming responsibility for all aspects of people's care when they're diagnosed with COVID, and they have been linking in with meeting welfare needs and providing clinical support. Very often the primary way that people were then isolated was through managed isolation and quarantine facilities. And obviously they had on site health facilities and they were providing all the food, et cetera for people. As we're shifting to greater numbers, as we've got more highly vaccinated population, we're able to safely support people to isolate in their own home or other alternative accommodation provided in the community.

And public health having taken responsibility for doing all those things are-- and I understand why they're doing this, they are finding it challenging to transition to a system where they trust other providers to do the work that they have been doing. At the same time they're asking us to make this change because they simply don't have the capacity to keep running as they are. So that care, the health care is being transferred to other clinical providers and the preferred option where somebody has a general practitioner and general practice team around available to them is that will be run out of that general practice team. Now some of our general practices do have capacity issues. But we're currently building systems that allow us to create a shared care record, which will allow multiple providers to jointly input into the care of one person and their household as well, noting that when somebody isolates there often is a requirement. [MUTED]

Looks like we've lost the connection guys. So perhaps if Vince dials out and dials up again. We'll give it a few minutes to see if-- here we go. You're back Joe. We lost you for a little bit there at the end.

Possibly a blessing for y'all. So I just I think with the connection not being ideal in the room that we're in I will probably stop talking for now. And I will pick up on-- I was giving some detail to David's question in the chat. I guess the short answer is general practice. And the general practice teams will absolutely be at the center of clinical assessments of people who have COVID-19 and are being cared for in the community. So that is definitely the way that we are moving. Some of the scale that's required as we get increasing numbers for those with lower risk may well be monitored through national providers but with the ability to escalate back to the local primary care team. And we're looking to implement an element of self service that the really low risk people as we move further into 2022. And that allows us to take a truly equity-based approach because we will be focusing all of our resources on those with the highest need.

But once again, if people who are self serving get a deterioration in their symptoms, then they can be escalated back into that more intensive clinical pathway. So I think that's probably me for now. I will ensure that Simone has access. Yeah, again, just noting a second lecture comment. Around the country-- and I think many people probably know, I'm a general practitioner by background. I'm still doing two days of general practice in Te Puke not quite rural, but certainly not in the middle of a big town. And we are actually now providing the Covid Care in the community, health care to all of our enrolled population. And actually we've put our hands up to provide clinical care to unenrolled Maori and Pasifika within that area as well because we're a popup Maori provider.

So it is happening, and it will roll out across the motu over the next few weeks.

All right. Thanks very much for that information, and being able to respond to those questions. Apologies for any of the technical disruption that occurred in that last little bit from Joe. I just want to thank Joe for-- I don't think we had the chance to thank him because he drifted off into the program. And I hopped into the seat to chair this. So Joe thanks a million for all the work you did earlier and certainly for the continued to work you are doing now. And all the best for the future. I think the other thing I was meant to mention was that we talked at the last meeting about how regularly you might want this in 2022. So the intention will be to run another one near the end of January. And just given the conversation that Joe had, it may very well that we sort of bring this group together instead of sort of bothering you guys with two meetings. We may run it as frequently or not but that's up to you guys in 2022 as much as anything else.

Look, I've received some really good news last week that due to good behavior I have been given parole from the program. And although I understand their intent, there is a high recidivism rate for people that parole from Ministry of health programs. I intend to reverse that trend and stay down in Canterbury. So I just want to thank you very much for your tolerance of me chairing this meeting for the last sort couple of months. I wish you all well. I'll be watching very closely from the safety of the walls of the Republic of Canterbury, and just want to congratulate everybody for an enormous 2021. And I know-- and I look at the names on here that we are pretty blessed in this country when I look at the talent that exists and the cooperation and the commitment of everybody. And I'm sure that's going to be required in 2022.

So I bid you farewell, all the best. And for those of you who are able to have a good break, and then the committee and a Happy New Year to you all. And I've no doubt-- this is a small country-- we will cross paths again some state in the future. mā te wā].