COVID-19 therapeutics, background media briefing

Speakers

+ Dr Ashley Bloomfield, Director General of Health

+ Sarah Fitt, Chief Executive of Pharmac

+ Dr Ian Town, Chief Science Advisor

 

Kia ora koutou, welcome again.

A small but perfectly formed group ear for this session which is focused really on treatments for COVID-19.

With me today I have Sarah Fitt, chief executive of Pharmac, who will be making comments later on.

And on the screen beaming in from Christchurch, Doctor Ian Town, the ministries chief science advisor. He will be also contributing to discussion.

It is great that we have got this opportunity to give you an update on some of the key treatments that are emerging for COVID-19, but also the process we haven't trained to make sure we can ensure these treatments are available for New Zealanders as part of our overall response.

I will talk about about the Medsafe process, to approve new treatments in due course. It will focus mostly on the different types of treatment and how they work, and the place they will have, and Sarah will talk through the work Pharmac has been doing and quite unusual circumstances, a bit like our vaccine purchasing and trying to get ahead of the game and putting in place advance purchase arrangements. That's we will go then we will open up for questions.

What I will say is that our statement, our daily statement will be out soon after the conclusion of this session, with the case numbers and so on. What I say a number today will be back under 100 which is pleasing, and it emphasises the impact that our public health measures, the restrictions under the alert levels framework and under the COVID protection framework, and of course our high and still increasing vaccination rates are happening and helping to control the outbreak in Auckland and to stamp out any cases that might have spread beyond the Auckland border. Our seven-day rolling average of cases at the moment is now 103.

It compares with 145 last week. 187 the week before. Clearly this is incredibly encouraging. We are just a week into the COVID protection framework and we will want to be seen what is happening in other week to ensure that those case numbers haven't started to increase again with the move to the framework.

There is no reason to expect that they will have, because during that two weeks our vaccination rates are not declining, they continue to increase. Importantly, they are increasing in our Maori population at a faster rate than in other groups, so we are seeing Maori rates catch up now, sitting around 85 to 86% first vaccination rates.

Now indeed, Nationwide, our coverage use sitting at around 89% for vaccination of the eligible population. We are still on track within the next few days probably before we had that Auckland boundary comedown is, that our nationwide coverage rate will be 90% and all Auckland DHBs led 90 % for vaccination. Which is usually encouraging.

We also continuing to make progress in issuing vaccine passes, over 3.3 million people have now downloaded a vaccine pass and 4 million passes have been issued, including many several hundred thousand for international travel people. Hopefully, being hopeful about the opportunity to travel next year.

Internationally, I'm sure you are all aware that a pandemic continues to cause a lot of problems globally. We can see Europe now is the epicentre of the pandemic, with very high case numbers in most countries there. If you look across a range of countries in Europe, many of them would equate to New Zealand having between three to 4000 cases per day. 10 to 20 deaths per day. It is a very significant ongoing outbreak in Europe. Obviously related to them being in the winter season.

One of the things we are turning our minds to it so do we prepare for next winter starting now, and our treatments and making sure we have got those available will be a key part of that. The US continues to lead globally in the wrong way in terms of the number of cases and deaths per day.

With Russia in second place. It is a sobering reminder of what can happen if this virus gets away in communities, even with relatively good vaccination rates.

It is fast approaching two years since the coronavirus was first identified in Wuhan, China. We have been living with a virus for this long but we have seen remarkable improvements in public health responses in a number of countries, the availability of a range of highly effective and safe vaccines, and now, very rapidly that element of treatments, in particular oral antivirals.

Several countries have now approved the use of one of these, minute per year, while the new treatments that Ian and Sarah will speak to. We are also in the game there as well and will come to that. Sarah is going to in due course talk about Pharmac's prepurchase agreements but first I will head over to Ian Town to talk about how the medicines are developed and talk about the role we expect them to play in our ongoing response. Ian, overdue.

>> Little bit of a delay there. Luke, do you want to check Ian is good to go? Go ahead, Ian.

>> Kia ora, everybody. Just having a little bit of a technical challenge there but thank you for the welcome and it's great to be with you today, bending in from Christchurch. The key to our response really has been the importance of science throughout and as just mentioned, that led to the ability to have safe and effective vaccines available throughout the world, including New Zealand. We are very well advanced with our vaccination program now, which is keeping people safe. As you know from the data, those who are fully vaccinated are much less likely to suffer severe health outcomes from contracting COVID. Of course, therapeutics like vaccines are just part of the broad suite of responses that the government has been overseeing through the ministry and other agencies. We have made big advances in our diagnosis and our contact tracing, and in all aspects of the response as we have learned and improved our processes. Critical amongst those are the abilities to diagnose somebody with active COVID-19 quickly. In that case, some of the new drugs including the one the prime minister announced, one of the Pfizer oral (inaudible), the key figures distracting is to be able to get that to the affected patient quickly. The ability to have rapid diagnosis and to set in place protocols led all mostly by our primary-care colleagues to ensure that that gets the treatment early. As we know from all antiviral treatments, it is absolutely critical to get that into the system before the virus is a chance to replicate and infect other parts of the body. So, very exciting and very much looking forward to talking a little bit later in these session about some of the other drugs that are currently available and in use in our hospitals, some will be available for use in primary care. Thank you.

>> Thank you very much, Ian. One of the things we have seen an AMA a touch of this, in the Auckland outbreak, is the rate of admission to intensive care has declined through the outbreak. The this is in part because of the impact of vaccination, meaning people who are not otherwise have seriously got unwell have had more moderate symptoms. He does also reflect the learning that has gone on there, and the early use are probably the most important drug, oxygen, but also antivirals and other medications. Ruefully on the Medsafe approval process, which is important. Medsafe approves or medicines in New Zealand, that includes some that might be used but not necessarily publicly funded by Pharmac. This is a prerequisite and it is about making sure there is excellent data on both efficacy and safety of any new medication. When you're in a situation at the moment with these medicines are being developed very quickly and tested on relatively small populations, it is very important we maintain the rigour and the robustness of that process because we want to ensure confidence of both clinicians and people who are being offered or administered these medications. Very often, Medsafe needs to go back to the manufacturers to get further data once the initial information is submitted. That can be quite an (inaudible) process. What I will say is to our assessment of vaccinations, and this we will include in our assessment of pharmaceuticals, we won't be cutting any corners. Medsafe will maintain its usual rigorous process. So, if we think about also where New Zealand sits globally, very often we receive data after other countries because we are small. For example, on the drug the UK regulator approved last month, the country that makes that has not yet submitted that data to us here in New Zealand. Clearly, Medsafe can't assess a medication and prove it unless they have all of that data. We are in the first instance at the behest of those manufacturers supplying it. That doesn't mean we sit back passively waiting for it, we are in active discussion with them. We also have in place after Medsafe then a technically advisory group which provides further advice to us on whether and how those medications might be used as part of our overall response. Then I am going to head back to you Ian to talk about more about that and some of the other medicines that already being used, or that might be on the horizon. I hope everyone else can hear me better than Ian seems to be able to. (Laughter)

>> Tank you very much, Ashley, for passing back to me. You mentioned the therapeutics technically advisory group. One of several bits we have set up at the ministry to help us with external aspects of the response. Doctor Nigel Raymond, and infectious diseases physician in Wellington, is the chair of our group. We are very lucky to have some experienced clinicians from Auckland including Doctor Chris Hopkins, who has actually worked in the UK and made a major contribution to the treatment of people in hospital and ICU. We have also very lucky to have Jessica, a general practitioner from (unknown term), and Doctor Sami, a resident medical officer in Northland. We have some really good people from around the sector. One of the things I just wanted to say around the antivirals is is a tricky space. Antivirals are much harder to develop and test and bring you practice man what we know more commonly of course, as antibody oaks. -- antibiotics. Antibiotics target the bacteria itself and don't impact on the rest of the bodies. Antivirals buy in interfering with the machinery in the sale, that the virus needs to replicators of and cause problems for our system, particularly in the lungs, so we have to be careful when we are designing these drugs to make sure that they don't have unintended consequences, yet still have the benefit of attacking the virus and is stopping it replicating. We expect people contracting HIV with the contact drugs to have a much more normal life than they may have done in the early days. One of the problems with these drugs is that the virus has developed resistance to these drugs very quickly and so we need to be alert to the fact that sometimes the drug design needs to change to keep pace with the virus itself. When we think about how these drugs have actually worked in the body, there are two things we are using therapeutics for. The first is to damp down the immune response will stop these drugs mainly used in more severe cases, people that end up in the intensive care unit. This is where one of the first drugs has showed benefit, (unknown term) it is being used widely throughout the world and a number of New Zealand doctors contributed to the study that showed when given to people that were deteriorating in hospital, dexamethasone would shut down the intensive room in response and lead to better outcomes for patients. (inaudible) flute quite some time. This is a drug that has often been used as well for rheumatoid arthritis and it is a drug that tends to dampen down the immune response. We have had access to that with excellent support from our colleagues at Pharmac to get extra supplies and make those available to our doctors in ICUs. The third drug that is being used in our intensive care environment is (unknown term) this is a specific antiviral drug, a bit like (inaudible) we have some experience in terms of managing people with influenza, you imagine being a little lukewarm as part of the descriptions I have had recently. This is a drug that has been shown to help patients who are recovering from COVID-19 and it tends to improve the recovery, the speed of recovery probably by reducing the spread of the virus within the lungs themselves. Again, good example of how these drugs can help the more severe cases. This is where some of the new oral agents are coming to the forward is the ability to affect the progress of the disease and those who have recently caught it. That is why the number of these oral agents that Dr Bloomfield has mentioned are showing great promise. If we can have a drug made available to someone with a recent diagnosis of COVID-19, then we are able to perhaps slow the progression of the condition and prevent them needing more intensive medical care or even ending up in hospital. Those are things that are very exciting. The other one is another result of really exciting science and that is (unknown term) a specific jewel antibodies that target the virus exactly like the vaccine does. These are drugs that complement the effect of vaccination by very specific target on the virus and help the body identify that as a foreign agent, virus and help the antibody respond along with the vaccination. These are very exciting things on the horizon, none of them are being used in New Zealand as yet but we're looking forward, with the support of Pharmac and Medsafe to having them available early next year. Just finally, before I finish and hand over to Sarah from Pharmac, there are a number of drugs you have asked us about previously which are not being used for the treatment of COVID-19. One of those is ivermectin which you have should herd is being touted as having good efforts. Research shows the drug is not effective and has some nasty side-effects we are definitely not recommending that. One of the other ones early on was (unknown term) as you recall. This was actually subject to a number of large critical -- clinical trials and should have no benefit at all. Just emphasising how important it is we take a rigorous approach to the evaluation of these drugs, that we undertake proper clinical trials and safety assessments before we introduce them for use in patients in New Zealand. Thanks very much and let me out of it to Sarah now from Pharmac stop several Mac thank you Ian.

>> Pharmac has been working to support the covert response for the last couple of years, working with many across the sector particular to ensure ongoing supply of medicine and devices. We have had significant challenges around global supply chain. The other key part of work is our work around securing a portfolio of covert treatments and we have been doing that for some time. For those treatments we are actually using funding from the government's COVID-19 response and recovery fund, so it is important to note these medicines are not being funded from our normal budget medicines. Of course, as we know, vaccinations are still the first and best line of defence against COVID-19 however, we want to make sure that New Zealanders who are unwell with COVID-19 had access to the new treatments being developed as soon as possible. As Ashley mentioned earlier, we are working quite differently, we have been proactively engaging with suppliers and negotiating advanced purchase agreement and for us, this is quite different. Often the evidence is quite limited, the trials are quite at an early stage and because there is a high demand for these medicines we need to ensure that we can secure treatment for New Zealand, so we are securing these advanced purchase agreements but they are all still subject to that Medsafe approval before the final agreement is made and the delivery is made. To help us make these decisions on which treatments to fund, we also have set up an advisory group and our advisory group focuses very much on the medicines but we have a number of members of the committee who are also on the ministry group as well, so there is good coordination between those two groups as well as members from our other subcommittees. They are very carefully looking at all the evidence we have got and also working on the access criteria for these medicines but of course, the access criteria are also going to be determined by how much stock and supply we can get. As I said, were working very closely with the Minister -- ministry of science and advisory group as well. As Ian has mentioned so far, we have proved funding for a few which have already been used in hospitals along with dexamethasone and something else. We have also secured stock of (unknown term) which as Ian mentioned, is a medicine for rheumatoid arthritis but because we have had some issues this is a backup which we have secured. As we have said, we have advanced purchase agreements for molnupiravir and the oral Pfizer antiviral treatment. That brings our suite of treatments secured so far to six, three of them already in use in hospitals, three of them are subject to Medsafe approval and we are hoping to secure stock for those the next year. We are continuing to work with other suppliers because there are a number of other agents available so we are continuing to work as we said, to have that wide portfolio of treatments available. Thank you, I will head back to Ashley.

>> Happy to close things off there, obviously treatments are going to play an important role in our ongoing response of the pandemic full stop I want to just acknowledge Sarah and her team for the work they have done and she mentioned at the start but one of the key challenges has actually been securing enough supply of the drugs we are already using and no work because there are huge demand globally, I think your team has done an excellent job of keeping us supplied their. And being, looking ahead over the horizon is what is coming and securing these medications for New Zealanders. Happy to open up to questions, we will try to involve Ian, I'm hoping the fibre cable between here allows us to do so in a timely way but open for questions.

>> Does any research (inaudible) but is any research suggest that any of these drugs could potentially lower the risk of long-term COVID-19? Can patients benefit somehow who have COVID-19 or at risk of having it along?

>> I could perhaps make a comment and so might have something to say and in once he gets the question at his and. Yes, first of all let's be clear, long covert is a thing and an increasing number of studies show that a good proportion of people suggesting around 30% have got residual symptoms between three and six months after their infection. Likewise, it was a study published in the last couple of weeks where people followed up with MRI scans down the road from when they had their infections and should actually some residual damage to their hearts, which is (unknown term) so we know it is actually relatively common even if it doesn't produce symptoms in COVID-19 infection. What I would say and in will correct me if I'm wrong, generally the more severe someone symptoms and the more severe their illness, the more likely they are to have residual symptoms and so by particular being able to treat someone early, to stop what might be mild disease progressing to more severe infection and more severe disease is likely to reduce the risk that they will have, at least ongoing symptoms that would affect their daily lives. Sarah, did you have any insights there?

>> I haven't seen any specific evidence round and I guess important thing is not a lot of people have received these treatments yet so it is probably a bit early to see that effect but as Ashley said, obviously the less severe your initial disease, the less chance you have of developing that long ongoing COVID-19. Any comment from you Ian?

>> Will come back in. Our correspondence is in crisis.

>> (inaudible) overseas we saw that it might lead to prescriptions and pharmacy, is that what you see happening for the Pfizer antiviral potentially? (inaudible) treating COVID-19?

>> I think the advantage of the two antivirals art tablet form, that certainly does make the potential to miss in the community a lot easier because it is a five day course. Government has to be given intravenously or through injections that will be a bit harder but certainly the oral treatments should be able to be given in the community. We are still working with the team here developing how that will actually be delivered to patient because of this the patient with COVID-19, you're not going to want them to be going to a pharmacy so you want to work out how to manage that. The other important thing is that for both of those medicines it is important that you start treatment quite early, so again is going to lead -- need to line up with testing. There are many people working on how we are going to get these treatments to patients who need a bus only having to oral treatments does make things a lot easier.

>> For the big picture having these treatments available now and not normalising COVID but having it similar to other viruses that have treatments?

>> I think vaccination is still the most desirable but this does give an option for people who haven't been vaccinated or who are immunocompromised and don't have the vaccine because they are an important group where these treatments will be useful.

>> To reiterate that point, the significance of the vaccines we have is hard to overstate. If you think about, there is no vaccine against the viruses that cause the common cold and even our vaccines against influenza each year, the efficacy varies between 40 and 60%. 60% on a good year and we have got vaccines that were developed so impressively quickly and we are seeing the benefits of those with efficacy against hospitalisation, severe disease and death of well over 90% and early, very early but encouraging news from Pfizer a couple of days ago, I'm surprised no one has asked about it yet, one small study about encouraging it does seem to be at least in the lab in the small study, efficacy of the Pfizer vaccine against the omicron variant with the proviso that it is the three doses, the booster dose does seem to make the difference and of course we have embarked on a booster campaign now already so we will be in a great position for when omicron crosses our borders.

>> That third dose then is the key, the most important aspect in the omicron fight. Do you see (inaudible) on a long-term antiviral treatments, how much of a role is going to be, you said you can't overstate the importance of vaccines, so on a percentage scale, how much are we going to see reliance on these antiviral drugs through winter if we cannot get that booster rolled out soon enough or other Back just on the booster program and the timing for us, when most people had the second dose, the timing for us will work well with the six-month interval for the booster. The time we really want people to have that high level of protection is through winter and you can see this in Europe. We have started already about 450,000 people eligible this side of Christmas, that will flow through to the New Year. We will be going into winter and we will be encouraging everybody to have that booster as we lead into winter. I think that is great from a timing perspective. Again, the treatments will be a part of this our suite of things. The key thing is the role the vaccination plays in stopping people getting seriously unwell, requiring hospitalisation or requiring ICU care. The oral antivirals, the new ones, are designed for people who might be at risk of a bad outcome because of pre-existing conditions or age. Even if they are fully vaccinated there will be some quite clear guidance around who those people are who might benefit, in addition to vaccination, especially during winter. When sometimes people might be exposed to other respiratory pathogens so may have a recurrent other respiratory illness which may make their symptoms will worsen for them at more risk.

>> Who spoke about the PayPal a lot of this evidence is still (inaudible). Possibly some of these treatments are available but not the same for COVID. How much of a difference would these antiviral treatments have made it they were available say, six months ago? Is there any way to know that?

>> I think we have done incredibly well with the number of admissions to hospitals and the numbers of patients in ICU. The treatments for the sicker patients, we have had all along. Really, these new treatments coming up for use much earlier in the disease. We have been able to access the (inaudible) all A3. Obviously (unknown term) is an old medicine that's been around for a long time. The treatment of the sicker patients we have a treatments available, it's really as it Ashley says with next to going into winter and being able to treat people early on to stopping going into hospital be will be the advantage next year.

>> It will be really important. Still the key thing to protect people is keeping the number of cases low at stopping people getting infected or being exposed to the risk of being infected in the first place. I was reflecting at a couple of days ago, we've added a large Delta outbreak in Auckland and it has extended beyond somewhere between 9000 510,000 cases, but we have had less deaths this year from COVID that we had last year. Which is in part reflects the age demographic of the pandemic, of the outbreak in Auckland, but it is also a reflection of the impact of vaccination and the impact of the learning that has happened in the early treatment of people who do require hospital level care.

>> These drugs are available and will be avoided available, other any restrictions on age? With different people catching COVID in different age groups?

>> That is what we are working through with our advisors at the moment because we want to make sure we are targeting, the supply will be limited, we want to make sure we are targeting the right groups. We will will be looking at things like comorbidities, people who are older and more at risk, but that's exactly what will will be working through over the next few weeks is defined those access criteria.

>> What is happening with the people who were already on these drugs for (inaudible)?

>> That has been quite interesting. We had about 400 patients on that first quite severe rheumatoid arthritis because of the global shortage of (unknown term) we were able to switch them to another medicine, which is actually very good and a lot of people were quite happy to change because the alternative was a tablet, the (unknown term) is as an infusion. A lot of patients have changed over but a lot of people have stayed on it and a lot of people have found it doesn't work as well for them. We have been able to keep supplies for those patients with rheumatoid arthritis who need it, but we have been able to then target the risk of the supply then for the COVID patients. But it has been a challenge, as Ashley says earlier, a huge global supply issue because the uses of these medicines went up significantly around the world. So far we have been able to maintain the supplies for both the non-COVID patients and the COVID patients that need it.

>> Said the patients that have rheumatoid arthritis and want to stay on (unknown term), are they able to do that?

>> Yes, about 100 of the 400 patients have stayed on it either because they haven't tolerated new treatment or they didn't want to change or it hasn't worked for them. A large number of patients have switched and it is easier for patients who have to go into hospital for infusion, just a tablet I take it home, so for some it has been more convenient.

>> Are patients being encouraged to switch to the alternative?

>> That is a discussion the patients had with a clinician but obviously we have been communicating with the clinicians and as a discussion I have. The more patients we have been able to switch, the more it frees up those supplies for our COVID treatments because it has been very useful for patients and that particularly in that intensive care setting.

>> Before we take the next question, I'm sure there are plenty, did Ian want to intervene with anything? I know it is hard for him.

>> And, just providing you the opportunity with any comments you have. No, no problem.

>> OK, he can provide feedback later on.

>> The terms of the treatments, what is the timeline (inaudible) factor in terms of infection (inaudible)?

>> The trials are showing that probably within the onset of symptoms you need to show staff these treatments within three to five days, so the earlier the better. There is a window of three to five days for treatments to start from the onset of symptoms. People getting the testing, when they have symptoms, is going to be really important so we can make sure we get the treatments to them quickly.

>> This is an important point. That will require people to get tested very promptly after the onset of symptoms, then of course the turnaround of the test result and being able to get people started. What we have seen in a number of cases recently is a tendency for people to wait often seven to 10 days after the onset of symptoms before seeking care. That has more recently led to any more serious illness for those people, although it does increase the chance they will affect others, but to be able to better from these notifications we need to make sure we have in place a system and emphasise and make it easy for people to access that testing once the diagnosis is made and they are, if they fit the criteria, they can get started on those medicines as quickly as possible.

>> What a rapid antigen test result be sufficient? Would there be a positive result there waiting for PCR for example?

>> Not at this stage, but if it is a result from a rapid antigen test and Summers was a dramatic we will be aiming to get a rapid PCR test done. The challenge with the rapid PCR testing machines as they can only delay numbers but if you have someone where there is a very strong clinical suspicion, and a positive rapid antigen test, you can do a test on a rapid PCR and have that back in an hour or two which then could mean early commencement of treatment.

>> Given that short timeframe, I guess what has been done for more isolated communities that avoid experienced critical health comes?

>> This will have to be at part of the planning. It has been a key part of the planning for the care and the community model which is now being rolled out and stood up nationwide. We will be able to use that model and the delivery of that model as the basis for being able to get those medications out, the testing and the medications out. One of the things that is usually exciting for someone who has been around the health sector for some time is seeing different information systems connecting up so that information can be made available wherever around testing results, people's clinical symptoms, then linking with to the pharmacy and working through about delivery of those drugs out to where they may be needed.

>> On today's test numbers? Obviously under 100 a week after the (inaudible), but are we seeing all will be seeing a result from the now? Can you explain that?

>> We are cautiously optimistic, you won't find us ever more optimistic than cautiously optimistic otherwise it tends to invite problems. I think you are seeing this downward trend, remembering also we have seen, if you think about the west of the country, including Waikato, which has been a level II under the old system or the orange level in the new framework, we haven't seen a big increase in cases. What we are seeing in Auckland now is a significant the client in case numbers. We will be looking to see that continue over this next week ahead of the Auckland boundary coming down. The important thing here is that is lower number of cases as possible in Auckland is great added that boundary ( because it means simply the pool of potential cases we might see outside of Auckland will be much much smaller. I think this is a really encouraging development and again, the impact that vaccination has had on the work that has gone into get those vaccination rates up is just outstanding.

>> On the matter of boundaries, (inaudible) is the latest area to talk about blocking Auckland's this summer. Is that going to be effective in preventing Delta spread?

>> What is affecting will be three things. First of all, people will be vaccinated. Secondly, the additional requirement that people are tested before they leave Auckland if they are not vaccinated. Arguably even more important than those two, people have symptoms either not to travel or go out wherever they happen to be but to stay at home and get a test and wait for the result of that test. The basics that serve us well right through the pandemic remain the key things.

>> So we should be be encouraging those three key things rather than talking about borders?

>> Certainly we know there are communities that are concerned about the potential for infected people arriving their communities. And infecting others in their communities, so we understand the concern. That is why you're seeing the police particularly working with (unknown term). I know there are communities working in various parts that are concerned as well. The thing that is encouraging that the COVID protection framework as it has that strong emphasis on the use of vaccination certificates for people to be able to access the sorts of places where people might get infected, based on the risk we know from the Auckland outbreak full stop it is there to protect people vaccinated and unvaccinated.

>> You recommended no traffic light until (inaudible) were vaccinated. Are we putting that group of children, five to 11, at risk? (audio dropout) before that group can get vaccinated?

>> No we're not. One of the things I would say on my part, I have actually, I am a big supporter of the new framework. And in fact, I have changed my mind that because I recognise that it provides a greater degree of protection than the alert levels system did because we now get some protection from that high-level vaccination. The second thing I will say is that the best way to protect the five to 11 sees for people, those eligible to be vaccinated, regardless of whatever alert level, is in place.

>> Being in the traffic light system, has that show new the process of being in that system? Obviously you are reluctant before then but being amongst it, has that changed your mind?

>> Is really a combination of things. As we get closer to, and the detail around the protection framework was finalised, the clear protections it offers, including the use of Accent passes even if there was an area of green, Accent passes would still be required for a number of things. The second thing is it has been usually encouraging to see those high vaccination rates and the clear impact it has had on the outbreak. It is given myself and my public health team here a high degree of confidence that the new framework is a great way for us to continue to protect populations including those who are not or cannot be vaccinated.

>> On advice and rejecting advice, it has come at this week a few times the governor does not necessarily followed the public health advice. -- the government. It was reported that the government chose to go with a wider application of the vaccination passport system rather than the public health advice for more high risk events. How does that sit with you that the committee choosing not to follow your advice?

>> To comments here. First of all, they are not doing something that is the opposite of our advice. Very often you will see them taking it further. Perhaps acting even more cautiously than our advice I think it should come as no surprise to people that Mrs make decisions, we provide advice, other parts of government provide advice and all government's take advice from outside as well and we see a lot of commentators and experts outside of government were providing advice on some of the advice is through formal channels like the groups that have been set up and led by (inaudible) and have been set up excellently to provide advice and it is the role of governments and particular cabinet ministers to look at all the advice and make decisions. I don't think there is a surprising thing, that is actually how the system is supposed to work.

>> One of the things you highlighted was that is the wider application with the rest of the trust that the government has built in regard to the COVID-19 response, do you see that as an issue? Do you think that more work needs to be done? Do you think the government has been unnecessarily cautious to the detriment of that trust?

>> That advice concerns around trust was actually provided by DPM see, our advice was the public health and part of that overall advice. One of the things I think has been good to see is ongoing very high level of trust and confidence of the public in our response and arguably, I know some people have a slightly different view but I think that our very high vaccination rates represent in large part, the trust and confidence people have in both the information has been provided and the way that the vaccine has been rolled out and delivered and the role it can play in our overall response and to see rates of vaccination that I would have dreamt about but I have very clear aspirations about. If they were trying to get me to come up with an eye resisted it when I told my team here that it had a nine in it, they felt really worried because they were planning on us achieving 70% coverage but we have continued to just deliver and New Zealand have responded and shown trust and confidence in what I think is not just I think demonstrating trust in the overall response but shows the people understand the importance of vaccination and it is serving us incredibly well. $$TRANSMIT

>> Going back to the treatments, one thing you might have indicated or been bothering is the population who would probably need to use these treatments and then secondary to that, need to form (inaudible) will there be a similar kind of means of communication around these, I can't even say half of it but how are we going to tell people how important they are but also what they even our, those sorts of things and how much of the population would need it?

>> The first part of your question around the modelling, because we need that number to work out how much meat order for the population so we have been looking at the modelling here but we have also looked overseas, separated good example is Ireland. We have found the modelling there is actually quite similar to here, they have got five -- high vaccination rates, the population density is quite similar we have actually been able to look at their numbers as well so we have used the modelling very much to guide how much of the stock we need to order to start with. I think as regards telling patients, I guess there is a balance because I think our messaging has been quite clear, even when we are announcing these treatments, the vaccination is still the best treatment. What we don't want is people to think we don't need to get vaccine because these treatments are available. Vaccination is still by far and away the best treatment but this gives us some other things in our toolkit, particulars were going to winter next year but I think once we have got the final agreements landed, obviously we will be putting it out information to prescribers, the teams working in the community because they will need to have the knowledge of working out which medicines use voice -- which patients at which time. I think you have to be very clear that we still want vaccination to be seen in the boost of campaign as well, going into next year is that is the number one protection for people.

>> To have another based on the island numbers, in terms of the New Zealand population, what can we expect?

>> We have used those numbers to decide how much order so we have ordered 60,000 courses of the molnupiravir and 60,000 courses of the Pfizer antiviral so that gives us 120,000 treatment courses so that is where we have learned to start with but obviously there is the opportunity we may be put -- able to order more but we need to make sure we needed to pace -- place reasonable order of the best of the knowledge we have at the moment full stop

>> Our aspiration would be that we don't need it and assume that we don't have to order more. The most important way to protect people and stop them getting unwell is to stop them getting infected in the first place so we will be working hard to maintain. Perhaps time for a couple more questions?

>> The vaccination roller, your advice was (inaudible) 15 years prior (inaudible) did that decision put (inaudible) at greater risk?

>> We went over this in detail in the tribunal. I don't think it was a greater risk because what cabinet was very focused on was ensuring that there was good access to Maori from early on for Maori to the vaccine from early on in the campaign and there were a number of that they put in place and authorised and we then rolled out through the program, including those approaches. The access to vaccine for Maori and Pacific providers and we saw the benefit of that with those early high rates of vaccination amongst over 65. And of course our investment in providers to make sure they were able to be out there vaccinating populations. Right from early on but especially once the age range was, the vaccine supply meant we could open up to all age ranges and there has been a huge effort that has gone into it. I would also say that fundamental to our response has been an understanding that if we let this virus get away in the community, the communities that will be hit hardest and we have since even in Auckland, would be our Maori and Pacific islanders. The whole elimination is tragic specifically and then a very tight suppression and protection approach under the new COVID-19 protection framework has been absolutely driven by that equity, understanding and has been driven by the government.

>> Can you talk about the decision to release Marie vaccinations and (inaudible) and why they decide to do that and why it took so long?

>> Just written to (unknown term) yesterday following the latest High Court decision on this and guidance to really outline the decision around the release of the final data and I would say that the communication and this latest release did have a particular issue that I needed to give really careful thought to and that there were several (inaudible) around the north island where we had made it clear that the view was that they did not want data for their members to be shared. Rightly, I think we had had to go through good process to be able to fulfil the expectations of us under (inaudible) to engage with them locally as well as our Maori providers and in discussion with the final collective. However, the court had given a fairly clear directive in its most recent judgement so I need to make sure that they were aware that I was now releasing the data and that data is on unvaccinated Maori in those areas. It is expressly for the purpose of the final collective being able to be followed up on Maori who either had had a first vaccine or who second vaccine has been delayed somewhat and it is expressly for that purpose and then working with and I have asked that the collective with other providers on the ground in the follow-up process and delivery of the vaccination. I'm looking forward to seeing that pay dividends and getting our vaccination rates up even further.

>> What was the response of any who didn't want their data shared when you contacted them?

>> I haven't heard back from them but I have spoken to them throughout this and they have made it clear that there was a tension here where there were, many of them were comfortable with the databank sheds at those other data that we shared very promptly once we have been through that discussion. For those that won't so enthusiastic about it, I wanted to make sure that we did go through true process and the best of our abilities, listen to their concerns but also many of them, they wanted to receive the data themselves so they could follow up with their members and facilitate it. Perhaps one last question.

>> With the borders opening next year, we are hearing that there is not yet been a clear specification for what happens once it opens was really to a coming over with the activation process when they get here, do they need to book a hotel or for example, if someone is going to Brisbane, are they allowed to isolate at home there on arrival? What is the plan?

>> The plan is all being worked through in the detail will be made available as soon as it has been signed off by the prime minister, which will be very soon but there will be, the intention is as described and that is that people can self isolate and for many and remembering that those who can travel back have to be New Zealand services for residents or partners of a family of. The vast majority of them will have a place to go to hear and yes, they will be able to travel to that place but there will be expectations on them, including testing requirements and those are all being finalised and will be publicised in due course, so that will be a topic for another discussion. Thank you very much for coming today.

>> Just one more, we have reports of a (inaudible) dying from COVID.

>> I cannot confirm anything but a statement will be coming actually and that will include any new death there might have been as well as our case numbers and so on and so forth and people numbers in hospital. Thank you very much. Thanks Ian for joining from Christchurch.