Safely transporting a cold-storage Covid-19 vaccine within New Zealand is hard enough.

Getting it to Tokelau is a whole other level.

Typically, travel to Tokelau starts with a four- to six-hour flight from Auckland to Apia, Samoa.

From there, the fortnightly boat takes 24 hours to arrive at the nearest atoll, Fakaofo.

It’s a further three and a half hours to Nukunonu and then a further six hours to Atafu, the northernmost atoll.

Not only is maintaining the cold chain a logistical challenge, there’s also the issue of ensuring, without entering the country, that local healthcare professionals know how to properly store, prepare and administer the vaccine, as well as know what to do if someone has an adverse reaction.

The Immunisation Advisory Centre (IMAC), based at the University of Auckland and run by UniServices, has taken on this challenge not only for Tokelau but also for Tonga, Samoa, Niue, Cook Islands and Fiji. 

As the Cook Islands prepared for the Covid-19 vaccine rollout in May 2021, some members of the IMAC team flew to Rarotonga to help set up vaccination clinics, standard operating procedures and cold chain management, as well as work with healthcare workers to prepare for the delivery and administration of the vaccine and manage adverse events.

However, with other Pacific countries’ strict border rules and New Zealand going into lockdown in August 2021, Programme Manager Moelagi Leilani Jackson and Nurse Educator Ellaine Ete-Rasch, with the support of IMAC colleagues Jude Young and Catherine Tobin, had to figure out how to effectively educate vaccinators in the five other countries from afar.

IMAC had already developed an online training platform for New Zealand vaccinators but had supplemented online learning with face-to-face training and support. This wasn’t possible in most of the Pacific.

The team was able to mitigate some of the challenges of teaching over Zoom through means such as shipping over equipment in advance to ensure learners had access to the items being demonstrated so they could use it at the same time.

“That was a first and very effective,” says Loretta Roberts, national manager of IMAC.

There were still challenges that weren’t as easily addressed from New Zealand.

“The internet connections on some of the islands did not permit everyone to use Zoom or in some cases to access the online learning platform at all,” says Jackson. “We used a train-the-trainer approach where countries would select their leads, we’d train them, and they’d train the nurses who didn’t have access to the internet.”

For those who didn’t have reliable internet access, IMAC provided materials designed for PowerPoint in PDF form so they could be printed out along with other support materials. These resources were also useful where data costs were a barrier.

In some places, technology access issues meant that people congregated for Zoom sessions, so Jackson and Ete-Rasch had to train as many as 20 people clustered around a single laptop.

“That’s another reason we always sent through written material to support, because we were aware that looking at this little screen would not provide the best-quality learning experience,” says Jackson.

For Jackson, who grew up on a smaller Samoan island a two-hour boat ride from the mainland, healthcare accessibility has always been an important issue. Her sister died of rheumatic heart disease when she was young, largely due to poor follow-up. This was a large part of what motivated her to become a nurse and more recently to take the job at IMAC. 

Although some health equity and accessibility challenges have been exacerbated by the pandemic – for example, patients can’t fly to New Zealand or Australia for advanced care – IMAC and the New Zealand government are working to overcome them.

New Zealand doctors are supporting Pacific doctors via Zoom and New Zealand has donated enough Covid vaccines to inoculate all eligible people. IMAC has provided the cold chain training and support for nearly 300,000 vaccine doses that have been sent over.

To date, IMAC has registered 360 vaccinators from the Pacific onto the online learning management system in addition to the face-to-face training conducted in Samoa and the Cook Islands. While it has been harder to evaluate success remotely, only one vaccination error has been reported and training evaluations have been overwhelmingly positive, say Jackson and Rasch.

“We have delivered the best we can, given the resources we have and the circumstances we’re under,” says Jackson. 

IMAC is currently conducting education on the paediatric Covid vaccine, which will increase the number of people protected.