Vaccinate all seniors next, experts suggest
MDs, studies challenge Ontario’s plan to target high-risk residents first
With the first round of vaccinations in Ontario long-term-care homes nearly completed, doctors are demanding that the province now turn its attention to getting needles in the arms of all seniors living in the community.
People over 80 are currently targeted under the second phase of the province’s vaccine rollout, not expected to begin until March. Vaccines will then be offered to older adults under 80 in decreasing five-year increments over the course of the vaccine rollout.
But questions have been raised about why the province is waiting, when studies have shown age is by far the biggest risk factor for death from COVID-19, and early data out of Israel — which moved swiftly to vaccinate anyone over 60 — has seen a dramatic decrease in illness and death among its vulnerable eldest population.
Dr. Samir Sinha, the director of geriatrics at Mount Sinai Hospital in Toronto, said the Ontario approach is flawed.
“I’m concerned right now that our current approach to our overall vaccine rollout is going to lead to more deaths that are not necessary, because we will have missed that opportunity to get older adults, in particular, the protection that they will need to prevent them from getting seriously ill and dying from COVID-19,” said Sinha.
Phase 1 of the province’s rollout — aimed at LTC residents and staff, health-care workers and Indigenous populations — has been beset with problems, including a slow start in December and more recently delays in vaccine shipments. As of Feb. 11, 442,441 doses have been administered.
“If you are going to do over-80s out in the community, you are not talking about a small number, you are talking about a lot of people,” Dr. David Williams said Thursday during a briefing from Ontario’s COVID-19 Science Advisory Table.
“If you are going to move on that, we have about 600,000 (people), we need a lot more vaccines,” said Williams, the province’s chief medical officer of health. “As soon as we get it, we’re going to be doing it. We’re going to be looking at those different priority areas.”
A recent U.S. study that analyzed electronic health records to predict COVID-19 mortality found age was the biggest factor.
“When older people are that much more likely to die if they do have COVID-19, how about we start with them and then think about the people who are at a higher risk of exposure,” said Dr. Hossein Estiri, one of the authors of the study.
In Ontario, nearly all of the 6,343 people who have died from COVID-19 since the pandemic began last year were over 60, with 4,541 older than 80, according to Public Health Ontario’s daily epidemiological summary Feb. 12.
“There is data coming in from some of the public health units that are starting to see higher death rates in the community,” said Dr. Adalsteinn Brown, cochair of the Ontario COVID-19 Science Advisory Table, at Thursday’s Queen’s Park briefing. “Again though, this is in older Ontarians and reflects the importance of priority vaccinations where they have the greatest benefit.”
The majority of admissions to hospital intensive care units in the province are people outside long-term settings and over the age of 60. Despite a recent drop in cases and positivity rates in every age group, according to Brown, there is concern that with the presence of more transmissible COVID-19 variants, the burden on ICUs will increase.
“If the B.1.1.7 variant behaves as it did in the United Kingdom, cases will start to grow here again in late February or early March,” he warned.
Sinha believes that rethinking the vaccination plan to include all seniors would reduce the admission of seniors with COVID-19 into intensive care. The result, he believes, is that health-care professionals would be at a lower risk of exposure to the virus and hospital capacity would be preserved.
“I feel that Ontario is deliberately choosing to wait to vaccinate its 3.5 million older Ontarians, maybe as early as April, and prioritizing them after essential workers who have much lower risk of getting sick and dying. I am very worried that we are going to end up with a huge death toll on our hands that could have been completely avoided.”
He points to Israel’s strategy, which prioritized elders first.
“It basically used one clear criteria, and that being age,” said Sinha. “Age trumps all other factors and that’s why I think it would make sense.”
A recent paper from the Science Advisory table outlined lessons that could be learned from Israel’s vaccine rollout: “Similar to Ontario, older people experienced a disproportionately high burden of COVID-related deaths in Israel. To address this disparity, Israel relied on a simple vaccine prioritization process, with age being the only determining factor, with the exception of healthcare providers and first responders.”
It concluded, “Since age is the single greatest risk factor for COVID-19 mortality, simplified distribution plans to maximize upfront administration of vaccines to older adults could avoid unintentionally prioritizing other groups who are at lower risk of death.”
But Ontario is sticking with its three-phase vaccine rollout, which is expected to open up to the general public in August. On Friday, the health ministry confirmed to the Star that due to the limited supplies from the federal government, Ontario will continue to vaccinate vulnerable people who have higher-risk outcomes or are at a higher risk of spreading the virus.
At Thursday’s news conference, Brown said “the decision to prioritize long-term-care homes for vaccination, however challenging, has worked and has saved lives … Daily deaths in these homes are declining.
“If we continue to prioritize a vaccination towards those who are most affected by the pandemic, whether in retirement homes, in shelters, among older Ontarians or in our hardest hit neighbourhoods and communities, we will continue to save lives.”
Dr. Stephen Hwang, a professor of medicine at the University of Toronto’s Temerty Faculty of Medicine, said even if all seniors were moved up in priority, there would still need to be an equity strategy to target seniors who come from marginalized and racialized communities, where populations are at a higher risk of dying from the virus.
“I think focusing on just using very simple selection criteria and then spending our energy on reaching out to those who would be disadvantaged in the process and have barriers to getting vaccinated would be the way to focus our resources.”
Ontario, whose population is 14.5 million, is expecting to receive 600,000 doses by the end of February and 1.2 million doses in March.
On Friday, Prime Minister Justin Trudeau announced that Canada is now on pace to receive 84 million doses over the next seven months.