A CONTAGIOUS FORM OF THE COVID-19 VIRUS SOME SAY COULD BECOME A `PANDEMIC WITHIN A PANDEMIC' IS UPPING THE URGENCY TO SPEED UP CANADA'S SLOW VACCINE ROLLOUT. IS THERE A BETTER WAY TO DO THIS?
WAYS FOR A BETTER SHOT AT WINNING THE RACE AGAINST TIME
Afrightfully contagious form of the COVID-19 virus some say could become a “pandemic within a pandemic” is upping the urgency to speed Canada's maddeningly slow vaccine rollout. Is there a better way to do this? Focus now on the under30s, the likeliest spreaders who are driving the winter wave? Move people who have already had COVID-19 to the back of the line, assuming they have some lingering immunity? Concentrate on vulnerable communities, including Black and other racialized populations? Ditch dosing deadlines for giving the second shot?
“One of the tough balancing challenges in this vaccine rollout is how much fine-graining to do,” Dr. David Naylor, co-chair of Canada's national COVID-19 immunity task force, said in an email to the National Post.
“We can tie ourselves up in knots trying to develop and implement a precisely and perfectly fair queue for vaccines, and time is very much of the essence right now.”
While Canada is staring down a SARS-COV-2 variant first identified in England believed up to 74 per cent more transmissible than the current dominant strain, and another variant from South Africa, it's not just a race between vaccines and mutations. Large parts of the country were in a mess before the variants emerged. Health-care workers are exhausted. Intensive-care doctors in Quebec and Ontario are dusting off triage protocols and conducting dry runs of who should get routed to the ICU and who should be left behind in preparation for a possible total saturation of ICU resources.
Federal modelling released Friday is predicting 10,000 cases daily by the end of January. Deaths may soon surpass those in the first peak. Provinces will face a scarcity of vaccine until millions more doses start arriving in April, while Alberta and Ontario are already running low of the approved Pfizer and Moderna shots.
Israel, by comparison, has vaccinated more than two-million people, at a rate of 25 doses per 100 people, according to Bloomberg data. The total number of shots given in Canada so far? A mere 458,000, or a rate of 1.22 per 100 people.
Are there ways of getting Canadians out of the pandemic misery any sooner?
1. YOUNG PEOPLE FIRST
After front-line workers, Indonesia, home to one of Southeast Asia's most devastating COVID-19 outbreaks, is prioritizing its young, working-age population, rather than the elderly, partly because its vaccine — Coronavac, made by China's Sinovac Biotech — comes with a scarcity of data on how it behaves in older people (it wasn't tested in people over 59). But officials also told Bloomberg that vaccinating those 18 to 59 would help Indonesia build a “fortress” around the elderly and slow viral spread.
In Canada, 20- to 29-year olds account for the highest percentage (18.7) of all confirmed COVID-19 infections. However, 96 per cent of the nation's more than 17,500 deaths have occurred in people 60 and older.
If the main goal is to minimize deaths, those 60 and older should go first, according to a recent preprint of a modelling study comparing five different vaccine strategies. There were a few scenarios in which prioritizing everyone over age 20 provided greater mortality benefits, but only under certain conditions — a large enough vaccine supply, say, and a vaccine highly effective in young adults, and less effective in the old.
Canada's two approved vaccines, Pfizer's and Moderna's, are 90 to 95 per cent effective at preventing people from getting sick with COVID-19, should they get infected. Less clear is whether they prevent people from spreading the virus to others, though vaccinated people may shed less virus, making them, therefore, less contagious.
“If everything were flipped, and what we knew was that the vaccines were 95 per cent efficacious in preventing transmission, but we had no data about whether it would prevent disease or mortality, perhaps that would shift my thinking,” said Maxwell Smith, a bioethics professor at Western University and a member of Ontario's COVID-19 vaccine distribution task force.
But 80 per cent of the mortality from COVID-19 has been among older adults in long-term care homes.
While he appreciates the argument it would be nice to prevent transmission in the first instance, given the high death rates among the elderly, “I think there's an ethical obligation to go in and protect those populations, first and foremost, before anyone else,” Smith said.
2. STRETCH OUT SHOTS
Both Pfizer and Moderna are two-dose vaccines, with a 21-day (Pfizer) and 28-day (Moderna) wait between the first jab and the booster. The Pfizer trials suggest protection starts kicking in 10 to 12 days after the first dose. CTV reported this week that seven residents of a nursing home in western Montreal have tested positive for COVID after getting their first shot. The infections occurred within 28 days of vaccination, meaning they could have started before vaccine protection kicked in. Still, the reports are fraying nerves over Quebec's decision to space doses out up to 90 days in order to vaccinate more people.
“There's been a little bit of polarization of view on vaccine timing in Canada,” said Naylor, with “fundamentalists” wanting to hold back equal numbers of second doses, to ensure strict compliance with the authorized dosing schedule, and “absolute speed demons who want first doses yesterday and second doses whenever.”
Most of Naylor's colleagues are taking a pragmatic approach, he said, aligning with Canada's National Advisory Committee on Immunization (NACI), as well as a World Health Organization scientific group, both of which have decreed doses can be stretched to 42 days apart in exceptional circumstances — severe shortages, for example.
The concern? While the first dose is considered protective, though not fully, it's not known how long that protection lasts, a worry given the variants and the potential for creating “made-in Canada mutants,” Naylor said. The second shot also provides a dramatic boost in immune response.
On the other hand, given the grim supply shortages some provinces find themselves in, a slight delay — going out to six weeks — may be necessary, on and off, to manage supply chain wobbles and avoid holding back large numbers of shots that could cost many vulnerable lives, Naylor said. In the Pfizer trial, some people received their second dose as early as 19 days, and as many as 42 days after the first.
3. DE-PRIORITIZE THE INFECTED
“There's no contraindication to immunizing people who have had a past COVID-19 infection,” Naylor said. However, the federal vaccine advisory group has said that, with limited supply, “initial doses may be prioritized” for those who have not had a previously confirmed SARS-COV-2 infection.
That could be a logistical nightmare: How do you screen everyone for antibodies to the virus before agreeing to inoculate them? Do we do serological testing on every single person we're trying to register for a vaccine? Think about the rollout thus far, Smith said. It could slow down the process further.
COVID reinfections can happen. There isn't great evidence concerning the duration of protective immunity that might come from having been infected naturally, and who is to say people previously infected would be protected against the new variants?
“You're gambling a bit there if you think that those who have had a previous diagnosis are any less in need to be vaccinated,” Smith said.
4. TARGET THE HOT SPOTS
COVID-19 hits poor neighbourhoods harder. Should we be focusing more on those living in the most racially and economically diverse communities?
In Quebec and Alberta, the COVID mortality rate in neighbourhoods with the highest proportion of visible monitories was more than three times higher than neighbourhoods with the lowest proportion of visible minorities, according to Statistics Canada. While it has had relatively fewer deaths compared with Quebec and Ontario, British Columbia's death rate was more than 10 times higher in neighbourhoods with the highest proportion of visible minorities.
“We know that Black and racialized communities have experienced a greater burden,” Smith said. Under Ontario's Phase 2, scheduled to start in April, populations facing barriers to the “determinants of health” — economic stability, employment, education, access to health services, decent and affordable housing — will be among those eligible for shots. A special group has been struck to “think that through a bit more, and get to a more granular level to see how that will be operationalized,' Smith said.
5. SMARTER, FASTER LOGISTICS
“Provinces need to know when supplies of given vaccines will arrive, in what numbers and with what degree of certainty,” Naylor said. Supplies need to be distributed strategically across sites and usage rates monitored so that people don't leave vaccines in storage others could happily, and rapidly, be deploying. “We need advanced logistics integrating both levels of government and the sites where vaccines are being given,” Naylor said. “Otherwise we'll be holding back vaccines in freezers as much by accident as design.”
How much fine graining do we do? When dealing with a countrywide rollout, broad guidelines make sense, Naylor said. But we also need the latitude to make “defensible exceptions.”
In the broader scheme, “here's how I see the math,” he said. The federal government has said it still expects to receive 6 million doses of vaccines by the end of March. With 6 million doses, 3 million Canadians can be immunized, leaving roughly 35 million more to get shots. Subtract about five-million kids under 13 (the merits of immunizing 0 to 12 are still unclear, Naylor said). That leaves 30-million teens and adults. “Immunizing twothirds of those 30 million souls won't stop the epidemic, but could slow things down meaningfully,” Naylor said.
That's 20 million people, or 40 million doses. The federal government has said we can expect 20 million doses of the Pfizer and Moderna shots in the second quarter, from April 1 to June 30. Approving Johnson & Johnson's one-dose vaccine would provide more breathing room.
But the bottom line is simple, Naylor said: We need to figure out how to move many times faster than we're moving now.