THE OTTAWA APPROACH
How the city’s team used data and determination to distribute the COVID-19 vaccine
Tracking the rollout of the COVID-19 vaccine with those in command
as debate raged about who should get the limited supply of the COVID-19 vaccine, death rates rose. The answer was clear to the people charged with distributing the precious vials: prioritize people living in long-term care. They were dying at rates that far outpaced any other group. But the province — hampered by storage restrictions surrounding the Pfizer-BioNTech vaccine — was not moving quickly to solve the problem.
Dr. Vera Etches, Ottawa’s medical officer of health, and Anthony Di Monte, general manager of Ottawa Emergency and Protective Services and co-commander of the Emergency Operations Centre’s command team didn’t wait. They assembled mobile “strike teams” to move the vaccine safely and immunize residents in the homes. They just needed Pfizer and the province to agree. So the Ottawa team went to work to persuade Premier Doug Ford and his officials.
“The province heard from us that we were really interested in getting the vaccine into long-term care homes,” says Etches.
Ontario government officials spoke to Pfizer. Word came down to Di Monte: Ottawa could try moving the vaccine. It was a pilot project for the rest of Ontario.
“THE OTTAWA HOSPITAL WAS VERY MUCH OUTPERFORMING
a lot of other areas in the province,” says Di Monte. “The province saw we were not only keen but organized and effective. So when they made the decision, they came to us.”
On January 5, mobile teams sped to the Perley and Rideau Veterans’ Health Centre, transporting coolers of vaccine. Within hours, the paramedics had given a first dose to all the residents who wanted it. No doses were wasted.
The province told all the other public health units they could now move the vaccine, using Ottawa’s model.
Exactly one month later, Di Monte got the news that mobile vaccination teams had finished immunizing residents in all Ottawa’s long-term care homes against COVID-19. The knot at the back of the emergency chief’s shoulders finally eased. “These are real lives that we were able to protect and potentially save,” he says.
Just seven weeks earlier, on December 14, 2020, the first 3,000 doses of the Pfizer-BioNTech vaccine had arrived in
Ottawa to a surge of hope.
Di Monte carries the relentless responsibility for a vaccine rollout that may soon run 24/7. He and his team of hundreds of city, hospital, and public health officials are charged with immunizing 800,000 people. That’s all the adults in the nation’s capital who want the vaccine.
Working virtually, the command team’s jobs have involved everything from locating and staffing buildings for clinics to the smallest detail of where to return empty vials. The team’s goal is to outpace the wily and adaptable virus whose more transmissible variants are even now gaining traction across the city. The team’s mantra is simple: get needles in arms, as fast as possible. That means nothing sits in any freezers, Di Monte stresses.
For Di Monte, vaccinating Ottawa’s most vulnerable residents in long-term care and retirement homes was not only critical, it also carried emotional weight. Of the 450 people Ottawa has lost to COVID-19 so far, 285 of them lived or worked in the city’s
28 long-term care homes. Some died in isolation, as policies intended to protect other residents from COVID-19 shut the homes to visitors. The anguish of spouses, children, and grandchildren kept from the bedsides of their dying loved ones ripped at the hearts of everyone involved in the fight against the virus.
Those deaths struck a particular chord with Di Monte. In the spring of 2020, his mother died of ovarian cancer in a Montreal hospice. The hospice was refusing to let family members in to see her because of COVID-19 policies. “They had completely locked down the institution,” recalls Di Monte. Only after his vigorous intervention and by donning protective clothing was he able to be with his mother as she died. Other families weren’t so fortunate. “When you see those terrible images in the news of people with their hands on windows … I understood it,” he says. “I got a glimpse of what could have been.”
Di Monte works closely with Etches, whose goal is to reduce the number of people who die or get seriously ill from the virus. “Everything we’ve been doing … has been based on science, on evidence from Dr. Etches and her team,” he says. Together, these public faces of Ottawa’s COVID-19 battle have the Solomonlike task of balancing vaccine priorities and limited supplies to ensure that the most vulnerable people in the city get protected first. They must act within the framework Ford and his provincial cabinet colleagues have created, which dictates who gets vaccinated and in what order.
Age is by far the highest risk factor, Etches points out repeatedly. People 90 and over in Ottawa have 9,000 times the risk of dying if they get COVID-19, compared with those under 40. Those 80 and over have 2,750 times the risk of death. Vaccinating the oldest in Ottawa first, once large quantities of vaccine are available, and moving down in five-year age ranges is guaranteed to reduce hospitalizations and deaths. That will reduce the strain on hospitals and — hopefully — the rate of transmission.
Doctors and nurses administered the first doses of the Pfizer vaccine to health care workers in the care homes who could travel to the Civic campus of the Ottawa Hospital. Etches and her team hoped that by immunizing the workers, some of whom were employed in more than one facility, they would help protect the residents.
Care staff who got the first shots were ecstatic. “I feel like I’ve won the lottery,” said Kelly Donahue, a personal support worker at the Perley and Rideau Veterans’ Health Centre. “I wanted to make sure I was able to have that extra protection for my residents because I’m working with such frail, elderly residents.”
But when it came to vaccinating the residents, the command team had a problem. Most of the vulnerable elderly couldn’t leave their care homes. And because the Pfizer-BioNTech vaccine arrives frozen and must be stored in special refrigerators at -70 C, the manufacturer insisted it stay at its initial distribution site at the Civic campus.
That’s how the team came up with the mobile teams of paramedics, pharmacists, and public health staff that would serve as a model for the rest of the province. Di Monte and his co-commander, Ryan Perrault, prepared the teams weeks in advance to sit on standby should they get the go-ahead to move the Pfizer-BioNTech vaccine.
Etches, who also chairs the Council of Medical Officers of Health’s COVID-19 Vaccine Working Group, and her team went to work on the province. They stressed the urgency of getting into long-term care homes. Their entreaties were hard to dismiss. More than 4,700 of the nearly 7,000 people who have died province-wide were living in long-term care.
Through data, determination, and their track record of effectiveness, the city’s team not only got needles in arms of thousands of people unable to access hospital clinics, they also helped other cities with the logistics of transporting the vaccine.
AS VACCINE SUPPLIES TRICKLED IN THROUGH JANUARY, the command centre kept sending out paramedic-led teams, vaccinating between 600 and 700 people a day. By January 15, 92 per cent of residents in the 28 long-term care homes had received their first dose of vaccine. People living in one high-risk retirement residence with an active outbreak of COVID-19, as well as one group home, also had their first doses.
The smiles from those getting vaccines were mirrored in the faces of the paramedics who immunized them, says paramedic chief Pierre Poirier, who accompanied some mobile teams. “It touches the soul,” he says.
On the same day that the city finished vaccinating residents in long-term care homes, 4,000 doses of the Moderna vaccine, which is easier to transport, arrived. The mobile teams could now travel to retirement homes. In just five days, residents of 33 retirement residences deemed high risk because of COVID-19 outbreaks had received their first dose. A week later,
on February 17, vaccinations began for members of Ottawa’s Indigenous community in culturally competent clinics. First Nations and Métis clients were immunized at the Wabano Health Centre; the Akausivik Inuit Family Health Team began vaccinating Inuit patients.
By the end of the day on February 23, the command team reached another milestone. The mobile teams, joined by family doctors and Ottawa Public Health staff, had given first-dose vaccinations to everyone who wanted them at all 82 retirement homes.
Dr. Nili Kaplan-Myrth volunteered to immunize in retirement homes. She has been critical of Ontario’s failure to involve family doctors, nurse practitioners, and nurses in its vaccine strategy. She’s among a group of doctors who have advocated to ensure Ottawa Public Health consults them on reaching the city’s most marginalized and isolated people.
She was unreserved, however, in her joy at vaccinating a 100-year-old woman, originally from Britain, at one retirement home. Kaplan-Myrth asked the woman if she understood why she was there. “She told me, ‘Of course, dear. I worked in the service during the [Second World] war. I gave needles. I’m ready!’ ”
The rollout to long-term care and retirement homes could have been faster, Di Monte says, but for the limited vaccine supply. Timetables were upended in February after both Pfizer and Moderna cut their numbers of doses. The uncertain supply forced the team to prepare multiple contingency strategies. They planned how to distribute the 9,000 doses per week they thought they would get and strategized about next steps if vaccine distribution dried up completely, devising round-the-clock scenarios. If the city was suddenly flooded with tens of thousands of doses, could they vaccinate in a drive-through operation?
When changes shifted the landscape, the Ottawa leadership team pivoted fast. On Valentine’s Day, Ontario added people over 80 to the groups prioritized to receive doses “immediately.” Retired general Rick Hillier, whose contract leading Ontario’s sputtering vaccine rollout was scheduled to end March 31, announced that a province-wide online system to book appointments would launch March 15. Mass clinics for the over-80 crowd could then open.
The province, which receives the vaccine the federal government orders, has been slow to roll out its doses. At any one time, as many as a third of its supplies have sat in fridges.
The command team wanted to go in a different direction. They adapted to a strategy Etches felt was more equitable. On February 24, 10 days after the vaccine priority change, the city announced pop-clinics for high-risk people living in seven of the poorest, most racialized neighbourhoods. In Sawmill Creek, Heatherington, Heron Gate, Ledbury, Riverview, Ridgemont, and Emerald Woods, people aged 80 and older, as well as adults receiving chronic home care in those areas, could get vaccinated at three community centres.
“The more we wait, the more risk we have of significant deaths,” Di Monte told council. “We are putting needles in arms of the groups that are the most vulnerable.”
Ottawa had been planning the high-risk neighbourhood strategy for months, says Etches. She’d started pushing it on November 16, 2020, when the city’s Vaccine Distribution Task Force was launched. (That task force morphed into the Emergency Operations Centre command team). She’s troubled by the vaccine rollout in the United States, she says, where younger, wealthier people have received the vaccine before those at greater risk.
“There is challenge sometimes in making sure people at the highest risk are protected first,” she says diplomatically.
People who have endured racial discrimination and have less access to higher education live in these high-risk neighbourhoods, Etches explained. Many work lower-paid service jobs, such as personal-support workers and aides in care facilities or cashiers and clerks in grocery stores.
Data Etches and her team published proved the disproportionate effects of the pandemic on people living in 33 of the city’s impoverished neighbourhoods. These residents have a three times greater risk of death if they get COVID-19 and a 2.6 times higher rate of hospitalization, Etches told Ottawa city council. Their risk of contracting COVID-19 is between five
“The more we wait, the more risk we have of significant deaths” - Anthony Di Monte
and 16 times higher than that of people living in the rest of the city. Vaccinating in those areas would reap disproportionately greater rewards in Ottawa’s drive to reduce the strain on the health care system.
Etches would rather immunize even younger people in those neighbourhoods. “My medical advice is to work with those communities and go down in age as far as we can, as fast as we can, down to age 45,” she says. “Being able to reach more age groups in a neighbourhood at once would be more efficient than returning to the neighbourhood multiple times.”
Etches and Di Monte announced the high-risk strategy on February 24; just two days later, an independent group of health experts urged Ontario to do the same province-wide. On February 26, the Ontario COVID-19 Science Advisory Table advised vaccinating by both age and high-risk neighbourhood. Once again, Ottawa’s model led the way for other cities navigating the rollout.
On March 5, the first of the pop-up clinics opened at the Albion Heatherington Community Centre.
Ottawa’s approach earned Hillier’s praise. “Ottawa’s been lighting the road for so much of Ontario since this vaccination program started,” he says.
When Ontario added the homeless to its priority list, the command team moved quickly again. The same day the first highrisk clinic opened, public health officials and Ottawa Inner City Health began immunizing people in shelters and on the street. A quarter of the more than 800 people living in shelters have tested positive for COVID-19 since mid-January alone. The outbreaks have forced several shelters to close to new admissions.
The command centre also has seven large vaccination clinics and two hospital-based clinics ready to open at 72 hours’ notice, Di Monte says. They can vaccinate 380,000 people per month as soon as enough vaccine is available.
There have been glitches and omissions in Ottawa’s rollout. The issues are due largely, family doctors say, to the province’s rules. For example, it’s not clear how many doctors, nurse practitioners, nurses, and other essential health care workers have been immunized. And in one instance of alleged queuejumping, two managers were let go at Stirling Park Retirement Community after staff members reported that the wife of one manager was given a dose of the vaccine intended for a housekeeper at the facility.
Critics of Ottawa’s vaccine rollout have highlighted groups at risk of serious illness or death who are being missed. “Patients of mine who have disabilities live in group homes that aren’t group homes that public health even keeps track of,” says Kaplan-Myrth. “We need to ensure that we all have the same ideas about where our vulnerable populations are and how we can get to them.”
Some family doctors are worried, too, about people who don’t have access to, or can’t navigate, the online appointment system. The command team is also wary of online overload. Alberta’s vaccine appointment booking portal and the system for Nova Scotia crashed because of overwhelming demand. Instead, Ottawa Public Health took appointment bookings for the neighbourhood clinics by phone.
There is also a call for family doctors to be allowed to vaccinate their own patients. Health Canada’s March 5 approval of Johnson & Johnson’s vaccine might make that possible, as the single-dose vaccine can be refrigerated in office fridges. But so far, there’s no word on when that vaccine will arrive.
Until there’s more vaccine, Etches urges patience. “It’s harmful when there’s competition set up across groups — people feeling why not me, why not them,” she says. “We want to address inequities and level the playing field. The reality is, it’s not possible to get the vaccine to everyone across the world all at once, so we do need to use the tools that we have.”
As head of emergency services for the city and previously head of paramedics, Di Monte has responded to horrific bus and train accidents, floods, and tornadoes. He never expected a global pandemic. At the same time, “I never thought we’d see the world’s scientists come up with a vaccine in such a short amount of time. That’s just a tremendous success story.”
A year after the first case of COVID-19 was officially identified in the city, having four vaccines to roll out is a problem Di Monte is certain his team can solve. “Ottawa is ready.”