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picture graphic showing risk of blood clots with vaccine, birth control pills average Canadian and covid infected patients

April 15, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Headlines

Reminders

  • Provincial stay at home order (click here) in effect until the end of April
  • All patients admitted to KHSC will undergo Covid-19 testing and all people entering the hospital will be required to wear medical grade masks.
  • Ontario Website now open to book vaccines for people over age 55 (initially): https://covid-19.ontario.ca/book-vaccine/ (click here). 
  • Universal masking: All patients and visitors to KHSC will be provided with medical masks at the doors of KHSC (to replace their cloth masks upon entry). Please wear your mask beginning on the front steps Do not enter the building without your mask on. Please be polite to the screeners-they are there to keep us all safe!!!
  • Team vaccine-we have your back (and your arm): To reassure all health care workers who incorrectly scheduled their 2nd shot and are waiting to reschedule or who wish to get vaccinated early:
  1. A)By April 30thwe will reschedule all incorrectly booked vaccines and we will respect the 4 month planned interval between vaccine dose 1 and 2. Please don’t call and lobby Team vaccine-they have this well in hand!
  2. B)There is very limited local vaccine as we have had some supply diverted to COVID-19 hotspots in Toronto. Thus it is difficult to shorten the interval between vaccines. One dose will safely sustain your immunity until the booster at 4 months.

1) Child care to be provided for health care workers (including faculty) by the City of Kingston beginning April 19th

2) COVID-19 vaccines have been given to 31% of KFL&A residents (click here) and are available for people 55 years of age and over in Kingston (click hereregister for a vaccine appointment online 

3) Astra Zeneca Vaccine has a strong safety record and is recommended by Health Canada after its recent review (click here): The latest on the vaccine induced thrombosis and thrombocytopenia (VITT) story

4) World vaccine roll-out tops 840 million people (click here)! Real world evidence that vaccination is safe and effective.

5) KFL&A COVID-19 rates continue to rise with 133 active cases locally and hospital ICUs full of patients with COVID-19 transferred from greater Toronto area: Faculty, staff and trainees at KHSC & SEAMO rise to the occasion, open new care units and deliver amazing care (see update from KFL& A Public Health)

6) Ontario infection rates are up as wave 3 is on the rise with 4,736 new cases yesterday, hospital capacity saturated and positive test rates at 8.0% (click here(click here): projections suggest new case rates could double

7) Canada’s COVID-19 epidemic: New and active case rates increased 29% in the past week and both deaths and hospitalizations are on the rise (click here) (click here): Wave three is large and lethal and we must both get vaccinated and adhere to public health rules 

8) The global pandemic continues to escalate: >138 million cases to date and new case rates on the rise (click here): up 5 million cases in 1 week!

9) FAQs-answers to common questions about the COVID-19 vaccines 

10) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC)-no deaths in past week…evidence vaccines working: click here

11) A big shout out to DOM colleagues, led by Dr. Chris Smith, Dr. Kristen Marosi, VP Renate Ilse, Michelle Matthews, POD Medicine, Dr. Mike O’Reilley, Dr. Laura Marcotte and Dr. David Taylor for handling the opening of a new HDH Medicine ward and consult service and supporting critical care as we deal with the influx of critically ill patients with COVID-19 from other regions.

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1) Child care to be provided for health care workers (including faculty) by the City of Kingston beginning April 19th The City of Kingston will be offering free child care for health care workers. Please go to the City of Kingston website and register if this help is needed. There will be 5 sites opening. I am unsure of the hours of operation. You will need to register with the city of Kingston and employment verification is required (i.e. providing a pay stub).

2) COVID-19 vaccines have been given to 31% of KFL&A residents (click here) and are available for people 55 years of age and over in Kingston (click hereregister for a vaccine appointment online 

www.ontario.ca/bookvaccine or by calling 1-888-999-6488

screenshot of app to eligible groups to get vaccine

For individuals who do not have a health card, phone number or email address, Call 343-477-0172. This telephone service is only available to local residents from Monday to Friday from 8:30 a.m. to 4:30 p.m.

Over 68,000 KFL&A residents have already been vaccinated (>31% of all residents) see below! 

kola current covid vaccination data

Progress in vaccinating the residents of KFL&A

Based on the national guidance for vaccine distribution it is not surprising that we have made limited progress in people under age 60 years (see below). This is a crucial deficiency which reflects health policy choices nationally, in terms of who we vaccinate first (the elderly), compounded by an ongoing lack of reliable vaccine delivery to Canada, It is crucial to vaccinate young people since those between ages of 12-40 have the highest rates of infection. These decisions are not in the control of local health authorities of hospitals.

various graphs showing vaccination by age group

Good progress has been made in vaccinating older residents of KFL&A but <20% of those groups most often infected (<age 40 years) have been vaccinated thus far.

2) Vaccine induced clotting is associated with the 2 COVID vaccines that use adenoviral vectors; but this vaccine-induced immune thrombotic thrombocytopenia (VITT) is so rare it should not delay the use of the AstraZeneca vaccine: All drugs and vaccines have side effects that can cause harm or even death. Whenever a treatment is administered a doctor and a patient are essentially agreeing that the benefits outweigh the risks. In this regard, one needs to understand the magnitude of the risk vs the benefit. 

To provide some perspective: The risk of developing a blood clot simply from being female far outweighs risk of developing a clot from taking a COVID vaccine. Women age 15-45 are more at risk for blood clots just based on their sex (1 in 3,300 risk of a clot). Many women choose to use birth control pills and this doubles their risk of clot to 1/1600. In contrast the risk of a clot after the Astra Zeneca vaccine is 1-4/million risk. Moreover, the vaccine will completely protect you from the much higher risk of contracting or dying from COVID-19. In the United Kingdom, where 20 million doses of AstraZeneca have been administered as of April 1st, there have only been 79 cases of blood clots likely linked to vaccination and <10% of these people have died (click here). The math clearly favours taking the vaccine. The Astra Zeneca vaccine has been reviewed again by Health Canada and its strong safety record has been confirmed. Health Canada once again recommends its use to stem wave 3 of COVID-19.

screenshot of news article with needle being put in armpicture graphic of AstraZeneca bottle, birth control pills Canada flag and the covid virus

However, for those that are interested in how the vaccine might cause clots and whether the problem is the antigen or the vector-read on! There are 2 new papers exploring the clotting disease that is associated in rare cases with the adenoviral vaccines (A-Z and J&J). 

Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination.Andreas Greinacher, M.D.et al and Sabine Eichinger, M.D. New England Journal of Medicine, April 9, 2021. DOI: 10.1056/NEJMoa2104840 (click here). 

Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. Nina H. Schultz, MD,PhD et al. and Pål A. Holme, M.D., Ph.D New England Journal of Medicine, April 9, 2021. DOI: 10.1056/NEJMoa2104882 (click here)

Both articles conclude that the unusual clotting events post vaccine are accompanied by thrombocytopenia (low platelet counts) caused by the unintended production of antibodies against a normal protein in the body (platelet factor 4 , PF4). These unwanted antibodies cause platelets to stick together and create blood clots in unusual places, like the brain, and they also reduce platelet counts which paradoxically promotes bleeding. The German study (see above) reported 28 cases of VITT, with a detailed description of the first 11 patients. They were aged 22-49 years and presented with serious thrombotic complications including cerebral venous sinus thrombosis (CVST), splanchnic vein thrombosis, disseminated intravascular coagulation (DIC), and pulmonary embolism. These problems occurred within 5-16 days of receiving the AstraZeneca vaccine. Six patients died. This group have now analyzed 40-50 cases, all of which show the presence of the PF4 antibodies. 

This combination of severe thrombosis and severe bleeding resembles another syndrome which is itself a complication of a widely used drug: heparin-induced thrombocytopenia (HIT). The new vaccine syndrome, named vaccine-induced immune thrombotic thrombocytopenia (VITT), and HIT are both diagnosed and treated in the same way, with the administration of intravenous immunoglobulins (IVIG) and anticoagulants. It is noteworthy we rely on heparin every day in the care of millions of patients; we did not discard it because of its ability to cause rare cases of HIT!

What about the Johnson & Johnson vaccine? The J&J vaccine resembles the AstraZeneca vaccine in that it uses an adenoviral vector to deliver the spike protein antigen. As with the Astra Zeneca vaccine the clot events with the J&J vaccine are also rare. We have not begun to use this vaccine in Canada but in the USA there have only been 6 cases of VITT out of 6.8 million administered vaccines. In my view, it is likely that VITT relates more to the vaccine vector than the spike protein antibodies since the 2 implicated vaccines use an adenoviral vector whereas all 4 vaccines generate antibodies to the spike protein and VITT has not occurred with Pfizer and Moderna vaccines, to my knowledge.

To summarize: The third wave in Canada is not yet controlled, we do not have adequate vaccine and quite frankly we do not have the luxury of not using the Astra Zeneca vaccine. If people make this choice there will be many unnecessary death and hospitalizations. The risks of the AstraZeneca vaccine causing VITT are rare…very rare! In contrast the benefits of the Astra Zeneca vaccine, which include an almost compelled protection from COVID death and severe COVID disease, are substantial. 

The bottom line: It would be dangerous policy and poor personal decision making to avoid taking the AstraZeneca vaccine (which results in ~1-4 chances/million of causing a clot) while COVID-19 itself confers a 2% risk of death, a 5-10 % risk of hospitalization and both these bad outcomes are prevented by the Astra Zeneca Vaccine. The numbers clearly give clear guidance: Take the 

3) World vaccine roll-out tops 840 million people (click here)! Real world evidence that vaccination is safe and effective.

colourful horizontal bar graph showing world then ranking of countries received vaccines

Canada’s vaccine roll out remains slow and we are paying a high price for this in the form of an aggressive 3rd wave of COVID-19

There is real world evidence the vaccines work. The graph below shows that in countries that have an effective vaccine roll out, like the UK, USA and Israel, rates of infection fall rapidly. In contrast, rates of infection are rising in Canada, where vaccine roll out has been slower. This is a global “real world” illustration that vaccines work! 

colourful line graphs

Variant viruses emerge when large numbers of people are infected. Canada is now seeing more than half of our cases resulting from variant viruses which are more infectious and likely more lethal than the initial SARS-CoV-2 virus. Here is a screen capture of a presentation Dr Gerald Evans gave reminding the 184 admins, trainees and faculty on the DOM Zoom which variants of concern (VOC) are present in Canada and noting that they are also more transmissible.

slide of RBD mutations on a zoom call slide of VOC transmissibility on a zoom call

Viral Variants of Concern are more transmissible

Most concerning is that these variant viruses cause more severe disease in young people and are more likely to cause death and hospitalization, as shown in this metanalysis below.

slide of meta analysis of the risk of covid 19 on a zoom call

Viral Variants of Concern are more lethal

Ultimately if new SARS-CoV-2 viruses vary too much from the “vaccine-targeted” virus the vaccine might eventually not work. The longer vaccines are delayed the greater the emergence of variant viruses (which are slightly less vaccine sensitive). This is a reminder of the urgency of a global vaccine roll-out. 

There is also real-world, made in Canada, evidence that the vaccines are safe (click here). Here are the Canadian vaccine safety data for all vaccines as of April 2nd (click here). After almost 6 million vaccinations in Canada there have been 3,089 individual reports of vaccine side effect (0.05%). Only 421 side effects were serious (0.007% ) and no one died!

six text boxes of info graphics

The bottom line: If you get vaccinated you have less than a 1/10,000 risk of a serious allergic reaction and no onehas died of the vaccines in Canada. In return you get >90% protection from a COVID-19 death. 

4) KFL&A COVID-19 rates continue to rise with 25 hospitalized COVID-19 patient and 416 active cases in our region and hospital ICUs full of patients with COVID-19 transferred from greater Toronto area: Faculty, staff and trainees at KHSC & SEAMO rise to the occasion, and open new in patient units delivering amazing care (see update from KFL& A Public Health)

There has been a change in Kingston from the normal rules of epidemics. Our local situation remains (relative to most areas) “good”. However, as part of the provincial tertiary care system we have changed our hospital status overnight, doing our duty and filling ICUs and Medicine beds with COVID-19 patients from Toronto, which is overwhelmed. This is the right thing to do; but it has been challenging to every level of the organization. We now have a paradox: Our hospital has the inpatient composition of a hot spot while local epidemiology is less dire. I raise this point to remind me to thank my colleagues for their exemplary professionalism and to remind them of Winston Churchill’s aphorism, “When you’re going through hell; keep going!”  We will get through this and we will be rightly proud of our role in defeating COVID-19.

The total number of cases in KFL&A since the pandemic began is 1119, not counting the resolved prison outbreak. This is up 100 cases in the past week. We are expecting the transfer of another 8 critical care COVID-19 patients and 10 direct transfers to the Medicine program. To deal with this we have created many new ICU beds, diverted staff to care for patients in ICU beds, increased ventilator supply, and opened an entire new Medicine ward and consult service at HDH. This has all happened in 2 weeks-WOW! I have heard messages of gratitude from colleagues in Toronto who appreciate our help in their darkest hour (see item 11).

current covid data for kfla

Most new cases in KFL&A are caused by a variant of concern (i.e. mutant virus) including many double mutant viruses (see below). 

pie graph and line graph showing variant covid cases

There are 25 people hospitalized with COVID-19 at KHSC 2 from KFL&A with most from the greater Toronto area. There are 416 active cases in SE Ontario, up from 141 cases 2 weeks ago. The breakdown of case location is: KFLA = 133; HPEC = 150; LLG = 133. In the past 3 days our KHSC lab has done 2587 COVID-19 tests at KHSC since Monday with 69 positive tests for a positive test rate of 2.7%. 

There has only been one death of a KFL&A resident since the pandemic began but we have had several deaths at KHSC of non-resident patients. These data are a reminder that COVID-19 is actively spreading in our region and that our region is not insulated from provincial realities. There has never been a more pressing need for following public health measures and to get vaccinated as soon as possible. With all tertiary care hospitals in eastern Ontario over capacity our ability to care for the many people who do not have COVID-19-the 99%-is more limited than at any time during the pandemic.

6) Ontario infection rates are up as wave 3 is on the rise with 4,736 new cases yesterday, hospital capacity saturated and positive test rates are at 8.0% (click here(click here): projections suggest new case rates could double.

number graphics

As seen below the weekly rates of new and active cases is up 34 and 35% respectively. Coincident with this death and hospitalizations are also up over 20%. Patients with COVID-19, particularly those in ICU, are being distributed from the greater Toronto area around the province as hospitalizations reach new highs relative to any prior point in the pandemic. There is tremendous overload at William Osler Hospital, Trillium and Scarborough. We are doing our part by taking patients with COVID-19 from these centers. We are expecting another 10 patients with COVID-19 to be transferred to Medicine from Toronto and 8 more to be transferred to Critical Care. The figure below shows things are going the wrong way in Ontario (thus the stay at home order). If you or a loved one are hesitant to follow public health rules or to get vaccinated think long and hard about these data. 

salmon coloured line graph

We are part of the provincial health care system and will do our part. This includes temporarily curtailing “elective” surgery and procedures. However, most of this elective care is not truly elective and the number 1 and 2 causes of death in Canada during the pandemic remain heart disease and cancer. Thus. we are acutely aware of our responsibility to provide care for the 99% of people who don’t have COVID-19. 

7) Canada’s COVID-19 epidemic: New and active case rates increased 29% in the past week and both deaths and hospitalizations are on the rise (click here) (click here): Wave three is large and lethal and we must both get vaccinated and adhere to public health rules.

map of Canada and surrounding waters

 

Wave 3 is more serious and more different than the 2 prior waves: All residents of Canada need to be aware that adherence to public health measures and acceptance of vaccines is critical. If you look at the right end of the line you can see it turning upwards-the 3rd wave. In addition the bottom panels continues to show a concerning rise in hospitalizations-with ICU beds in much of Canada full! We all need to do our part to keep the health care system afloat so that people who do not have COVID-19 can continue to receive essential health care. The state of hospitals is worse than at any point in the pandemic.

various types graphs

Hospitals in Canada are full with very limited ICU capacity

salmon colour bar graph

COVID-19 in Canada April 15th 2021

There have been 23,489 COVID-19 deaths thus far and a cumulative national case mortality rate of 1.7%. Canada has performed ~30.2 million COVID-19 tests with a cumulative test positivity rate of 3.59%. Rates of infection are rising in BC, AB and Sask, as well as in Ontario. Manitoba remains stable. Quebec is also trending upward. 

Canada’s vaccination roll-out: 9 million vaccines administered thus far (21.7% of population) (click here)-see below: To date, 12.6 million doses of COVID-19 vaccines (including Moderna, Pfizer-BioNTech and Astra-Zeneca) have been delivered. Thus far, only 71.9% of delivered doses have been administered. This reflects recent arrival of vaccines but also our relative inability to quickly administer the vaccine to patients. 844,021 Canadians are fully vaccinated (click here). Canada is still well back in the pack (not in the top 30 countries) with only 21.7% of the population vaccinated.

map of Canada with provinces labelled along with the amount of vaccines administered

8) The global pandemic continues to escalate: >138 million cases to date and new case rates on the rise (click here); up 5 million cases in 1 week!

satellite image of earth from space

There have been ~138.5 million cases of COVID-19 since the pandemic began, up almost 4 million cases since last Monday! There have been 2,976,972 COVID-19 deaths since the pandemic began. Active case rates (orange graph below right) are rising (orange graph above). This is a reminder of the need for global vaccination. We will not end this pandemic until the entire world has access to vaccines. Until then we will continue to have the development of mutant viruses that not only hurt the unvaccinated people but threaten to defeat the protection conferred by vaccination. 

world map with yellow dots and the ranking of countries with most covid cases and deaths

The USA, with 31.4 million cases and 564,557 deaths has roughly the same total number of cases as the next 3 most affected countries combined (India, Brazil and France). India now has the second most cases globally. While the USA has accounted for ~25 % of the global pandemic things are improving rapidly, with over 190,000,000 vaccinations completed (click here) and a promise to have all Americans vaccinated by April, 2021. Americanow has a 5.2% positive test rate, lower than Ontario’s 8.0%) (click here; see below). We are now in the sad position where the US government is advising Americans not to come to Canada because of our poorly controlled epidemic. Canada can and must do better; but congrats to the Biden administration for turning the US around!

colourful memo advising Americans not to travel to Canada

US advises against travel to Canada!

9) Here are answers to some updated FAQs with answers to common questions about the COVID-19 vaccines (most recent at the top).

grey human faceless figure with orange question marks swirling around head

1) New FAQ: Does one dose of vaccine provide protection from COVID-19? Short answer: yes (within 2 weeks). Pfizer vaccine confers 80% immunity within 2 weeks of first shot (click hereA real world study by the U.S. Centers for Disease Control and Prevention (CDC) evaluated the vaccines’ ability to protect against infection, including infections that did not cause symptoms. The study looked at the effectiveness of the mRNA vaccines among 3,950 participants in six states over a 13-week period. About 74 % of people had at least one shot, and tests were conducted weekly to catch any infections without symptoms. BothCOVID-19 vaccines developed by Pfizer-BioNTech and Moderna reduced risk of infection by 80% two weeks or more after the first shot. Immunity rises to >90% 2 weeks after the booster shot. This is reassuring, since Canada has spread out the interval from 1 month to 4 months, due to limited vaccine supply, as we try to get more people their 1st shot.

FAQ 2) If I have a solid organ transplant or I am a cancer patient should I have my second vaccine dose at the original interval? 

The short answer is yes (although it is not based on clinical trial data). Emerging “real world” data (aka experience) suggests that transplant recipients and active cancer chemotherapy patients (with specific treatment and timing considerations) are now eligible to have their 2nd dose of COVID-19 vaccine at the original interval (<30 days from dose 1); rather than the revised 16-week interval. KHSC is currently in the process of operationalizing this new recommendation (which was issued at noon today).

FAQ 3) Which vaccine will/should I get? The short answer is that all vaccines effectively prevent COVID-19 death and severe adverse outcomes-so take the one that you are offered. They are all safe. That said, the vaccine someone receives will depend on your age, where you live and where you are vaccinated. The AstraZeneca-Oxford vaccine, which has an overall effectiveness of 62%-vs >90% for Moderna and Pfizer, will be administered mostly through pharmacies and primary care clinics, as will the Johnson & Johnson vaccine (I suspect). This is the case because they both can be stored safely in a regular freezer (click here). The AstraZeneca vaccine is recommended for people between 18-64 years of age. The mRNA viruses (Pfizer/Moderna) are recommended for people over age 64 years. The advantages of getting a vaccine earlier (even if it’s a little less effective) outweigh waiting longer for a more effective vaccine. This is especially true since all vaccines seem to prevent death and severe COVID-19 complications. Emerging data show that the Astra-Zeneca vaccine is safe and effective in people over age 70 years (based on real-world data emerging from its use in the UK) (click here). In the recent US study it was over 90% effective in preventing severe COVID-19 and prevented death with 100% effectiveness!

FAQ 4) Which COVID-19 Vaccines have been approved by Health Canada? Currently Canada has 3 approved vaccines: Pfizer, Moderna, and Astra-Zeneca (as of last week). The Astra Zeneca vaccine was approved on Friday and may arrive as soon as Wednesday (click here). Canada is expecting 445,000 doses of this vaccine this week. The vaccine appears to prevent COVID-19 spread and severe COVID-19 pneumonia and death; however, it has the lowest effectiveness overall (62% protection).The J&J vaccine was just approved by the FDA in the USA (click here). It has not been approved in Canada yet but this is expected to occur in the next 2-3 weeks. The J&J vaccine has several advantages. In a study with people in 3 continents one dose of J&J was 85 per cent protective against the most severe COVID-19 illness and the safety profile was as good as other vaccines. The J&J vaccine is a single shot vaccine (unlike two shots for Pfizer and Moderna). In addition it can be stored in a simple office refrigerator, allowing it to be rapidly deployed in the community. The bottom line: All approved vaccines are protective against severe adverse outcomes and I would advise you to take the first vaccine you are offered!

FAQ 5) Does the vaccine work against new variants (mutations) in the SARS-CoV2 virus? Short answer is a qualified YES. The vaccines work albeit not quite as well for the variants. In the 144,000 participants in all randomized clinical trials of vaccines to date, those receiving any active vaccine had only 3 cases of severe COVID-19 (vs 37 in the control group). There were no deaths in people who were vaccinated with any of the vaccines versus 5 deaths in the control group. Even though absolute protection is slightly less for UK and South African variants the vaccines (including the AstraZeneca vaccine and J&J) prevent serious adverse outcomes (like hospitalization and death). Thus, despite variant viruses the vaccines are lifesavers!

FAQ 6) I’m on a blood thinner, can I be vaccinated for COVID-19? Short answer YES. Here is a more detailed answer from an Canadian agency with expertise on the use of blood thinners, Thrombosis Canada

memo from thrombosis Canada regarding those getting vaccines

FAQ 7) I have a history of allergic reactions, can I be vaccinated for COVID-19? Short answer YES. Out of ~1.8 million vaccinations there have only been 21 reported episodes of anaphylaxis (the most serious type of allergic reaction). Most (70%) of these events occurred within 15 minutes of the vaccine (which is why you will be monitored for this period of time post vaccine). There were also 83 cases of non-anaphylaxis allergic reaction after Pfizer-BioNTech COVID-19 vaccination with symptom onset within a 0–1-day risk window. Most (87%) of these allergic reactions were classified as nonserious. Thus, the risk of severe allergic reactions to the Pfizer vaccine are low and manageable. Allergy testing is NOT necessary prior to COVID-19 vaccination even in people with history of allergies. It is important note that none of the people who developed anaphylaxis after vaccination died and most did not have a prior history of anaphylaxis (see table below). The incidence of anaphylaxis is lower still with the Moderna vaccine. The Canadian Society of Allergy and Clinical Immunology has recently updated and reinforced this advice (see Tweet below):

tweet regarding those with allergies and getting the vaccine

The adverse effects of the COVID-19 vaccines in clinical trials are similar in vaccinated people vs people who got a placebo-saline injection except for: local pain at the vaccine site and increased muscle ache and headache, all of which were more common with the vaccine but were short-term (see below). This is a very good safety profile relative to other vaccines.

table of side effects with Pfizer vaccine vs placebo

The CDC does advise against the use of the two mRNA vaccines for a very select group of people with the following allergy histories (click here):

  • Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
  • Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
  • Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*

FAQ 8) I’m immunosuppressed, should I get vaccinated? This question has a less clear answer. First, be reassured is no virus (dead or alive) in the Pfizer or Moderna vaccines so it is not possible for a person to get infected from the vaccine. However immunosuppressed people were not included in the initial clinical trials. That said, they probably are safe to be vaccinated but this is more a matter of expert opinion. In Canada the National Advisory Committee on Immunization (NACI) currently advises that the COVID-19 vaccine should not be offered to populations excluded from clinical trials “until further evidence is available.” However, they also say “an immunosuppressed person or those with an autoimmune disorder can still be vaccinated if a risk assessment deems that the benefits of vaccine outweigh the potential risks for the individual.” (click here).

The British Society for Immunology recently issued a statement indicating that vaccination is safe in immunosuppressed people (click here), albeit the resulting immune response may be weaker. They remind us that because there is no virus in the vaccine there is absolutely no risk of acquiring COVID-19 from the vaccine. Dr. Mike Beyak (gastroenterology) nicely summarized evidence from a registry of ~4500 patients who were immunosuppressed for their inflammatory bowel diseases (Crohn’s disease and ulcerative colitis). There was no increased risk of contracting COVID-19 in these 4500 patients. Apart for patients on prednisone, there was also no increased complications from COVID-19 when it occurred. Interestingly, some biologic therapies (antibody treatments for IBD) actually appear to reduce adverse outcomes in IBD patients who contracted COVID-19. This is not surprising since the truly bad outcomes in COVID-19 seem to occur in people who mount a hyper-aggressive immune response. Overall these data are good news for our many patients with rheumatoid arthritis, asthma and IBD who are on immunosuppressive therapies. However, since these people were not included in the vaccine clinical trials, it is advised they consult the physicians/clinic that is managing their care to inform their vaccine decision.

FAQ 9) How long can I wait after my first dose to get a second vaccine dose? It appears a second dose at day 42 is as effective in producing a neutralizing antibody response as when the dose is given at day 21 (the normal interval from dose 1). This more lenient 42-day protocol has been approved by Health Canada.

needle and syringe drawing vaccine from a bottle

FAQ 10) Can I get COVID-19 from the vaccines? This answer is simple-NO! None of the approved vaccines in Canada contain the virus itself. They do not contain live virus; they do not contain dead virus. Canada’s approved vaccines (from Pfizer and Moderna) contain only the messenger RNA (genetic code) to allow you cells to make the viral spike protein which then triggers your immune cells to build anti-spike antibodies which protect you. The Astra Zeneca vaccine is much the same but delivers the SARS-CoV-2 spike protein gene via a chimpanzee adenovirus-vector. Again, there is no virus (not dead; not alive) in this vaccine (click here). So, while you might get a sore arm or a fever from vaccination this is just your immune system responding as it should; there is no chance of getting COVID-19. Obviously one could contract COVID-19 around the time of vaccination the normal way, before the vaccination’s protection develops (i.e. in the first 2 weeks after vaccination). 

FAQ 11) Are vaccines safe? Yes, serious adverse effects of vaccines are rare (occurring in only 167 of 1.4 million Canadians vaccinated). Most people get (at worst) sore arm at the injection site, fatigue, or fever, all signs the immune system is being activated. Based on the clinical trials and experience in millions of people who have been vaccinated world-wide we can be reassured of vaccine safety and efficacy. All the side effects (called adverse events and abbreviated AEFI) are tracked and reported by the government of Canada (see below). (click here) (last updated Feb 26th).

FAQ 12) Is it safe to increase the time span between dose 1 and 2 of the COVID-19 vaccine? Most vaccines are given with an initial dose and a booster dose 3 months later. The reason the COVID-19 vaccine regimen initially specified a shorter interval was simply the rapid pace of the clinical trials which compressed the vaccination interval. Regulators approved the vaccine based on the information that came from these trials. With time it is now clear that spacing out the interval up to 4 months is safe and effective. This longer interval between vaccines allows more people to get the first dose asap and as the data have shown, the first dose yields substantial immunity within 1-2 weeks. That said, once vaccines become more available it would be prudent to return to the initial interval between vaccine doses.

10) Improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC)-no deaths in 2 weeks…evidence vaccines working: click here.

three senior citizens sitting at a table all wearing masks

Most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and LTC facilities. While LTC residents account for only 5.3% of all cases in Ontario, they account for 51.8% of all 7244 deaths in Ontario. As of today, the 3,755 deaths in nursing homes (No DEATHS in the past week) account for ~57% of all deaths. There are 22 active COVID-19 cases in LTC residents and 121 active cases in LTC staff, the lowest numbers in months. These numbers continue to decline, which is very encouraging! For example a month ago we were seeing death rates of >100/week; now it is 2/week. These graph below shows the beneficial impact of the province’s decision to prioritize its limited initial vaccine supply of health care workers and residents of Ontario’s LTCs. Note the rapid decline in both staff (yellow) and resident (orange) COVID-19 case numbers coincident with vaccination!

colourful graph showing decline in cases in ltc

Vaccines crush COVID-19 in LTCs (leaving this graphic in the note because it is such an awesome testimonial to the power of vaccines in vulnerable people)

Regular reminders-On hiatus today

11) A big shout out to DOM colleagues, led by Dr. Chris Smith, Dr. Kristen Marosi, VP Renate Ilse, Michelle Matthews, POD Medicine, Dr. Mike O’Reilley, Dr. Laura Marcotte and Dr. David Taylor for handling the opening of a new HDH Medicine ward and consult service and supporting critical care as we deal with the influx of critically ill patients with COVID-19 from other regions.

There are moments as a Department Head when one feels incredible pride in the behaviours of one’s colleagues. Wave 3 of COVID 19 has led to one such moment and the pride extends across the entire organization. Our team, secretaries, administrative assistants, trainees, technicians, nurses, pharmacists and laboratory staff have selflessly reorganized their work life on the fly, allowing us to accept the transfer of large numbers of sick COVID-19 patients from the GTA. The Department of Medicine’s doctors, trainees and admins have risen to the occasion and gone the extra miles in many different ways to support the care of these patients. For example, we have opened Johnson 3 at HDG as a 31-bed internal medicine inpatient unit. Dr. Mike O’Reilly (cardiology) and Dr. Chris Smith (GIM) are the inaugural attendings. Donna Newton is the Charge Nurse, Tyler Hands is the Program Manager and Tom Hart the Director for this area. Dr. Laura Marcotte is the inaugural attending on a new surgical consultation service at HDH. We have created a backup service roster to staff this new clinical enterprise and I am so proud of the volunteerism and professionalism shown by members of the extended DOM family at all levels. Note the comment in response to our efforts to help our colleagues in the GTA from a surgeon in Scarborough (below):

screen shot of tweet

Stay calm, Stay informed, Stay Home, Stay Well! …. Get Vaccinated

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