May 10, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Dr. Archer's Updates on COVID-19

General DOM News & Events

| 11 May 2021

An article for your interest: (click here)

ambulance and paramedics outside KGH emergency

Helping India The Department of Medicine has collaborated with the Red Cross through a fundraising page to help support the Red Cross efforts on the ground in India. To date we have raised $5,725. Our funding will provide COVID-19 education, hygiene items and handwashing stations as well as supporting the health care system and quarantine centres.

tweet to donate to India with photo of young boy on bicycle receiving care package from Red Cross worker

Reminders

Provincial stay at home order (click here) in effect until the May 20th
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 open to book vaccines for people over age 40 for all people and is now open for people ages 18-44 in hot spots https://covid-19.ontario.ca/book-vaccine(click here).

screenshot of registration page for covid vaccine

Vaccine Hunters: In addition to standard registration processes to sign up for vaccines, people are vaccine hunting using sites that search out vaccines they are eligible for. I recommend that you use e-resources like Vaccine Hunters to find sites that help you identify a vaccine source. This is a legitimate approach. Remember, we all need to get vaccinated, so if you can find a vaccine for which you’re eligible you should take it without guilt… take it with pride and enthusiasm!

screenshot of tweet to help Canadians find vaccines

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!

1) Transfer of patients with COVID-19 to KHSC from Toronto slows

2) KFL&A update: almost 45% of people over age 16 years of age vaccinated (see update from KFL& A Public Health)

3) High-Risk Health Care Workers Now Eligible to Receive a Second Dose of the COVID-19 Vaccine at a Shortened Interval (click here)

4) Why you should take AstraZeneca Vaccine if offered-almost complete protection from COVID-19 death and 99.999% freedom from Vaccine induced thrombosis and thrombocytopenia (VITT) and a chance to party! (click here) (click here)

5) World vaccine roll-out tops 1.3 billion people (click here)! The pandemic explodes in India (where vaccination rates remain low) and the Department of Medicine launches a Red Cross donation site to aid India (click here)

6) Wave 3 begins to subside as Ontario infection rates fall with 2716 new cases and a 9.1% positive test rate (click here) (click here):

7) Canada’s COVID-19 epidemic shows a decrease in new and active cases (down -7 and -5%, respectively) and hospitalizations (-5%); but hot spots remain in Nova Scotia and the Northwest Territories (click here) (click here):

8) The global pandemic continues to escalate: ~158.4 million cases to date (up >3 million since last Thursday)new case rates on the rise, particularly in India (click here):

9) COVID-19 Vaccines FAQ: (click here)

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

Good news: It’s nurse’s week; The doctors in the Department of Medicine are dropping off Tim Horton’s cards as a small thank you to our amazing colleagues. We are thanking nurses, admin staff and technologists, all of whom are mission critical parts of the team!

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1) Transfer of patients with COVID-19 from Toronto slows: As wave 3 begins to decline in Ontario we are seeing a decrease in the rate of transfer of patients with COVID-19 from the Toronto area. KHSC now has 31 patients with active COVID-19 in hospital (red bar-graph on left below). All but 3 of these patients are from the greater Toronto area. are in ICU while 12 are cared for on Medicine’s COVID-19 unit, Connell 3. In addition Medicine is also caring for 12 individuals from Toronto who have recovered from COVID-19 (see green bar on graph below).

We have adequate bed capacity (183 beds) and ventilator capacity (28 ventilators) to continue to support local care of patients. The Medicine program remains busy with 168 patients in hospital (14 less than last week). Our new Johnson 3 ward at Hotel Dieu hospital is very active. I am extremely grateful to the faculty members and resident physicians who have stepped up and provided their support for this expanded bed capacity at a new site. We are anticipating a ramp up of care for the 99%, all those people waiting for non-COVID-19 care (stay tuned)!

various colourful graphs showing bed allocation and availability at KGH

KHSC has adequate bed capacity for care of local patients

Summary of our COVID-19 cases at KHSC: transfers begin to decline

2) KFL&A update: almost 45% of people over age 16 years of age vaccinated (see update from KFL& A Public Health)

The total number of cases in KFL&A since the pandemic began is 1420, not counting the resolved prison outbreak or people from other regions. This is up 32 cases in the past week. There are now 130 active cases in KFL&A, similar to last week (see below). There are 3 residents of KFL&A in hospital. Our test positivity rate in the past week is 1.67%, up 0.2% from last week. There have only been two deaths of KFL&A resident since the pandemic began but we have had several additional deaths at KHSC of non-resident patients. In Leeds Lanark Grenville county there have been 58 deaths with 8 deaths in Hastings-Prince Edward County. There are currently 250 active cases in the region, which is a plateau (see below). There are 11 regional outbreaks of COVID-19.

blue bar graph with red dotted line showing decline in SE Ontario covid cases

pie and bar graphs showing increase in variant of concern covid cases

Local active cases is a reminder we are seeing active community spread. Most cases in KFL&A are due to variant strains of the SARS-CoV-2 virus (see above-lower panel)

Currently 44.9% of the people living in KFL&A who are over age 16 years have received at least 1 dose of a COVID-19 vaccine (see below). The local goal is that everyone over age 18 in the KFL&A region should be vaccinated by the end of May!

two horizontal yellow and purple bar graphs showing vaccinations given by age in KFLA

table showing vaccination numbers in phase 2 in KFLA

Vaccination rates are rising steadily in KFL&A (even in younger people)

3) High-Risk Health Care Workers Eligible to Receive a Second Dose of COVID-19 Vaccines at a Shortened Interval (click here).

screenshot of news article title that high risk healthcare workers to receive 2nd covid shot earlier

You will recall that Ontario extended the interval between dose one and dose two of the COVID-19 vaccines to try and allow more people to get a first shot (which provides good but not full protection). As vaccine supply improves we are now changing course (a bit). High-risk health care workers who will be eligible for the shortened second-dose interval. Eligibility for booking will begin by the end of the week of May 10, 2021 This is a brand new announcement this am and we at KHSC are seeing how we deal with this (stay tuned for details on how to book)

All hospital and acute care staff in frontline roles with COVID-19 patients and/or with a high-risk of exposure to COVID-19, including nurses and personal support workers and those performing aerosol-generating procedures:
- Critical Care Units
- Emergency Departments and Urgent Care Departments
- COVID-19 Medical Units
- Code Blue Teams, rapid response teams
- General internal medicine and other specialists involved in the direct care of COVID-19 positive patients

All patient-facing health care workers involved in the COVID-19 response:
- COVID-19 Specimen Collection Centers (e.g., Assessment centers, community COVID-19 testing locations)
- Teams supporting outbreak response (e.g., IPAC teams supporting outbreak management, inspectors in the patient environment, redeployed health care workers supporting outbreaks or staffing crisis in congregate living settings)
- COVID-19 vaccine clinics and mobile immunization teams
- Mobile Testing Teams
- COVID-19 Isolation Centers
- COVID-19 Laboratory Services
- Current members of Ontario’s Emergency Medical Assistance Team (EMAT) who may be deployed at any time to support an emergency response

Medical First Responders
- ORNGE
- Paramedics
- Firefighters providing medical first response as part of their regular duties
- Police and special constables providing medical first response as part of their regular duties

Community health care workers serving specialized populations including:
- Needle exchange/syringe programs and supervised consumption and treatment services
- Indigenous health care service providers including but not limited to:
  - Aboriginal Health Access Centers, Indigenous Community Health Centers,
  - Indigenous Interprofessional Primary Care Teams, and Indigenous Nurse Practitioner-Led Clinics

Long-term care home and retirement-home health care workers, including nurses and personal support workers and Essential Caregivers

Individuals working in Community Health Centers serving disproportionally affected communities and/or communities experiencing highest burden of health, social and economic impacts from COVID-19

Critical health care workers in remote and hard to access communities, e.g., sole practitioner

Home and community care health care workers, including nurses and personal support workers caring for recipients of chronic homecare and seniors in congregate living facilities or providing hands-on care to COVID-19 patients in the community

The third wave in Canada is not yet controlled and quite frankly we do not have the luxury of not using the Astra Zeneca vaccine. The UK has gone “all in” on AstraZeneca vaccines and is reaping the benefits of approaching herd immunity. The city of Liverpool recently allowed people with negative COVID-19 tests to attend a concert without masks to guide the reopening process (click here).

large crowd of people in Liverpool nightclub

large crowd of people at a Liverpool nightclub

Britain is showing us our future as head toward reopening. In the UK 33.8 million people have received their first vaccine doses, with a quarter of adults receiving two doses (click here). In a non-peer reviewed pre-print article the positive benefit of the vaccines are clear. Amongst 52,000 hospitalized COVID-19 patients in the UK only 526 had been vaccinated with 1 dose of either the AstraZeneca or Pfizer vaccines and of those, 113 died. So the vaccine (especially one dose) is not perfect…but it’s pretty darned good!

The rate of adverse effects of COVID-19 vaccination in Canada (by type of vaccine) may surprise some readers (click here). Note the rates of adverse effects thus far are lowest with AstraZeneca vaccines.

purple bar graphs showing vaccine side effects

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. There is a rare complication of the AstraZeneca vaccine, a clotting and bleeding syndrome called vaccine-induced immune thrombotic thrombocytopenia (VITT). To provide some perspective on the low risk of developing this rare blood clot after the A-Z vaccine there have been <10 cases of VITT in Canada out of more than >1.1 million shots administered(two in Ontario, and one each in Alberta, Quebec and New Brunswick). Thus VITT is very rare! In contrast the benefits of the Astra Zeneca vaccine, which include an almost complete protection from COVID death and severe COVID disease, are substantial. The key point you need to know is that this rare complication occurs in 5-10 cases/1 million people vaccinated. 99.999% of vaccinated people will NOT develop VITT with the AstraZeneca vaccine. In those very rare cases where VITT occurs it usually manifest 4 days-1 month post vaccine. Symptoms include: persistent and severe headache, difficulty moving parts of your body, seizures, blurred or double vision, shortness of breath, or back, chest or abdominal pain or swelling/pain in a limb (click here). VITT is treatable and most patients affected have survived.

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 5-10/million risk. In the United Kingdom, where 20 million doses of AstraZeneca have been administered as of April 1^st, 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.

For those are interested in how the vaccine might cause clots and whether the problem is the antigen or the vector-read on! There are 2 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). Both the new vaccine syndrome, 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 17 cases of VITT out of more than eight-million doses of Johnson & Johnson's viral vector vaccine (click here). 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.

Updates: Canada has had 2 deaths attributed to VITT reported in a previously healthy 54 year woman, Ms. Francine Boyer, in Quebec (click here) Following her vaccination, Ms. Boyer suffered from severe fatigue and headaches. She was hospitalized locally and then transferred to the Montreal Neurological Institute but died two weeks post vaccination. Despite this tragic death the benefits of this vaccine, and all other COVID-19 vaccines, clearly outweigh the risks (discussed below). Since my last note a woman in her 50s died in Alberta (click here). Alberta has had 2 cases out of 253,000 vaccines administered.

The bottom line: It would be dangerous policy and poor personal decision making to avoid taking the AstraZeneca vaccine (which results in ~4 chances/million of causing a clot) while COVID-19 itself confers a 1.5% risk of death, a 5 % risk of hospitalization and both these bad outcomes are prevented by the Astra Zeneca Vaccine. The numbers clearly give clear guidance: Take the first vaccine you are offered! This advice is supported by Federal and provincial guidelines.

Before we get to an update on the progress in global vaccination I thought you might be interested in a new study that is beginning in the United Kingdom. Health regulators there have authorized a very interesting study. In return for ~$6200 USD health, young, unvaccinated volunteers (age 18-30 years) are agreeing to have coronavirus placed in their nose to cause an infection. The goal is to better understand immunity (and eventually the effects of vaccination on immunity). Obviously the study is controversial; but worth knowing about (click here).

World vaccine roll-out tops 1.3 billion people (click here)! Real world evidence that vaccines work!

colourful horizontal bar graph showing world vaccine doses administered then ranking by country

Vaccines are they key to ending COVID-19 and the graph above shows some vaccine champs (China in the lead). Unfortunately, the good news about progress in vaccine administration largely applies to a few countries (China, UK, USA, Canada, Israel). If we replot the graph above to show not the total number of vaccines given but the number given per 100,000 residents, it becomes clear that India (and most of the word) has had little vaccination.

colourful horizontal bar graphs showing vaccines administered per 100 people ranking of countries

Vaccines/100,000 population show how a slow the global vaccination program (note India and the world at bottom)

There is real world evidence that the vaccines work. Look at the fall in confirmed COVID-19 cases in the USA, UK and Israel (and Chile) where vaccines have been widely deployed; vs India (where they remain scarce). The per cent of Indian people vaccinated remains low and the country is paying a high price with people dying rapidly. Suffering is intensified by shortages of basic supplies like oxygen. Canada is beginning to show benefits of our vaccine program (brown line above).

colourful line graphs showing daily new covid cases by country

Vaccinated countries head toward a post-COVID-19 era with low rates of infection (see USA, UK, Israel); not so for India

In light of the unfolding tragedy in India, the DOM has launched a fund raising site using Red Cross. If you wish to join us in making a donation click here (the tax receipt issued to you personally by the Red Cross.) I did it and it made me feel better!

fiundraing page to donate to India showing a young boy on a bicycle receiving care package from Red Cross worker

India foreshadows what will likely happen in Africa. Very little vaccination has occurred in the African continent. We cannot end this pandemic without effective and equitable global vaccination. We need to turn our attention to international vaccine distribution as soon as possible.

There is also “made in Canada”, evidence that the vaccines are safe. Below are the Canadian vaccine safety data for all vaccines as of April 30th (click here). After > 13.4 million vaccinations in Canada there have been 3,800 individual reports of vaccine side effects (0.028%). Only 748 side effects were serious (0.006% ) and there has been ~8 cases of VITT (estimated), and 2 people with VITT have died.

Amongst vaccinated Canadians adverse events were most common among those ages 18 to 49 years (47.0%), and usually occurred in females; 4-times more often than males (47.9 vs 11.5/100,000, respectively).

The bottom line: If you get vaccinated you have less than a 6/100,000 risk of a serious allergic reaction and only two people has died from a COVID-19 vaccine in Canada. In return you get >90% protection from a serious COVID-19 infection and almost complete protection from a COVID-19 death.

6) Wave 3 begins to subside as Ontario infection rates fall with 2716 new cases and a 9.1% positive test rate (click here) (click here):

number graphics highlighting current covid data in Ontario

COVID-19 in Ontario May 6th 2021: We are experiencing an encouraging drop in the 7-day rolling average of new cases, active cases and hospitalizations (slide courtesy of Dr. Gerald Evans) (see below).

line graph with numbers along graph and dates across the bottom

salmon coloured line graph with 4 text boxes below

Wave three of COVID-19 is beginning to subside (see above) with 13% falls in both new and active cases and a 5% decrease in hospitalizations; however, Ontario still has hotspots (especially in Toronto) and our hospitals are still over stretched with 1632 people with COVID-19 admitted.

7) Canada’s COVID-19 epidemic shows a decrease in new and active cases (down -7 and -5%, respectively) and hospitalizations (-5%) but there are hot spots in Nova Scotia and the Northwest Territories (click here) (click here):

green map of canada with the surrounding bodies of water

salmon coloured bar graphs with 4 text boxes below

With many provinces having enacted stay home orders and with rising vaccine rates in Canada we are seeing new and active case rates fall modestly and hospitalizations decrease 5% (above). This will only be sustained if we follow public health rules while we await vaccination!

various types of graphs showing Canadian covid data

COVID-19 in Canada May 10^th, 2021 (note high rates of active cases in NS and NWT-above left

To date we have had 1,290,050 cases of COVID-19 since the pandemic began. The case mortality rate is 1.5% with 24,651 deaths. The current hospitalization numbers are much higher than in the 2^nd wave of COVID-19 in late 2020 (with 3659 people in hospital today-down from >4100 on Thursday last week). We have done ~33.5 million COVID-19 tests with a cumulative positive test rate of 3.85%. 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 slowly improving.

Rates of COVID-19 are sharply increasing in both Nova Scotia and the Northwest Territory and these jurisdictions have ordered much tighter public health rules; which is the only defense to community spread until their residents are vaccinated.

line graphs showing increase in cases in NWT

COVID-19 cases rise at unprecedented rates in the Northwest Territories.

line graphs showing increase in covid cases in NS

COVID-19 cases rise at unprecedented rates in Nova Scotia.

Canada’s vaccination roll-out: 16.09 million vaccines administered thus far (39% of population have received at least 1 dose) (click here)-see below: To date, 18.2 million doses of COVID-19 vaccines have been delivered and 88.6% of delivered doses have been administered. Thus, Canada’s vaccine gap has narrowed compared with last week. The gap reflects recent arrival of vaccines but also our relative inability to quickly administer the vaccine to patients. 1,256,694 Canadians are fully vaccinated (click here).

update and map of Canada with each province labelled and the number of vaccine doses administered

8) The global pandemic continues to escalate: ~158.4 million cases to date (up >3 million since last Thursday)new case rates on the rise, particularly in India (click here):

satellite image of earth taken from space

There have been over 158 million cases of COVID-19 since the pandemic began, up over 3 million cases since last Thursday! There have been 3,295,405 COVID-19 deaths since the pandemic began. Death rates are once again plateauing (white graph below right).

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

COVID-29 May 10^th, 2021: a global snapshot

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.

The USA is a success story: The pandemic is improving in the USA largely due to an effective vaccine program. America now has a 3.3% positive test rate, an ongoing trend of declining rates! (click here; see below). The American turnaround should offer hope to Canadians-this should be us in 2-3 months!

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

grey faceless human figure holding hands to head with orange question marks surrounding head

FAQ 1: Can I take a different second vaccine for COVID-19 (click here)

Chances are you can mix and match (i.e. one shot Pfizer; one shot AstraZeneca); but the science is not in yet. Researchers in Britain have launched a study to determine if it’s safe and effective to mix different vaccines (Pfizer and A-Z) that protect against SARS-CoV-2, the coronavirus that causes COVID-19. Participants will be allocated, at random, (rather like a flip of a coin) to receive one dose of one approved vaccine and a second dose of either the same approved vaccine, or a dose of a different approved vaccine. Participants will also be allocated at random to the timing of receiving these doses – some will get a boost dose four weeks after the first dose and some will get a booster at twelve weeks. Some believe that one vaccine type (mRNA vs adenoviral) may be better than the other in triggering the various aspects of the immune response. While we await the research results I would suggest taking the two doses of the same vaccine brand (but stay tuned for updates).

FAQ 2: I’m pregnant, should I get the vaccine?

Vaccination is recommended for all women who are pregnant or breast feeding at any time in pregnancy unless there is some specific reason not to be vaccinated. The reason for this advice is that the mRNA vaccines for COVID-19 appear to be safe in pregnant women (click here) whereas COVID-19 has higher morbidity (is more severe) when contracted during pregnancy.

pregnant woman getting vaccine from health care worker

tweet with graphs relating to pregnancy and vaccines

FAQ 3: 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 here) A 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 1^st shot.

FAQ 4: 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 5: 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 6: 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 7: 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 8: 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 getting the vaccines

FAQ 9: 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 NOTnecessary 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):

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 10: 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 11: 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 interval is necessitated by our vaccine shortage and has been approved by Health Canada.

syringe with needle drawing vaccine from bottle

FAQ 12: Can I contract a COVID-19 infection 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. The J&J vaccine also uses an adenoviral vector but again, there is no SARS-CoV-2 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 13: 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 April 16^th).

FAQ 14: 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. My second dose of Pfizer vaccine will occur 4 months after the first dose I received.

9) Sustained improvement in COVID-19 in Ontario’s Long Term Care facilities (LTC)…evidence vaccines working: click here

three senior citizens sitting at a table 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 8029 deaths in Ontario. As of today, the 3,762 deaths in nursing homes account for ~46% of all deaths. There were no new deaths in LTCs due to COVID-19 in the past week. There are 67 active COVID-19 cases in LTC residents and 155 active cases in LTC staff, the lowest numbers in months. These numbers remain low and stable, which is testimony to the effectiveness of mass vaccination in a high risk population! For example a month ago we were seeing death rates of >100/week; now it is 0-5/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!

line graph showing decline in cases in LTC since vaccines given

Now this to friends and family who are vaccine hesitant: Vaccines crush COVID-19 in LTCs: an awesome testimonial to the power of vaccines in vulnerable people.

Regular reminders-On hiatus

Good news: It’s nurse’s week!!! Dr Chris Smith, Deputy Head of Medicine, Michell Matthews POD Medicine, and I are visiting Medicine and Critical Care wards at KHSC, on behalf of all our physicians, to thank the entire health care team for their outstanding service during the pandemic. Here are some pics from today as we dropped off Tim Horton’s cards on Connell 9 & 10. A little thank-you gift for nurses, admin staff and technologists, all of whom are mission critical parts of the team!