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April 22, 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 Mid May
  • 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 40 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!

1) KFL&A COVID-19: KHSC has 46 hospitalized COVID-19 and 7 patients recovering from COVID-19 in hospital patients from the Toronto (vs one local case) (see update from KFL& A Public Health)A proud moment of service by faculty, staff and trainees!

2) An ongoing conversation I am having with my patients in clinic: 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.

3) World vaccine roll-out tops 950 million people (click here)! Real world evidence that vaccination is safe and effective.

4) Ontario infection rates remain high but there is sign of a plateau in wave 3 with 3,682 cases (down from 4,447 new cases on Monday) and positive test rates decline to 7.8% (down from 10.5%on Monday)-but hospital capacity saturated in Toronto (click here(click here): 

5) Canada’s COVID-19 epidemic-better than last week: New and active case rates increased more slowly (2 and 16%, respectively) in the past week but both deaths and hospitalizations are on the rise, 17 and 19%, respectively (click here) (click here): 

6) The global pandemic continues to escalate: >144 million cases to date and new case rates on the rise (click here): up almost 3 million cases since Monday!

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

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

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1) KFL&A COVID-19: KHSC has 46 hospitalized COVID-19 and 7 patients recovering from COVID-19 in hospital patients from the Toronto (vs one local case) (see update from KFL& A Public Health)A proud moment of service by faculty, staff and trainees!

table of current kfl&a covid data

There has been a change in Kingston from the normal rules of epidemics. Our local situation is good (relative to most areas) and is improving. 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. We will get through this and will be rightly proud of our role in helping to defeat COVID-19.

The total number of cases in KFL&A since the pandemic began is 1195, not counting the resolved prison outbreak or people from other regions. This is up 30 cases since Monday, with most cases being young people, associated with the Queen’s University outbreak. However, in SE Ontario cases numbers are fortunately in decline, a response to vaccination and rigorous public health measures. 

We have 46 patients with COVID-19 in hospital (red bar-graph on left below), all save one from the greater Toronto area. Thirty one (31) patients with COVID-19 pneumonia are in critical are beds and 22 are in Medicine beds (active cases 15; recovered but hospitalized cases, 7; green bar on left graph below). Patients are mostly coming from Scarborough health. We have 20 transfer planned for the near future.

various graphs of khsc bed capacity

KHSC has grown from a 500 bed hospital to a 600 bed hospital in a very short time to meet the tertiary care needs of Ontario and assist patients in Toronto in a very meaningful way.

Cases in SE Ontario have dropped 50% in the past week and we now have 255 active cases in SE Ontario, with 85 cases in KFL&A and a total of 255 cases in SE Ontario (see below). 

bar graphs

New cases in SE Ontario have declined by 50% in the past 2 weeks due to vaccines and compliance with public health measures

Most new cases in KFL&A are caused by a variant of concern (i.e. mutant virus) including many double mutant viruses (see bottom panel below). These variants are more infectious and may be more lethal.

pie and bar graph

In the past 4 days KFL&A has done 2495 COVID-19 tests with a positive test rate of 1.0%. (0.8% for residents of KFL&A). IN this regard, as with case numbers, SE Ontario is in relatively good shape compared to most of the province. Positive test rates locally are in rapid decline (see green line below) (unlike the case for the province as a whole-orange line).

daily line graphs of test positivity

Rates of test positivity improve substantially in SE Ontario April 22nd

There have only been two deaths of KFL&A residents since the pandemic began but we have had several 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.

Despite the good news locally, COVID-19 is actively spreading in our region with the latest outbreak being amongst students at Queen’s University. An outbreak was declared 11 days ago amongst a group of people in the University area . These young people, ages 18 to 29 years, make up over 70 per cent of the active cases in the KFL&A region (click here) and account for over 70 cases. This is why a local lakeside park was closed near the University. This is a reminder that we are quite literally NOT IMMUNE! 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 near 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.

On a more positive note, over 78000 KFL&A residents have already been vaccinated (>35% of all residents)! This is 7000 more vaccines than Monday! While good progress has been made in vaccinating older residents of KFL&A, <20% of those groups most often infected (people <age 40 years) have been vaccinated thus far as we follow provincial vaccine administration guidelines that focus on vaccination of older populations first.

table showing vaccines given in kfla

Great progress has been made in vaccinating the residents of KFL&A

Thanks to Team Medicine who have worked hard to convert Connell 3 to a completely COVID-19 specific ward while simultaneously opening a new 31 bed Medicine ward at the Hotel Dieu. KHSC is also rapidly opening new ICU beds and has diverted staff from clinics and surgical programs to care for patients in these beds. We have also increased ventilator supply (bottom right above). The public would be impressed if they could see what I see every day-faculty cheerfully doing a great job, caring for patients and educating trainees. In less than 2-weeks we have built unprecedented COVID-19 capacity and accepted >50 COVID-19 patients with more coming. These transformations have all occurred in just two weeks-WOW! I have heard many messages of gratitude from colleagues in Toronto who appreciate our help in their darkest hour. 

many hands in the air forming a heart shape

The heroes in this KHSC/Queen’s University FHS response are not solely or even primarily doctors. The unsung heroes are the nurses, staff, technicians, respiratory therapists, pharmacists, administrators, administrative assistants, clinical secretaries and trainees, and our colleagues at SEAMO and the Dean’s office. They have stepped up and accepted the challenge to ensure we keep our fellow Ontarians safe as we make the final push to get through wave-3! It’s not just Medicine and ICU Departments either, all the Departments in the Faculty of Health Sciences and colleagues at Providence Care Hospital are doing their part to handle the surge. KUDOS to all of you…you make me proud. 

2) Read below for an ongoing conversation I am having with my patients in clinic: 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.

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.

health Canada news article photo of physician giving vaccine in patient armpicture graphic of blood clot risks from vaccine vs other things

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 first vaccine you are offered! This is once again supported by Federal and provincial guidelines.

3) World vaccine roll-out tops 950 million people (click here)! Real world evidence that vaccination is safe and effective.

colourful horizontal bar graph of vaccines administered by country

High vaccine uptake countries (USA, UK and Israel)

Vaccines are they key to ending COVID-19 and the graph above shows some vaccine champs (USA in the lead). Canada’s vaccine roll out is slowly accelerating 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 that 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 “real world” illustration that vaccines work! Also note the concerning situation in India where vaccines in this populous country are rare (as a percentage of the population). Canada will eventually join these happy ranks likely in May (I predict).

line graphs showing new daily cases by country and the huge increase in India

High vaccine utilization rate countries, like the USA, UK and Israel, have seen a rapid reduction in new cases of COVID-19-Inida is a new source of great concern

There is also real-world, made in Canada, evidence that the vaccines are safe (no updates since Monday). Here are the Canadian vaccine safety data for all vaccines as of April 16th (click here). After > 11 million vaccinations in Canada there have been 3,444 individual reports of vaccine side effects (0.045%). Only 464 side effects were serious (0.006%) and there has been one presumptive case of VITT and no vaccine related deaths!

The bottom line: If you get vaccinated you have less than a 6/100,000 risk of a serious allergic reaction and no one has died of any 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. 

4) Ontario infection rates remain high but there is sign of a plateau in wave 3 with 3,682 cases (down from 4,447 new cases on Monday) and positive test rates decline to 7.8% (down from 10.5%on Monday)-but hospital capacity remains saturated in Toronto (click here(click here): 

number graphic for various covid data in Ontario

Things are improving in Ontario-but hospitalizations will likely remain high for 2-3 weeks: a typical lag between new cases and hospitalizations/death

As seen below the weekly rates of new and active cases is up 8 and 17% respectively. Coincident with this, deaths are up 33% and hospitalizations are up over 21%. 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, as summarized earlier in this note. 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 colour bar graph

As has been true since the beginning of the pandemic the infections remain most common in the young whilst the vast majority of deaths are in the elderly (gray bars on left below). There is a similar infection rate in males and females.

green and red horizontal bar graphs showing number of cases by age group

5) Canada’s COVID-19 epidemic is better than last week: New and active case rates increased more slowly (2 and 16%, respectively) in the past week but both deaths and hospitalizations are on the rise, 17 and 19%, respectively (click here) (click here): 

map of Canada and surrounding waterssalmon coloured bar graph showing cases in Canada

COVID-19 in Canada April 22nd 2021

various types of graphs showing wave 3 covid data in canada

Wave three is large and lethal and requires that we all get vaccinated and adhere to public health rules: Hospitals in Canada are full, with limited ICU capacity

All residents of Canada need to be aware that adherence to public health measures and acceptance of vaccines is critical. To date we have had 1,152,399 cases of COVID-19 since the pandemic began. The case mortality rate is 1.63% with 23,810 deaths. The hospitalization numbers are much higher than in the 2nd wave of COVID-19 in late 2020 (with 4,285 people in hospital today). Most infections are being spread by close contact. We have done ~31.1 million COVID-19 tests with a cumulative positive test rate of 3.69%. 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. Rates of infection are up in most Canadian provinces, although most sharply increased in Ontario, BC and Alberta.

Canada’s vaccination roll-out: 11 million vaccines administered thus far (26.5% of population) (click here)-see below: To date, 13.7 million doses of COVID-19 vaccines (including Moderna, Pfizer-BioNTech and Astra-Zeneca) have been delivered. Thus far, only 80.6% of delivered doses have been administered. Thus, Canada still has a vaccine gap with delays in administering received vaccine (see below). Lately this mostly relates to hesitancy around the AstraZeneca vaccine, which will hopefully be resolved by reassurance from Health Canada that the vaccine is safe. This vaccine gap is most pronounced in Ontario (see below). This gap reflects recent arrival of vaccines but also our relative inability to quickly administer the vaccine to patients. 965,579 Canadians are fully vaccinated (click here).

black and grey bar graphs

Canada’s vaccine gap (gray vs black bars): If all vaccines were administered the day they were received there would be no difference between the gray and black bars.

6) The global pandemic continues to escalate: >144 million cases to date and new case rates on the rise (click here): up almost 3 million cases since Monday!

satellite image of earth taken from space

There have been ~41.5 million cases of COVID-19 since the pandemic began, up almost 3 million cases since last Thursday! There have been 3,062,945 COVID-19 deaths since the pandemic began. Death rates (white graph below right) are again on the rise. As usual rising deaths following rising case numbers by 3-4 weeks. 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 ranking lists by country with most cases and deaths

Global COVID-19 April 22nd 2021: New cases on the rise in orange (bottom right)

Our next big challenge: We need to vaccinate the world-not just wealthy countries. This is not done just out of a sense of compassion and equity. Widespread vaccination, to the point of herd immunity, is necessary to stop viral mutation and immune evasion. There is little vaccination in the African continent and this creates a pandemic breeding ground for evolving viruses. Africa will need our help-and the sooner we start the more effective that help will be.

The USA, with 31.8 million cases and ~569,000 deaths is progressively accounting for less of the daily new cases as the disease surges in India and Brazil. India now has the second most cases globally. While the USA once accounted for ~25 % of the global pandemic things but now accounts for 22% of the burden as other countries like India, Brazil and France surge. The pandemic is improving in the USA largely due to an effective vaccine program, with over 216,000,000 vaccinations completed (click here) and a promise to have all Americans vaccinated by the end of April, 2021. Americanow has a 4.7% positive test rate, much lower than Ontario, 7.8%) (click here; see below). 

line graphs

We are 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 if we want to see the border open!

screenshot of colourful travel advisory for us citizens not to travel to Canada

US advises against travel to Canada!

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

grey human figure holding hands to head and orange question marks surrounding 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 for those taking vaccine

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):

screenshot of tweet from Dr. Archer regarding allergies

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 from 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, this data is 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.

syringe and needle drawing vaccine from 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.

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

three senior citizens all wearing masks sitting at a table

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 (not sure if this is a change since numbers were at this level, revised down and now back up) account for ~51% of all deaths. There are 42 active COVID-19 cases in LTC residents and 135 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. The 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!

graph showing decline in ltc cases due to vaccines

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 today

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

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