June 17, 2021 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
For KHSC staff and faculty re vaccinations:
- Vaccine on call list coming soon: For all KHSC staff-there will soon be an “on-call” list where you can sign up to get vaccines that are left over at the end of day (usually because of cancelled vaccine appointments). Stay tuned.
- Please feel free to get your second dose of vaccine wherever it is first available. For example, if it is available earlier via KFL&A booking (click here) then please avail yourself of this source. However, we would ask if you do get vaccinated elsewhere please cancel your KHSC vaccine appointment and let occupational health know so that we don’t waste vaccine.
1. KFL&A update: 3rdwave resolving with 4 active cases locally (3 in hospital), only 0.5 cases/100,000 people in the past week and ~74% of eligible residents (12 years and older) vaccinated at least once (see update from KFL& A Public Health).
2. Wave 3 continues to subside as Ontario infection rates fall with 384 new cases yesterday (a 28% weekly decline in the new case rate), a 15% weekly decline in hospitalizations and a low positive test rate (1.5%) (click here) (click here):
3. Canada’s COVID-19 epidemic rapidly resolving with > 30 million doses of vaccines administered: New and active cases (down -28% and -31%, respectively) and hospitalizations falling (-17%) (click here) (click here).
4. World vaccine roll-out tops 2.5 billion people (click here): mainly rich countries benefiting.
6. Reopening the USA-Canada Border? Likely not happening in June (click here).
7. FAQs-answers to common questions about the COVID-19 vaccines.
8. Continued Stability in COVID-19 in Ontario’s Long Term Care facilities (LTC)…1 death in the past week-evidence vaccines working: click here.
KFL&A update: 3rd wave resolving with 4 active cases locally (3 in hospital), only 0.5 cases/100,000 people in the past week and ~74% of eligible residents (12 years and older) vaccinated at least once (see update from KFL& A Public Health)
The 3rd wave has largely resolved in SE Ontario. However, we have received patients with COVID-19 from Northern Ontario (the Porcupine health region, where the 3rd wave is not well controlled. We have only 12 patients with COVID-19 at KHSC and 75% are being cared for by Medicine (Connell 3-see below). Only 3 patients are from KFL&A, the rest were transferred from the Porcupine region (see increased rates of active infections in this region relative to all other regions of Ontario below).
Wave 3 continues in the North (Porcupine Health Region)-and we are caring for their hospitalized patients (slide courtesy of Dr Gerald Evans)
We also have 16 patients recovering from COVID-19, also cared for by the Medicine Program. To date we have cared for >150 patients from the GTA and Northern Ontario with COVID-19 at KHSC. KUDOS colleagues and staff!!! Effective Monday we are ramping up clinics toward pre-pandemic levels (although volumes will still be limited by the size of waiting rooms and ongoing masking/physical distancing requirements).
The Medicine program remains extremely busy with non-COVID-19 care. We are looking after 200 patients at KHSC and run an additional ward at HDH.
KFL&A retains a highly desirable COVID profile with almost no new cases in the past week (see below).
Resolution of wave 3 in KFL&A
Vaccination is proceeding very well in our region (see below) with 75% of adults having one vaccine dose and 17% having had two doses.
Vaccination is proceeding well in KFL&A with 73.7% of people over age 12 years having been at least partially vaccinated (note lag in achieving full vaccination- pink curve)
The total number of cases of COVID-19 in KFL&A since the pandemic began is 1546, not counting the resolved prison outbreak or people from other regions (see below). The pandemic is clearly resolving in SE Ontario (due initially to a painful lockdown and now due to widespread vaccination).
Resolution of wave 3 in SE Ontario: only 18 active cases
2) Wave 3 continues to subside as Ontario infection rates fall with 384 new cases yesterday a 28% weekly decline in new case rate, a 15% weekly decline in hospitalizations and a new low positive test rate (1.5%) (click here) (click here):
Ontario has made amazing progress toward quashing wave 3 and is poised to more fully reopen this month. All metrics (new infections, hospitalizations, and positive test rates) are headed in the right direction (see below).
Wave 3 resolving in Ontario
Premiere Ford is now discussing an earlier move to Phase 2 reopening (stay tuned) (click here). However, some health regions (Waterloo) have ongoing problems with high incidence of the delta variant of SARS-CoV-2 (click here) and the North has an ongoing wave 3 surge in cases. Thus, I suspect Phase 2 reopening dates will vary by region.
Waterloo region needs more complete vaccination to quash delta variant spread
3) Canada’s COVID-19 epidemic rapidly resolving with > 30 million doses of vaccines administered (65% of eligible Canadians have had 1 dose): New and active cases (down -28% and -31%, respectively) and hospitalizations falling (-17%) (click here) (click here)
Resolution of Wave 3 in Canada June 17th, 2021
New and active case rates falling rapidly and hospitalizations declining (above). We have had 1.4 million cases of COVID-19 since the pandemic began. The case mortality rate remains at 1.45% with 26,001 deaths (see below). We have done a cumulative 36.6 million COVID-19 tests with a cumulative positive test rate of 3.84%. The current hospitalization numbers are also declining (with 1288 people in hospital today (down from >4100 3 weeks ago-see below).
COVID-19 hospitalizations declining across Canada June 17th-
Canada is no longer a vaccine laggard: 65% of Canadian have had at least one shot and 15% are fully vaccinated! 30.6. million doses have been administered, up 3 million vaccines from 1 week ago (click here): To date, 33 million doses of COVID-19 vaccines have been delivered and a record high 92.2% of delivered doses have been administered. 221,000 people per day are being vaccinated. Canada is near the top of the pack in vaccines administered per day now! (see below)
4) World vaccine roll-out tops 2.5 billion people (click here): but it is mainly rich countries benefiting
Vaccines are they key to ending COVID-19 and the map below shows some vaccine champs (Canada, UAE, Israel. USA, Bahrain, Chile, and the UK in the lead); however, Africa remains a vaccine desert.
Africa remains a COVID-19 vaccine desert
Progress in vaccine administration largely applies to wealthy countries. This is not only unjust; it also allows the creation and spread of new viral mutants, like the delta variant, which are more infectious and may lead to immune evasion thereby keeping the pandemic going. Fortunately, the US is weighing in with a donation of 500 million vaccines to low income countries (click here). Canada should consider doing something similar. Mr. Trudeau has now committed to share 100,000,000 vaccines abroad by the end of the year (click here).
New case rates are declining globally (see below). That is good news but there are 2 caveats! First, in some countries the accuracy of case counts and death rates is uncertain. India recently acknowledged a serious undercounting of deaths.
Global decline in new cases of COVID-19
Second rates of new infection are on the rise in many parts of India, Africa and South America (see map below).
The world still has many COVID-19 hotspots
6) Reopening the USA-Canada Border? Likely not opening in June (click here)
The pandemic is improving in the USA largely due to an effective vaccine program. America now has a 1.9% positive test rate, the lowest rate since the pandemic began (click here; see below). It appears likely that Canadians who fly home and who have been fully vaccinated against COVID-19 will no longer be forced to stay in quarantine hotels or quarantine beginning in July.
The date for a more complete border opening remains a topic of active debate. However, the land border between Canada and the USA, which has been closed to non-essential travel since March 21, 2020, appears unlikely to reopen this month per Mr. Trudeau. In a poll published by the Angus Reid Institute three weeks ago, nearly half of participants expressed the wish that the border stays closed, either until fall (27 per cent) or until the end of the year (21 per cent). Hopefully this will not be the case, as fully vaccinated people are, from a medical perspective, extremely low risk travelers.
7) FAQs-answers to common questions about the COVID-19 vaccines:
New FAQ 1: Is a single shot of the mRNA COVID-19 vaccine protective? For those who are anxiously awaiting shot 2: be reassured that there is excellent protection from shot 1. The slide below shows the effectiveness of 1 shot vs 2 shots of each of the mRNA vaccines in health care workers. So, while you wait for shot 2 you are highly protected (slide courtesy of Dr. Gerald Evans). (2 shots are still recommended).
If you had AstraZeneca as your first vaccine you are likely frustrated/confused/annoyed about the lack of information re: shot #2 (click here). The cause of the uncertainty is not vaccine supply (we have lots of AstraZeneca vaccine available). The cause of the uncertainty re your second shot is the very confusing data on the incidence of a rare clotting/bleeding complication called VITT which is associated with the AstraZeneca vaccine. VITT has occurred in 28 Canadians (click here) and likely occurs in 1/100,000 people that receive this vaccine. Unfortunately, reported rates of VITT vary widely by country from 1/25,000 to 1/200,000, which has been a challenge to understand and has made health policy to say the least confusing (click here).
Personally, I am convinced the vaccine is safe and our monitoring systems (with 15 million vaccines given thus far) shows that adverse reactions are not higher with AstraZeneca than other vaccines (they actually are lower-click here and see below).
In the UK where lots of AstraZeneca has been used it is clear risks of VITT are low and are even lower for the second shot (click here)! More than 22 million first doses of the AstraZeneca vaccine have been administered with only 209 cases of VITT reported (~1/100,000 people).To date, vaccine with 4 a cases of rare clotting were reported following the second shot (1 in a million people).
In the past week (May 21st) many provinces (including Ontario and BC) authorized second dose administration of AstraZeneca. In BC for example, Dr. Henry indicated “British Columbians who opted for the AstraZeneca plc COVID-19 vaccine for their first dose will be able to get their second doses from the same manufacturer” (click here). I fully support this policy…this vaccine is very effective and has changed Britain from a COVID-19 plagued country to a reopening society!
FAQ 3: Are mix and match vaccine strategies safe and effective? Another possibility for those who had AstraZeneca for their first dose is to take Pfizer or Moderna vaccines for dose 2. This strategy does appear safe and we are awaiting proof it is effective. There is a small clinical trial of 663 people underway in Spain assessing this mixed and match vaccine strategy and results look encouraging (it is tolerated and safe-click here); but it’s still too early to know if it as effective as the two dose of the same vaccine regimen. The data to date shows that a Pfizer booster in people that got an AstraZeneca first shot increased protective antibody levels. The study investigators state: “After this second dose, participants began to produce much higher levels of antibodies than they did before, and these antibodies were able to recognize and inactivate SARS-CoV-2 in laboratory tests. Control participants who did not receive a booster vaccination experienced no change in antibody levels.
One cautionary note of a mix and match approach is that a UK study called Com-COV, which analysed combinations of the same two vaccines, found that people in the mix-and-match groups experienced higher rates of common vaccine-related side effects, such as fever, than did people who received two doses of the same vaccine (click here) (34% vs only 10% if the two doses of vaccine were the same brand).
FAQ 4: What we know about vaccine induced thrombosis and thrombocytopenia (VITT) (click here) (click here)-any why the Astra Zeneca vaccine is still a safe and effective Many provinces including Ontario have put a hold on using the AstraZenca vaccine because of a rare complication called VITT (click here), which involves unusual clots in veins in the brain and elsewhere. In my opinion this decision is unjustified. However, I acknowledge this is a challenging public health policy. We do not yet know whether the province will approve the use of a 2nd dose of AstraZeneca in those who already received a first dose. I present a summary of the data below to help inform you.
- The risk of VITT in Canada as of May 8, 2021 is estimated to be approximately 1 per 55,000 doses (click here).
- There is tremendous and unexplained variation in the incidence of VITT between countries, ranging from 1 case per 26,500(Norway) to 1 case per 127,300
- No major safety warnings, other than rare anaphylaxis, were reported in the A-Z clinical trials with tens of thousands of adults.
- Cerebral venous thrombosis occurs (as seen in VITT) spontaneously in people who are not vaccinated! The incidence of cerebral thrombosis of the venous sinuses in the head is 0.22-1.57/100,000 unvaccinated people which is similar to the incidence of VITT post vaccine (1 case per 100,000 exposures). This raises question about the extentto which the AstraZeneca vaccine actually increases the incidence of cerebral venous sinus thrombosis above that seen normally in the general population
- The European Medicines Agency has identified 169 possible cases of cerebral venous sinus thrombosis and 53 possible cases of splanchnic vein thrombosis among 34 million recipients of the AstraZeneca vaccine
- Adverse reactions to the AstraZeneca vaccine (as tracked by Canada) are lower than with the other COVID-19 vaccines
- Immune thrombocytopenia and bleeding (without thrombosis-clots) have also been reported with Moderna and Pfizer vaccines. The European Medicines Agency has reported 35 possible cases of VITT among 54 million recipients of the Pfizer–BioNTech mRNA vaccine,and 5 possible cases of cerebral venous sinus thrombosis among 4 million recipients of the Moderna mRNA vaccine.
FAQ 5: Is VITT less common with the second dose of AstraZeneca vaccine? (short answer yes-1/million cases).
Yes it is! In the UK where lots of AstraZeneca has been used it is clear risks of VITT are low and are even lower for the second shot (click here)! More than 22 million first doses of the AstraZeneca vaccine have been administered with only 209 cases of VITT reported (~1/100,000 people).To date, about 4.4 million people in the U.K. have received a second dose of the vaccine with 4 a cases of rare clotting were reported following the second shot (1 in a million people).
FAQ 6: 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.
FAQ 7: 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 1st shot.
FAQ 8: If I have a solid organ transplant or I am a cancer patient should I have my secondvaccine 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 9: 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 10: (updated May 20th, 2021): Which COVID-19 Vaccines have been approved by Health Canada? Currently Canada has 4 approved vaccines: Pfizer, Moderna, and Astra-Zeneca and J&J (click here). Pfizer and Moderna are mRNA-based vaccines while AstraZeneca and J&J vaccines use a non-infectious adenoviral vector. All vaccines target the viral spike protein and none containing the SARS-COV-2 virus. The J&J vaccine is a single shot vaccine (all others require two shots). The bottom line: All approved vaccines are protective against severe adverse outcomes and I would still advise you to take the first vaccine you are offered!
FAQ 11: updated May 20th 2021: Does the vaccine work against new variants (mutations) in the SARS-CoV2 virus? Short answer is 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). Recent data shows levels of neutralizing antibodies are lower against mutant strains than the original SARS-CoV-2 virus BUT (and this is important) the levels of antibody produced appear to be sufficient to prevent (or at least markedly attenuate the severity) of COVID-19 (click here ) Thus, despite variant viruses the vaccines are lifesavers!
FAQ 12: 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.
FAQ 13: 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):
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.
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 14: 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 15: 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.
FAQ 16: 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 17: Are vaccines safe? Yes, serious adverse effects of vaccines are rare (occurring in only 1391 of 25.3 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 June 4th 2021). Note there are only ~5 serious adverse responses for every 100,000 vaccines administered in Canada.
FAQ 18: 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.
8) Continued Stability in COVID-19 in Ontario’s Long Term Care facilities (LTC)…1 death in the past week-evidence vaccines working: click here.
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 3,781 deaths in nursing homes account for ~46% of all deaths. There was 1 new death in LTCs due to COVID-19 in the past week. There are 21 active COVID-19 cases in LTC residents and 20 active cases in LTC staff, the lowest numbers this month. These numbers remain low and stable, which is testimony to the effectiveness of mass vaccination in a high risk population!
Stay Well! …. Get Vaccinated!!!