Jordan Heath-Rawlings: Hello! Are you by any chance confused about Canada’s COVID-19 vaccination program? Do your parents qualify yet? Well, how old are they and where do they live? And are they over 80? Oh, wait! No, I’m being told it’s over 75 no, unless they are between 60 and 64, but not if they are between 65 and 75, because there could be health complications with the AstraZeneca vaccine. Oh, wait! I’m being told those health complications are not health complications after all. Forget it. Don’t worry about that. Get the AstraZeneca. Okay. You can book your vaccination in your provincial government’s online portal. Oh, that’s down? No worries. You can book through your local public health unit. Oh, they say that you have to call the pharmacies? Okay. Call the pharmacies. No, not those pharmacies. The other ones in the other neighborhood. Oh, they don’t have enough supply. Well, we’re getting 2 million doses at least this week alone. Oh, the province doesn’t want to ramp up until those doses are already in the freezers? Okay. Well, how long will that take? What if say the Americans give us a ton of extra shots? That’s great. Now who gets credit for that? Whatever, don’t care. Okay. You found a pharmacy. You got your parents their first shot. Amazing. And now they come back in a month for round two, right? Wait! Now it’s four months. Okay. Well, if they say that’s all right, it must be okay, I guess? All right, quit it. Look, you have questions. About the COVID-19 vaccine rollout. About the science behind the vaccines. About the new deliveries that are coming. And how much they will ramp up our schedule. And how and where to book these things. That’s understandable. It’s f***ing confusing. We’re here to help. I’m Jordan Heath-Rawlings. This is The Big Story. Sabina Vohra-Miller is a clinical pharmacologist. She spends a lot of time debunking vaccine misinformation, and she is the co-founder of the Vohra-Miller foundation. Hello, Sabina.
Sabina Vohra-Miller: Hi, thanks for having me here again.
Jordan Heath-Rawlings: Of course, I think we’re at the point where we probably need regular vaccine updates, just to clear up the confusion that I really quickly listed off in the intro. And maybe if I had to ask you, somebody who spends a ton of time talking to regular Canadians, how this vaccine rollout is being perceived on the ground, what would you say?
Sabina Vohra-Miller: I think most people are extremely frustrated. The rollout has been abysmal so far, in Ontario at least. And I think that even across the other provinces, I’ve heard similar concerns, similar you know, frustrations from people, from Canadians all over Canada. So I don’t think it’s going very well here.
Jordan Heath-Rawlings: What are the biggest complaints that you hear, maybe aside– because we’re going to get into the amount of time it’s taking and that kind of stuff– aside from the actual length of time? What are the complaints that you hear?
Sabina Vohra-Miller: Yeah. So I think first of all, it’s been you know, with respect to the online portal that Ontario was supposed to have set up a long time ago– I mean, keep in mind that we should have ramped up our vaccines in January, which means that our online portal should have been actually ready to go in January. And, you know, here we are, when we opened it up to 80+ in Ontario, we still didn’t have an online portal. And every, you know, public health unit had to sort of scramble to set their own portal. You know, hospitals were taking the charge and setting their own online systems in place as well. Whereas really, we should have been ready to go in January when we were initially expecting our vaccines to ramp up. Even such, you know, right now there’s basically in Ontario, two parallel extremes on how you can get the vaccination. Either it’s through a pharmacy with a specific vaccine, or it’s through the provincial rollout. And it’s very confusing because there are different criteria for each. And on top of that, you know, I think the vaccine sites that are being picked by the Ontario government have been inaccessible. You know, there’s lack of parking for a lot of different sites. I’m getting a lot of complaints from elderly citizens who are talking about how these sites are not accessible. And on top of that, we’re asking them to stand out, you know, in the line in the bitter cold. And these are, you know, keep in mind frail, elderly Canadians who are obviously mobility challenged for quite a few of them as well. And you’re asking them to wait in line for several hours to get their vaccines. And on top of that, it seems like, you know, we’re playing the catch up game. I mean, this past weekend, for instance, our vaccination numbers were abysmal. Meanwhile we have over 250,000 vaccine doses sitting in our freezers, and we know we’re only going to be getting more and more starting this week. So what exactly are we waiting for? It’s, you know, the role-out really has been very confusing. People are frustrated, they don’t know where to go, and they’re just waiting to get more clarity.
Jordan Heath-Rawlings: What about in terms of the big picture, you know, you described Ontario there, which is for sure the province that has had the most challenges thus far. But in terms of like, overall supply, percentage of all Canadians getting vaccinated, how quickly it’s ramping up on a national scale, you know, do we get too tied down to the daily numbers? Like we did 58,000 in Ontario yesterday, and today we only did 30,000. Are we roughly on track? Or are we falling behind as a country?
Sabina Vohra-Miller: Yeah. So, I mean, I think I would let the data and the numbers speak for themselves here, but you know, Canada tracks 90th in the world on vaccination. So we’re really far behind. And if you look at our Canadian overall numbers, only 6% have received one dose. And, you know, I think it was 1.5% that I’ve received both doses so far, you know? And so I think that in terms of the numbers that we’re supposed to be– forget absolute numbers, but just looking at the percentages of Canadians that, you know, should be vaccinated by Q1. We are far behind what we had originally hoped to vaccinate. And I think that, you know, we obviously had challenges with respect to our vaccine supply. But at the same time, we have been getting more vaccines the last few weeks, and our ramp up has not matched our dosages that we have right now.
Jordan Heath-Rawlings: I want to ask you about just the confusion around who’s eligible for which vaccines, where. You know, you mentioned a minute ago that it was 80 plus in Ontario, before the portal opened. At the same time it was 75 plus in Montreal. Now Ontario is on 75. Plus Montreal is now down to 70 plus. I know NBC they’re down to 70 plus. And I guess my question is like, I understand it will vary as doses become available in different places, but how are people supposed to understand the way these vaccines are allocated? And does it breed anger and resentment? Because that’s what I’ve seen online.
Sabina Vohra-Miller: Yeah, that’s such a great question. I think different provinces have taken different stances on their rollout. For instance, you know, you mentioned Quebec, but in Quebec, for instance, they made a very early decision to delay the second dose. And that’s really the reason why they’re able to ramp up their vaccinations and bring down their age limits, much sooner than Ontario has. And the other thing that Quebec has done really well, they’ve prioritized hotspot areas. Whereas we’ve seen that that’s not happening in Ontario for instance. You know, we talked a lot about how to make the vaccine rollout equitable. And then the Ontario plan comes forward and does not include any of the suggestions that were put into place. Like for instance you know, even with the pharmacy rollout that is currently occurring in Ontario, it’s only happening in three areas. So it’s Toronto, not even the hotspot areas in Toronto, we see like a complete vaccine desert in terms of pharmacies in the areas of Toronto that are hardest hit, like Northwest Toronto. And then the other areas that have this pharmacy pilot include Windsor and the KFLA area. Whereas some of the more harder hit areas of Toronto, for instance, Northwest Toronto, Scarborough, Peel, all of Peel, you know, we don’t have that pharmacy rollout occurring over here. So I think some provinces have done a much better job of ensuring the vaccine rollout is a lot more equitable. We haven’t really done that here in Ontario. But again, like having this double stream mechanism with separate criteria is confusing. You know, a lot of people are confused about when is their turn? What process do they use? What stream do they use to get their vaccination? You know, I can tell you that my husband booked my father-in-law’s appointment this morning when they opened up 75 plus. And my husband was confused, and he’s a tech geek, you know, very capable person. And he was confused about which option to pick. And you know, we just haven’t done a great job of trying to explain what the process is. And I think it’s getting more confusing when different provinces have taken a slightly different approach to it. Because again, there’s the equity in terms of vaccine distribution comes into play.
Jordan Heath-Rawlings: Well, I’m not going to ask you to try to explain how various provincial governments see this thing. But one of the reasons that we asked you back is to explain some of the science behind a couple of decisions that I’ve heard are really confusing some people who are eligible. So maybe since you already mentioned it, start with the concept of delaying that second dose, because I can remember from the very moment the vaccines were approved, that it was supposed to be kind of a strict two-shot regimen. And then it seemed like the vaccine supply was slow to come, so we just dragged that out, and I want to know what’s behind that decision and if it’s safe.
Sabina Vohra-Miller: Yeah, such a great question. And it really is a complex topic, but very important to discuss for transparency. You know, I think that what we need to understand is that the only absolute in science is that there are no absolutes, right? And so throughout the pandemic evidence has evolved and recommendations have changed based on new data. For the public, this may come across as scientists flip-flopping, but in reality, it’s definitely that data is changing and we’re trying to make the best decisions possible with the situation that we currently have at hand. And I think what ends up happening is that the science moves faster than policy. And so policy is always trying to play catch up. But you know, when you look at data, first of all, it’s important to take into account the totality of evidence. Right? And so here we’re talking about not just data that we have from clinical trials, but it also means looking at data that is occurring in real world. And so we have had a rollout of, you know, over 157 million doses across the world globally. And we’re getting a lot of data becoming available as these vaccines are being rolled out across the world. And we also have things such as you know, physical parameters, like what our vaccine stock is like. And then also epidemiological data on like current rates of transmission, what the variants of concern look like, you know, what proportion of our current cases have to do with variants. It’s become basically a race against variants at this point in Canada. And secondly, when we’re making, you know, guidelines such as this, an important principle to remember is that we have to take a harm reduction lens. Right? And so in this situation, given that variants are increasing at an alarming rate, and we have limited vaccine stock so far. So what is the best course of action to prevent more sickness and more deaths? Keeping our hospital capacity and check if we know that ICUs are completely full, we’re building field hospitals in parking lots again. And so how do we do this while also protecting the most vulnerable and marginalized people, right? The other thing to remember is that even in clinical trials, you know, we have some data that goes up to two months, and in fact, some data from AstraZeneca that goes past three months. And if you actually just look at how antibodies work, they don’t simply go from a hundred to zero, right? Instead they have a stepwise decline. So I think that if we extrapolate there is reason to believe that there is still some degree of protection that exists three to four months out after the first dose. So I think that the bottom line here is that in an ideal situation, if we had tons of vaccine stock, if the variants weren’t taking over, we would follow the vaccines’ label based on what the trial data says, what the indication says for the vaccine. But considering, you know, the totality of the evidence that we have right now, the situation we are in right now, using the principles of harm reduction, there is a basis to these recommendations of extending the second dose to four months. I do think that over time we will have better data and I also think that perhaps once our vaccine stock ramps up, these recommendations might not be necessary and everyone is able to get a second dose on schedule. What this does allow us to do in the time being is, you know, is offer close to all Canadians a chance at a first dose and at some protection. Now with the one caveat, I do want to mention that new data is coming up with respect to delaying second doses in those who are immunocompromised, specifically patients who are transplant patients or patients who have specific types of blood cancers. We’re seeing that the one dose is not sufficient to keep them protected. So I do think we need to take a more nuanced look at this. And I think that those who are extremely vulnerable and those who are elderly should be getting their doses, you know, not necessarily at a four month delay, perhaps somewhere in between where we have some data to get them fully protected. And I think the rest of us will do fine with one dose until we have a better stock.
Jordan Heath-Rawlings: Let me ask you about AstraZeneca in particular, because this weekend, my parents, who are older than 65, but not yet 75 to qualify for a vaccine through the province, were offered the AstraZeneca vaccine at a local pharmacy. I told them to watch out for it and ask and see if they could get it. And they said no, because they had heard these guidelines that said that could cause health complications in people over 65, they have a couple of underlying health conditions that made them worried. And, you know, I was mad at them because I told them to take whatever shot they could. But this is an example of what you’re talking about. Right? Like these are smart, liberal people. They’re not vaccine hesitant. They’ve just heard information that has since become outdated, and they’re not always online paying attention to like what the new research is every day. And there’s gotta be tens of thousands, if not hundreds of thousands of Canadians in that boat.
Sabina Vohra-Miller: Yeah. I completely agree with you. I think we have not done a good job of trying to keep people up to date with information, especially since it’s changing so fast. And I think this is really an example of where top-down, one size fits all communication strategy simply doesn’t work. You know, and I think we haven’t done a good job of explaining why the 65 plus recommendation occurred, right? If there was no additional safety concerns in the 65 plus age group, that was something we did not do a good job of clarifying. You know, the question at that point was with respect to whether it was efficacious, like whether it was as efficacious in the 65 plus age group. And this is because of the clinical trials, they didn’t have a lot of COVID events that occurred. So COVID infection events that occurred in the clinical trials. And so it’s all event-based with these trials. And if you don’t have anyone getting organic infections in the trial, you can’t actually assess efficacy, right? And we just didn’t do a good job of explaining this. And then the other thing we haven’t done a great job of explaining is that the efficacy end points of all of these vaccines are not the same, right? And so you can’t really look at the 95% of Pfizer and then compare that against the AstraZeneca efficacy, because each trial had their own efficacy end points, they’re not head to head trials. And I think a lot of people have spent a lot of time trying to, you know, match up these numbers where I think the bottom line here is that every single vaccine that we have right now has prevented severe illness to a really, really, really good rate. And in fact, close to a hundred percent for preventing things like hospitalization and preventing deaths, right? And that really is the key thing that we need to be telling people. Like when it comes to AstraZeneca, you know, I think my favourite analogy to use is, if you’re out in the cold and you’re naked, and if someone comes and offers you a really nice warm jacket, would you turn it down and say, sorry, I’m only going to take a Canada Goose parka? You know, like I think that we need to understand that the AstraZeneca vaccine is extremely efficacious in preventing some of these really terrible outcomes with COVID. And if you have the chance to get the vaccine, please, please, absolutely do get it when you’re offered the vaccine, I think that that has to be the bottom line across the board.
Jordan Heath-Rawlings: I want to play devil’s advocate there with you for a second. Let’s say in that hypothetical situation, you could turn down the jacket because you knew that the Canada Goose parka was coming like 30 minutes later. Which is the situation I think a lot of people who are 70 and 65 and up are in right now. They’re seeing the age ranges go down for qualifying for Moderna or Pfizer, and they’re saying no.
Sabina Vohra-Miller: Yeah, but I also want to then counter that and say, doesn’t take very long for hypothermia to set in.
Jordan Heath-Rawlings: Yeah, that’s true.
Sabina Vohra-Miller: And like, you know, when it comes to, like, I’m just looking at my perspective. I have, you know, my father and my in-laws, who are in the age group that are, you know, trying to get vaccinated. And my father-in-law was able to get his for 75 plus, but I’m trying to get my mother-in-law the AstraZeneca vaccine because she’s younger. And I think that, well, you know, at the end of the day, you know, it’s my mother-in-law who goes to the market to buy groceries. My mother-in-law goes to the pharmacy to get her meds. All of these points of exposure and contact that people have. And especially with the variants, we know that they are a lot more transmissible. We’re also getting data that they are a lot more lethal. And so if I can actually get my mother-in-law protected today, why wouldn’t I take that protection? I would absolutely take that protection. And I think that’s what I’ve been trying to explain to all the older adults in our family and in our you know, in our friend circle as well, that if you have the vaccine today, get whichever one you’re getting offered. Because protection today is so much more better than maybe protection two weeks or three weeks of something down the road.
Jordan Heath-Rawlings: Can you just explain a little bit more, because this is a specific concern that some people have, about what we know about blood clots and the AstraZeneca vaccine? Cause that was the worry my parents had.
Sabina Vohra-Miller: Yeah. And I think that the one thing we need to understand is that, you know, when we do things like post-market surveillance is so important to observe for any extremely, very adverse effects, right? These are things that we don’t necessarily see in trials, even though actually the clinical trials had 30,000, 40,000 participants in it. When we’re talking about an event that occurs that is exceptionally rare, we’re looking at one in a million or one in, you know, several hundred thousands. These are not things that actually we would see in a clinical trial. If you do see it in a clinical trial, it might be one event. And that ends up being more like noise, right? But when we actually are giving these vaccines to millions and millions of people, that’s when we actually see some of these potentially extremely rare effects coming up. And so the European Medicines Agency, EMA, basically found no evidence of any link of you know, blood clots or abnormal bleeding with the AstraZeneca vaccine. But they did look into this very rare form of blood cot called cerebral venous sinus thrombosis, it’s called CBST. And that’s basically, you know, a blood clot that occurs in the brain in addition to having these really low platelet counts. And what they did see is that there was a slightly higher number of these specific rare blood clots that occurred after the AstraZeneca vaccine. But we don’t necessarily know whether it’s actually caused by the vaccine yet. It may be. But in total there were only 18 cases of these that occurred in 20 million doses, right? And so I think that what we have to really remember is that it’s an extremely small absolute risk possibly associated with the vaccine, specifically in women ages 20 to 50. But the thing that we have to get keep in mind here is that COVID-19 infections are associated with a much marked increased risk of developing blood clots, right? And so when we’re looking at risk-benefit analyses over here, the bottom line here is that the AstraZeneca vaccine benefits far outweigh any possible very small absolute risk of these serious adverse effects, right? At the end of the day, AstraZeneca is still very safe, very effective in preventing severe COVID illnesses. And we have to really take into account the fact that COVID-19 infections themselves have a much higher risk of actually causing blood clots.
Jordan Heath-Rawlings: The last thing I want to tackle with you, while we have you, is what’s going to happen the next few weeks? Because I feel like we’ve been hearing a lot of, and in Ontario for sure, but also in other provinces, a lot of talk about like, well, we don’t want to ramp up until all the supplies are there because we don’t want to have to the ramp down again. And if I’m reading this right, that I’m looking at here, we’re going to get 2 million or more doses as a country this week with another 2 million plus the next week, and more vaccines are coming from the States, apparently. So, you know, is this next two weeks, the kind of push comes to shove in terms of how high we can push the actual process?
Sabina Vohra-Miller: Yeah. So I think with this, you know, yes, I know that we are going to be ramping up our vaccines. We’re going to be getting millions of doses every week, starting this week onwards. So, absolutely, yes. But you know, the whole premise of waiting until we have stock to ramp up, in my opinion, is not the right decision. We have 250k doses sitting in our freezers here in Ontario right now. We know we’re going to be getting more vaccines this week and next week, and the following week. That means 250,000 Ontarians could have been vaccinated this past week, and weren’t. Imagine what impact that would have had if you know, 250,000 Ontarians had at the 60 to 70% protection against severe illness, right? We would be in a completely different situation. In my opinion, we should have already revved up. I think that we’re playing the catch-up game again. And that’s going to basically cost us in terms of lives.
Jordan Heath-Rawlings: One more question, just because I am curious now, what kinds of numbers, or at least what kind of you know, doubling or tripling will you be looking for over these next couple of weeks that’ll indicate if we’re able to ramp up high enough to reach our targets?
Sabina Vohra-Miller: At this point, looking at how variants are playing out, we know that they are a lot more transmissible, which means RT is going to go up right. When RT goes up, it means that you need a lot more of the population to be vaccinated to get to herd immunity. So, I mean, we’re looking at minimum having 80% of the population vaccinated. And that’s going to be a hard task, because at this point, kids are not vaccinated, right? So that means that basically every single adult who’s being offered the vaccine needs to accept it. So we’re going to need to see very, very high numbers of acceptance of the vaccine to get to where we need to be. Especially given the variants are around the corner and we don’t necessarily have– with things opening up in a lot of provinces, I think that it’s going to be a really, really hard race to catch up.
Jordan Heath-Rawlings: Something tells me that we’ll be talking again in a few weeks, though I hope everything goes smoothly and maybe we don’t. Either way, thank you so much, Sabina for explaining this to us.
Sabina Vohra-Miller: Oh, it’s my pleasure.
Jordan Heath-Rawlings: Sabina Vohra-Miller, a clinical pharmacologist, who has been so helpful explaining this stuff. That was The Big Story, for more from us head to thebigstorypodcast.ca. You can also find us on Twitter at @thebigstoryFPN. You can ask us vaccine questions and we can just pass them on because I don’t know the answer. You can also talk to us via email at firstname.lastname@example.org. And as always, we are in your favourite podcast player, in Apple and Google and Stitcher and Spotify. And I am not kidding when I say this, we appreciate every review we get. So if you are so inclined head on over and let us know what you think. Thanks for listening. I’m Jordan Heath-Rawlings, we’ll talk tomorrow.
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