[00:00:00] Jordan Heath-Rawlings: If I told you that a couple of months ago, someone could ask you, “Hey, did you see what the NACI said about VITT?” and you would understand that question. That would probably be a clue that something was about to go wrong with Canada’s vaccine rollout. It is unfortunate that the National Advisory Committee on Immunization, that would be NACI’s, approach to the AstraZeneca shot and VITT, which is a rare adverse side effect of adenovirus vector vaccines, has caused so many Canadians to be scared of the AstraZeneca vaccine and has caused Ontario and Alberta to, in fact, stop offering that vaccine as a first shot. But NACI was just following the science, which is changing every day.
Unfortunately, hundreds of thousands of Canadians can’t change the decision they’d already made to get the AstraZeneca vaccine, a decision that was made for them at the [00:01:00] time by dozens of health professionals who insisted that the best shot was the first one you could get in your arm.
Is that still true? What’s changed in terms of absolute risks? How does the latest guidance on the AstraZeneca vaccine serve Canadians? What is missing from that guidance? And most importantly, what about the hundreds of thousands of Canadians who, like me, maybe like you or someone you know, already have one shot of AstraZeneca.
What’s next for them?
I’m Jordan Heath-Rawlings, this is The Big Story. Sabina Vohra-Miller is a clinical pharmacologist. And she is a co-founder of the Vohra-Miller Foundation. Hello Sabina.
Sabina Vohra-Miller: Hi Jordan, thanks for having me.
Jordan Heath-Rawlings: I’m sorry we have to keep having you back, but, uh, the messaging on vaccines is very confusing and people are scared. Including me.
Sabina Vohra-Miller: I totally get it. And it’s just been [00:02:00] a complete, um, revolving door with respect to what is happening with AstraZeneca. So I will try my best today to try and reassure people.
Jordan Heath-Rawlings: Okay, well, why don’t you just start first by explaining exactly what is happening with AstraZeneca in Canada, but also particularly I guess, in Ontario and Alberta.
Sabina Vohra-Miller: Okay. So, you know, I think that what we need to first remember, and I think that I remember discussing this on a previous podcast session, but you know, the issue is that policy always plays catch up with science. Typically science doesn’t move this fast, but because we’re in a middle of a global pandemic, science is evolving so incredibly fast and policy is basically just trying to play catch up.
Um, but you know, I think it should give us reassurance that these changing guidelines mean that we are actually adapting policies to match what science is telling us. So I think that, you know, just to start with, I think there should be reassuring, [00:03:00] even though it does come across as a lot of flip-flopping, it’s not, it’s just trying to catch up with science and the fact that we are being nimble is, you know, incredible.
Um, and the other thing that people have to understand is that when we take these public health decisions, um, these have to be done transparently and we have to build trust with the public. And we do this by allowing Canadians to be empowered to making these informed decisions. And that’s why, a lot of this, especially from NACI has been, you know, they’ve been exceptionally transparent. Um, but I will say that their communication hasn’t, hasn’t been, you know, it hasn’t really been done properly. And I think that has led to a lot of confusion. But I do appreciate that they are being transparent and trying to guide, um, Canadians with information.
So, what I would like to do maybe is first to take you through what is happening in Ontario and in Canada, and then try and [00:04:00] put all of this into context.
Jordan Heath-Rawlings: Please do.
Sabina Vohra-Miller: So, um, NACI came out with their, you know, uh, around 10 days ago or so, they came out and they said that they prefer mrNA vaccines. I personally don’t agree with the word ‘preferred’, I think that it ends up causing a tier system with vaccines. But what they were trying to explain is that given the fact that we are getting a lot of mRNA vaccines, and these mRNA vaccines are not associated with this very rare, but very serious side effect. Then, you know, if we have the choice, we should be using a vaccine that doesn’t come with these risks.
Um, and subsequent to that, um, in Ontario, we found that the risks of VITT have been approximately one in around 60,000 per the announcement that was made yesterday by Dr. Williams. Um, and across globally, we’re seeing that these risk estimates of VITT have changed [00:05:00] significantly. So in the early days we thought the risk was anywhere between one and 250,000 to one in a million. Now we have a better understanding and the risk estimates have been updated to one in 26,000 to one in 127,000.
Jordan Heath-Rawlings: How does that happen? How do they get updated? Um, I understand that there’ll be updated rapidly, but that’s a big jump.
Sabina Vohra-Miller: That is a huge jump. And the, and there’s actually two reasons for it.
First of all, these, um, side effects can take up to 28 days to manifest and, um, you know, be, uh, identified and so-
Jordan Heath-Rawlings: Right.
Sabina Vohra-Miller: You know, you, you always have that lag time with respect to, um, measuring some of these side effects.
The second thing here is that initially in the early days, we didn’t really know what these blood clots would look like, they’re very specific in the way they occur and, and how they clinically present. Once we knew what to look for, we were actually able to diagnose and identify, [00:06:00] um, much quicker. And also, uh, we were able to, you know, there were several that we went back and said, actually, now we know exactly what you’re going through. This is, uh, this is the condition called VITT. Um, and so we were able to actually qualify them as a side effect with the, um, vaccine.
All of this takes time, that’s the issue with it. Um, and you know, to be honest, um, it was only somewhere around mid March when the first VITT case actually came to be, so. This has actually transpired really quickly, and under two months we have so much more data, um, on what this is.
Jordan Heath-Rawlings: Okay. That’s a lot. And we’re going to unpack it. What does this mean for people like me who got their first dose of AstraZeneca and now have no idea what to expect?
Sabina Vohra-Miller: Such a great question. Okay. So let’s get back to the risks. I love talking about risk versus benefit, because I think I’ve mentioned in the past that there’s actually nothing in life that comes without risks.
The idea here is that we have [00:07:00] to quantify what the risks are, and talk about what the benefits are, and then try and make an informed decision as to whether the benefits outweigh the risks. So going back to the risks, the risk of VITT, which is this severe blood clot, um, we now know, occurs between one and 26,000 to one in 127,000, depending on the jurisdiction. So it’s still rare, but the risk estimates are higher now.
Um, and then on the flip side is the risk of COVID and this includes factors such as the COVID in the area you live in, your age, your exposure risk, i.e. are you an essential worker? Are you actually able to work from home? The long-term health impacts of COVID as well as what happens if you come home with COVID, how many other people would you, uh, you know, expose to COVID?
Um, and of course the, one of the critical parts over here is what is your alternate vaccine stock. So if you’re delaying a vaccine and you’re waiting for an alternate vaccine, how much longer do you have to wait? And [00:08:00] that’s important because a month ago, if you had to actually say, um, you know, that you were not, we were going to decline AstraZeneca and wait, your wait for an mRNA vaccine would be more than a month or even longer? Because only in the last month have our deliveries for mRNA vaccines increased. Right? And so if you’re delaying a vaccine you’re, every, every day that you delay a vaccine means a day that you’re actually going to be potentially be exposed to COVID.
And keeping in mind that in the last month in Ontario alone, 800 people, more than 800 people have died due to COVID. So that’s the context that we have to keep in the back of our mind. So if you look at this, um, you know, we can now see that even with the facts that, COVID in Ontario and Alberta is still exceptionally high, um, AstraZeneca still does make sense for those over 50+ in high COVID areas. If you look at the number of ICU admissions that are prevented [00:09:00] by AstraZeneca, the benefits are still there for those who are 50+ in hotspot areas.
However, we are in a position right now where we’re getting tons, more mRNA coming in. So, if we are getting all of this mRNA coming in, then why are we taking on this additional, extra risk of a side effect when we don’t need to? And that really is the basis of why Ontario and Alberta have essentially decided to put a pause on AstraZeneca.
Now on those have already received AstraZeneca, again, you know, going back to the fact that more than 800 people in Ontario have died due to COVID, and the fact that this number would have been so much higher had people not been getting vaccinated with AstraZeneca in the last month. So if you have been vaccinated with AstraZeneca, don’t panic, in fact, don’t even have remorse because you have protected yourself and you’ve also protected your close family [00:10:00] members, because of the fact that you’ve been vaccinated.
Um, and so that was absolutely the right decision to have made in the last, you know, four to six weeks while we been talking about VITT, and while this information has been evolving, it’s the right decision to have taken. It’s a very efficacious vaccine. It will protect you from severe outcomes of COVID and it will also protect your family members, um, through you being vaccinated.
Jordan Heath-Rawlings: But what does it mean for my second dose?
Sabina Vohra-Miller: Right. And so that is where things get tricky. So two things, first of all, if you have been vaccinated in the last 28 days with AstraZenica, I would urge everyone to just take a quick look at what the various symptoms look like for VITT, so that you’re well-prepared and, you know, being informed um, really helps with, um, knowing how to advocate for yourself as well. So keep an eye on what the symptoms are and if you do have any of these symptoms of the severe side effect, then get immediate attention first of all.
Um, second [00:11:00] of all, when it comes down to the second doses, um, so this is, you know, there’s two things to it. First of all, we’ve seen in the UK at least that second doses seem to have a slightly lower risk of VITT. So it’s approximately one in a million is what they’re seeing right now. That said only six million second doses have been given so far in the UK, because they’re also taking that three month delay strategy like we are. Um, and we’re likely not out of the 28 day period for all of these. So this is going to change a fair amount, which is why for now, Ontario is saying, let’s just hold off on even second doses for AstraZeneca until we have more information from UK.
At the same time, there’s also a study that is occurring right now in the UK called Com-CoV, and it’s actually looking at combining different types of vaccines. So they’re basically looking at AstraZeneca and Pfizer being given. Um, and this [00:12:00] study is actually going to read out in fact, within the next month or so. So we should have this data coming out very, very soon.
Frankly, I actually think that this, the combining these two vaccines, uh, platforms will actually probably also provide you with a higher immunity. We’ve seen with other vaccines that when you’re giving these combination type one. So they’re called heterologous prime boost. Um, we’ve seen that actually, that that can provide better immunity. So that’s what I’m really hopeful for. Obviously, you know, we need to wait to see what the data looks like, but if that data looks good, you know, there’s a very good possibility that we will be recommending an mRNA vaccine as a second dose for everyone who’s gotten AstraZeneca.
Jordan Heath-Rawlings: So I’m hopeful about that too, because I want a double dose of like superpower different vaccines. That would be great. But you know, as you mentioned right off the top, um, the science is evolving [00:13:00] rapidly. So what if we wait for that science and then the report is inconclusive or it says actually there was this other side effect if we mixed the vaccines, like where does that leave? I’m not saying that’ll happen, but like, to your point, we just don’t know. And where would that leave me and other people who got AstraZeneca? Would, would it be like, okay, well, roll the dice with your second dose then?
Sabina Vohra-Miller: You know, I, I totally get that. And I think that that has caused a lot of confusion and apprehension, um, amongst a lot of people.
I mean, I’ll be honest. My mother-in-law got AstraZeneca on the same day that my father-in-law got Pfizer and, you know, she has the exact same questions right now. And you know, one of her questions is, does, does it mean that she has to repeat her dosage? Um, personally, I’m very hopeful, um, to be honest, with the Com-CoV study, I actually have a very good feeling that that’s going to, the data is going to look really good. Um, I think we’ll have more information within the next few weeks.
I also do want to say [00:14:00] that there is, um, you know, we have actually done this, use a strategy of heterologous, uh, or complimentary prime boosts with other vaccines with really good results. And so if we extrapolate that, I have a really good feeling that this is going to work out well for AstraZeneca, those who have received the first dose of AstraZeneca, and going with mRNA for the next dose.
Jordan Heath-Rawlings: Here’s another question. Um, and we saw lots of questions from our listeners, for sure, but also just all over Twitter, right. It’s really confusing. So Ontario and Alberta have announced they’re going to pause the first doses of AstraZeneca or stop them completely. What about the other provinces? Like if you’re living in BC or Newfoundland right now, and you’ve got an appointment booked for this week for an AstraZeneca vaccine. Like what do you do?
Sabina Vohra-Miller: Yeah, so confusing. Um, you know, and I think that really, that is where we go back to what the [00:15:00] NACI’s guidelines are. So if you look at NACI’s guidelines, they basically say that, you know, if you are living in an area where you have low COVID, um, and you have the ability to wait for an mRNA vaccine, then their recommendation is essentially to wait for an mRNA vaccine.
Um, and again, this, you know, goes back to the risk/benefit because if you look at what the risks are, um, both waiting for a vaccine in an area with low COVID, um, and what the risks are of this blood clot. Um, if you do some of these analysis, you will see that, um, waiting for an mRNA likely is a better option in this situation.
Um, but of course, you know, this is, this really comes down at this point to a personal risk/benefit. A lot of people are, are, you know, willing to take these informed and calculated risks, again, because we are in the middle of a global pandemic. And, um, you know, while perhaps in, [00:16:00] in BC, you know, the risk of, um, COVID is lower, someone’s individual risk could be much higher based on the type of job they they’re working in and their personal exposure risk, or it could also mean that, you know, they live in a multigen housing with parents and grandparents. And so the risk of bringing COVID home is, um, a lot more severe.
Um, so I, I do think that this is where informed decision making plays a huge role and people should look at what their risks are of both waiting for an mRNA vaccine, versus what the risks are of these blood clots and make an informed decision for themselves.
Jordan Heath-Rawlings: Thank you so much for clearing that stuff up, or doing your best on an evolving situation. Um, while we have you here because you’re so good at explaining this stuff. Um, we’ve not really had any guidance right now on what it [00:17:00] is safe for people with one dose to do, um, before their second dose, after the two week period, uh, et cetera. I know there’s some guidance in the USA, but like we’ve got 40% of the population with one dose now, like. Folks want to do stuff. Um, what can they do?
Sabina Vohra-Miller: Yeah. And I, you know I think it’s such a miss with respective public health communications. Um, I think that this should have, these guidelines and these recommendations should have been put forward by public health a long time ago, given that a huge percentage of the Canadian population are in this limbo phase.
But the way it stands right now with one dose, we know that the one dose does have protection against COVID, but until you actually have both doses, you are not fully protected. Um, and so my personal recommendation in this situation would be to continue the way you have been before you were vaccinated.
Jordan Heath-Rawlings: Aw, man.
Sabina Vohra-Miller: I know, I’m sorry. But you know, have to also put that caveat in that a couple of [00:18:00] provinces have taken a very non-scientific, um, route of basically shutting down all outdoor activities. I personally don’t agree with it. The risk of COVID, um, outdoors is much, much lower. And if you, you know, try and continue with some of your social distancing measures, um, outdoors, the risk is really minimal.
And so I personally would recommend given that we’re now heading into summer, um, that people really should be taking maximum advantage of, uh, being outdoors. I think that once, um, you know, our cities are out of the lockdown, we should be encouraging, um, family, you know, small, intimate, outdoor gatherings with just family, the way we did last summer with little bubbles of 10 people.
Um, and I think we should really be encouraging that because, um, it’s just not tenable to expect people to be in a lockdown and also tell them that they [00:19:00] can’t, you know, do anything outdoors, either. We need to be supporting people. We need to tell them what is low risk and how to do these things safely. We just haven’t done a good job of it.
Um, anything indoors personally, I still think is, um, you know, a complete no until people have been fully inoculated with two doses. So that unfortunately does not change.
Jordan Heath-Rawlings: The last thing I want to ask you is just to get your honest opinion, because there was a ton of criticism in the early days about how slow vaccines were to arrive. Then there was criticism about, um, how the provincial governments were rolling them out. Um, and we’ve certainly talked about vaccine inequity. But it also really seems to me like the past few weeks have been pretty hopeful. Like we’ve really ramped up. I guess what I’d ask you is are we ahead of, behind where you thought or hoped we’d be at this moment, or are right on track? Like what’s your assessment?
Sabina Vohra-Miller: We have really picked up the pace over the last four weeks. We have done an incredible job of [00:20:00] getting people vaccinated and it’s been, you know, everyone’s sort of coming in and pooling resources, communities, volunteers, everyone has basically stepped up the game and get, and like, it’s like a serious hustle right now to get everyone vaccinated.
And I am just amazed, and you know, I, I also do think that, um, you know, we have to remember when in talking about inequities, we really need to now remember that we are so privileged and lucky to be in a position where we can pick and choose vaccines because majority of the world is not in this position.
And for instance, Covishield, which is AstraZeneca in India, um, could have been making a huge difference. And, and people, you know, there are millions of people who are dying daily in India right now. Um, and you know, I think people really need to understand that [00:21:00] we are so incredibly lucky and privileged living in Canada and the way that, uh, you know, our procurement has occurred, our vaccine stock has happened, the way that we’ve been pushing vaccines out, um, you know, the last couple of weeks, whereas the rest of the world is not necessarily as lucky as us.
Jordan Heath-Rawlings: That’s a really good thing to remember while I’m trying to be picky about my second dose. Sabina, thank you so much as always. I hope we don’t have to bother you again for a while, cause I hope they can get the messaging clear on this, but it’s good to know we can call you if we need to.
Sabina Vohra-Miller: Absolutely. And you know, I really do want to reassure people that if you have had the AstraZenica vaccine, it’s a great vaccine. You’re going to be protected. Hopefully we have more answers with the second dose, but please don’t panic. And please don’t have remorse because what you did was the right thing to have done.
Jordan Heath-Rawlings: Sabina Vohra-Miller, a clinical pharmacologist, co-founder of the Vohra-Miller Foundation. [00:22:00] That was The Big Story, for more from us, including other episodes with Sabina about other vaccine communications mix-ups, you can head to thebigstorypodcast.ca. You can find us on Twitter at @TheBigStoryFPN, you can usually find Sabina through that too, because we’re always tagging her. You can also talk to us anytime via email, you can ask questions like the ones I just put to Sabina. We talk to the experts, we want your input as to what we should ask them. Email us at thebigstorypodcast, that’s all one word, all lowercase, @rci.rogers.com [click here!]. Last thing before we go, you can subscribe or follow or like or whatever the podcast player wants you to do to The Big Story in any podcast app you choose.
Thanks for listening. I’m Jordan Heath-Rawlings, we’ll talk tomorrow.
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