Should Canada divert vaccines from regions with low COVID-19 levels to hot spots?

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In a week bookended with significant COVID-19 vaccine delays while cases of coronavirus variants continue to climb in Canada, experts are divided on whether vaccines should be diverted from parts of the country with fewer cases to those with hot spots.

Hard-hit provinces 'suffering,' some say, while others don't want regions with low case numbers 'punished'

There's debate among health experts over whether redirecting doses between provinces is a better approach to tackle the higher rates of hospitalizations and deaths faced by hard-hit regions.(Stephane Mahe/Reuters)

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In a week bookended with significant COVID-19 vaccine delays while confirmed cases of coronavirus variants continue to climb in Canada, experts are divided on whether vaccines should be diverted from parts of the country with fewer cases to those with hot spots.

On one hand, Canada's three hardest-hit provinces have collectively received more than 10 times the Atlantic provinces, which have had much lower COVID-19 levels.

But at a per-capita level, the situation looks much different.

Ontario, Alberta and Quebec have each received between 2,200 and 2,800 doses per 100,000 people, while Prince Edward Island has over 4,700, Nunavut close to 13,300, Yukon more than 14,000 and the Northwest Territories in excess of 21,000 doses.

"I know cities in Canada that have more patients hospitalized than there are patients in the Atlantic with COVID-19 total," said Dr. Zain Chagla, an infectious disease specialist and associate professor at McMaster University in Hamilton, Ont.

"They have functional health care, they're separate from the rest of Canada. That's fine, it's working for you, but let us take the doses — give it to the rest of Canada that's suffering."

But others say the vaccine should be distributed equitably across the country because outbreaks can flare up quickly.

Alyson Kelvin, an assistant professor at Dalhousie University in Halifax and a virologist at the Canadian Center for Vaccinology who is evaluating vaccines with the VIDO-InterVac lab in Saskatoon, said Atlantic provinces that have faced serious lockdowns shouldn't be forced to wait.

"It's almost like you're continuing to punish certain groups that have been following the rules," she said.

The federal government, meanwhile, isn't ruling out shifting who receives how much of future shipments, but it's a thorny issue both logistically and ethically in a country with vast disparities and limited vaccine supply.



'Redistribution' required

Chagla said while an equitable approach to vaccine distribution in Canada is admirable, it doesn't make sense on the ground in places with disproportionate spikes in cases like Toronto and nearby Peel and York Regions.

He's among the health experts suggesting that regions with larger populations and more widespread COVID-19 levels be prioritized in Canada's vaccine roll-out, due to the higher rates of hospitalizations and death they face.

"Especially if you're having issues with vaccine shortages, we should probably do a bit of redistribution to these higher geographical spots as well," said Dr. Sumon Chakrabarti, an infectious disease physician with Trillium Health Partners in Mississauga, Ont.

Chakrabarti says that in areas of the country where community transmission is high, long-term care facilities will bear the brunt of harm because residents are most at risk of severe outcomes and death from COVID-19 as the virus spreads.

"That's where we should be focusing our vaccinations. And right now in Atlantic Canada, with due credit to them, they don't have very much community transmission," he said.

"So I think that the best thing to do right now would be to shift that over to hot spots."

'I know cities in Canada that have more patients hospitalized than there are patients in the Atlantic with COVID-19 total,' said Dr. Zain Chagla, an infectious disease specialist and associate professor at McMaster University in Hamilton, Ont.(Craig Chivers/CBC)

Vaccines 'not the tool' to contain outbreaks

Dr. Lisa Barrett, an infectious diseases physician and immunologist at Dalhousie University in Halifax, said that from a scientific perspective, vaccines are meant to work on a wider population level and shouldn't be used to try to contain flare ups.

"This is not the tool that was ever meant to be a primary firefighting mechanism for hot spots," said Barrett, "It was meant to be the long-term forest management that keeps things in good shape, when they're in reasonable shape already."

"But having said that, is it a wrong thing to get long-term care vaccinated in hot spots where there is currently no vaccine? No, that's a good idea; those people are likely to die."

Kelvin says vaccines should be equally distributed throughout Canada, because even if an area has low levels of COVID-19 transmission for the time being, it doesn't make a population any less vulnerable.

Canadian virologist Alyson Kelvin maintains that Atlantic provinces shouldn't be forced to wait on vaccines.(Liam Richards/The Canadian Press)

"Northern communities had nothing for a really long time, but they were absolutely vulnerable to drastic and damaging consequences if the virus got in," she said.

"So to use that as a reason to not vaccinate those populations could lead to some serious consequences."

Dr. Anna Banerji, an infectious diseases specialist and Indigenous health expert at the University of Toronto, said remote Indigenous communities in particular need to remain prioritized for vaccines, due to the poor quality of healthcare they already receive.

"The average person in Canada, if they get sick, if they've been exposed, they can go to see a doctor or go to a hospital," she said.

"But when you're in these remote communities, you need to fly down into hospitals that are usually further south or far away. So that means that if you're sick, then you have to wait."

Feds not diverting doses

For its part, the federal government is staying the course on its vaccine distribution plan, with no plans to redirect doses from provinces and territories with low levels of community transmission — but that could change.

"We have not considered shifting doses from one province or one jurisdiction to another at this time. I think it would be counterproductive to do that in the midst of our immunization plan," said Maj.-Gen. Dany Fortin, the military commander leading Canada's COVID-19 vaccine logistics, during a press conference Thursday.

"What we could anticipate being prepared to do is adjust based on per-capita distribution at the locations that require the most future shipments long enough out for provinces to plan accordingly."

It would be 'counterproductive' to shift doses between regions in the midst of Canada's immunization plan, said Maj.-Gen. Dany Fortin, the military commander leading Canada's COVID-19 vaccine logistics.(Justin Tang/The Canadian Press)

Canada's Deputy Chief Public Health Officer Dr. Howard Njoo said the emergence of more contagious variants has led to active discussions with health officials across the country, but he ultimately feels the provinces are better positioned to redistribute vaccines within their jurisdictions.

"They're the people who have the data and know what's going on in terms of the situation on the ground with respect to specific outbreaks and what variants might be emerging," he said. "They can make the adjustments I think much more easily."

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Concerns over rural, urban divide

Other physicians agree the focus shouldn't be on redistribution across the country, but rather where supplies are most needed within each region.

"It does feel like it's a bit of a distraction to argue about which province should have more," said Dr. Nili Kaplan-Myrth, a family physician in Ottawa. "That's not the point."

Within Ontario, for instance, there's a stark divide between which regions were sent vaccines, she said, with healthcare workers in rural areas still waiting to be vaccinated while hospital staff in larger cities are often receiving shots sooner.

"If you work in a hospital that already has the vaccine, and your name comes up, or they had extra doses, it was like this kind of quick free-for-all — 'come down and get the vaccine' — because we don't want to throw out any doses," she said.

"That only works for people who are already there, and so it doesn't work when you're hundreds of kilometres away."

A Canadian North flight lands on the tarmac in Iqaluit at the end of December, carrying Nunavut's first doses of the Moderna COVID-19 vaccine.(Jackie McKay/CBC)

That's also a concern for the Society of Rural Physicians of Canada (SRPC), which issued a statement in late January calling on all Canadian vaccine task forces to consider the potential disparity that could arise if the needs of rural communities aren't met.

Both long-term care and retirement homes in many rural and remote areas haven't been vaccinated at the same rate as settings in urban areas, despite experiencing outbreaks at various facilities, the organization stressed.

In Ontario, for instance, COVID-19 immunization clinics had been held at all 87 long-term care homes in Toronto by mid-January, while vaccinations for all of Lambton County near the Ontario-Michigan border only started on January 26 — even as that rural region continues to face deadly outbreaks at multiple long-term care homes.

"If one or two people get sick, or need to be isolated or quarantined, that can have major detrimental effects on the entire health system in a rural area," said SPRC president Dr. Gabe Woollam, a physician working in Happy Valley-Goose Bay, N.L.

"That's one of the reasons why we see it as very important to ensure equitable access to vaccines."



Determining best approach ethically 'tricky'

Given the competing priorities and perspectives on how to vaccinate Canadians effectively — all while the country faces a vaccine supply crunch — there's no perfect approach for policymakers trying to wade through the debate.

"I look at the communities that could be devastated if they had the virus spread through them," said Kelvin.

"If we went to a model of only vaccinating places where the virus was, then I think we would be in some serious trouble in some places."

University of Toronto associate professor Alison Thompson, a researcher on the ethical issues arising from public health policies, stressed there's no easy road here: staying the course won't please everyone, while redistributing doses between regions would be logistically challenging.

"What we're ultimately saying is that some people are more vulnerable than others," she said.

"It's tricky ethically."


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