Canadian doctors debate booster shots

To hear Ottawa physician Dr. Mary Fernando tell it, time—not categories of people—matters most when it comes to determining the need for a third dose of COVID-19 vaccine. “I’m very concerned about national eligibility guidance on this issue, which is being filtered by the provinces to their liking,” said Dr. Fernando, a non-practising doctor and budding crime writer who shares her opinions on medical and political issues with more than 10,000 followers on Twitter. “You can change recommendations but not science— and the data clearly shows that the efficacy of vaccines eventually wanes for everyone.” Initially, Dr. Fernando said it was believed that only two doses of the COVID-19 vaccine would suffice—a supposition that has not held true over time. “That’s not unusual,” she added. “As evidence emerges, things change. Many vaccines have three doses. The bottom line is that the number of shots doesn’t matter —we need to get this infectious disease under control.” As provinces continue to mull over and/or act on the latest recommendations from the National Advisory Committee on Immunization on who needs booster shots of the COVID-19 vaccine, doctors too are weighing in to what is now a hot-button issue in most developed countries with high rates of double-dose vaccinations. A recent online opinion poll by the Medical Post found that half of doctors (49%) supported the notion that all Canadians should get a booster shot. Nearly a third (30%) said seniors living in congregant setting and the immune-compromised should get a third shot—a recommendation that was included in the updated guidance that NACI issued on Oct. 29. Thirteen percent of respondents said doctors should have a say as to which of their patients gets a booster, while 9% agreed with the suggestion that it is “morally wrong for us to be giving Canadian residents a third shot when so many other countries have so much progress to make on initial vaccine doses.” “Why only seniors living in congregant settings?” asked one of the 168 physicians from across Canada who took part in our non-scientific survey. “Many young/middle-aged mental health clients living in this type of group-home setting may also benefit.” Family doctors, the physician added, are “best for identifying more ‘at risk’ patients who would benefit from a third dose. Our government has (also) chosen to allow more flights in from countries that are behind in their vaccine rollout so yes, we should also be considering helping others to get this under control. Manage the resource and allocate accordingly.” Read: Dr. Mary Fernando: The new NACI guidance on third doses is both excellent and lacking Another physician suggested Canada look to countries that were in the forefront of the vaccine rollout to consider vaccine efficacy in terms of protection against mild diseases over time. “We know this is a seasonal virus and that cases will rise (with some decoupling of cases/hospitalizations),” the doctor wrote. “The U.K. is now pushing heavily boosters for those over 50 and many are pushing for further shut downs. “A large proportion of vulnerable Canadians had their vaccine over six months ago and therefore I’d argue they should get a booster if they hadn’t had COVID.” The doctor also expressed surprise at how few of his colleagues believe the decision should be left to physicians, and that previous infection with COVID is not accounted for. “For example, the protection from severe disease to a young healthy 18-year-old male who had COVID (and) got two vaccines may not be greater than 1/5,000 which is the current estimate for myocarditis in this population after a second mRNA vaccine and may be (we don’t know) higher after a booster,” he wrote. “These discussions are best left to a primary care/pediatrician and the patient.” Hospital capacity, he added, has not been increased this winter in Canada, which ranks dead-last among OECD counties in terms of hospital beds. “Brampton still has one of the worst hospital beds per capita in the developed world,” he wrote. “We are worse positioned than 2019 in terms of hospital beds: few new beds created, still near 10-20% ALC levels, backlog of cancer migration/elective surgeries, lack of healthcare obtained by patients during pandemic, increased mental health admissions (especially in teens), decreased staffing due to burn out/retirement, small but significant effect of vaccine mandate on staffing, overrun EDs due to primary care not seeing symptomatic kids, etc.” “Solid point,” added another poll respondent. “The fact we always run at 90% to 95% capacity seems to be overlooked. Canada needs more healthcare workers and infrastructure. Instead we argue which political party controlled the pandemic better.” For her part, Dr. Allison McGeer, a medical microbiologist and infectious disease specialist at Toronto’s Mount Sinai Hospital since 1989 and a member of the NACI, understands the concerns and frustration that doctors—like many Canadians—might feel in regards to the booster shot debate. “Data and immunization programs are complicated—but you need recommendations that are simple and can be communicated and acted upon,” said Dr. McGeer, who notably worked with the late Dr. Donald Low, who garnered national fame during the SARS epidemic. The challenge with COVID-19, she added, is that there are several different vaccines available with different dosing schedules and still-evolving data regarding decline and protection. “In some cohorts protection seems to be declining over time,” said Dr. McGeer. “But some issues are contextual, like rates of infection and age groups. That all plays in to how we use boosters. “We also want to make sure the timing is right so that we have long-lasting effect and not use more doses than we need,” she added. “We’re in a period of significant flux to determine the benefits of vaccination for different groups of people.” Adding to the mix is the incertitude in much of the data, the wide range of opinions, and if, how, when and where vaccinations can be ramped up if the need for a third dose is declared nationwide. “A pandemic is unprecedented in our lifetime,” said Dr. McGeer. “We’re trying to get data to decision makers as quickly as possible. This is life and death stuff.” “In my view there is enough evidence now of waning immunity in older adults,” she added. “So the NACI recommendation for an age-related booster approach is exactly correct. After that it gets a little murkier—at least for now.”

Canadian doctors debate booster shots

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