Canadians will get their say on who they think should get any COVID-19 vaccine first, thanks to a research team led by the University of Alberta’s Shannon MacDonald, assistant professor in the Faculty of Nursing.
Canada’s National Advisory Committee on Immunization (NACI) unveiled its list of priority recipients today. Priority groups include health-care workers, people in long-term care, teachers, transit workers and those with chronic conditions.
MacDonald’s team will issue a national survey to find out what Canadians think about the list, part of a COVID-19 rapid response research project funded by the Canadian Institutes of Health Research.
“Our survey will ask people in the prioritized groups whether they even want to get the vaccine first,” said MacDonald. “If you plan to give it to X group first, but X group has no intention of getting it, then your plan is not going to unfold how you anticipate.“
MacDonald expects a viable vaccine to be available by next summer, but she pointed out that supply will be limited and it will take months before public health protective measures will be eased and life can return to “normal.”
According to MacDonald, deciding who gets vaccine access first is just one of the tasks facing the Canadian health-care system as it prepares to carry out the largest immunization campaign in our history.
Finding something that works
There are 45 vaccine candidates in some stage of clinical evaluation around the world, and hundreds more in development. They all hope to be one of the first to show they can prevent infection by the deadly virus, which has killed 1.2 million people and infected more than 47 million globally to date.
MacDonald pointed out there can be a big difference between efficacy in the controlled environment of a clinical trial and real-world effectiveness.
“When you are developing and testing a vaccine, you must measure efficacy in healthy patients who are all within a certain age range in order to get a licence,” she said. “That shows how well the vaccine works in a perfect scenario.”
“However, many factors can impact real-world effectiveness,” she said. “For example, if it ends up being a two-dose vaccine and you get only one, or you get them too close together or too far apart.”
MacDonald also noted the unfortunate irony that those who are older or have compromised immune systems, and are thus most vulnerable to severe COVID-19 disease, are also most likely to have a poorer response to a vaccine.
MacDonald said national governments will have to make the judgment call about whether a vaccine is effective enough.
“In part it will depend on your expected uptake,” MacDonald said. “If you think you’re only going to be able to vaccinate half the people, then you really need the vaccine to work well in order to achieve a population-level benefit.”
Guaranteeing supply
The Canadian government has committed a billion dollars to purchasing deals with a handful of international pharmaceutical companies that seem to be at the front of the pack in the race to produce a safe and effective vaccine. It has also sent $440 million to the international COVAX initiative, which is meant to ensure that no matter which country gets the breakthrough first, the resulting vaccine gets shared equitably around the world.
“If we haven't picked the winner and somebody else has picked the winner and they’re part of the COVAX initiative, we’ll get a portion of their supply,” explained MacDonald. “But how much of that depends really on how much the manufacturer has been able to produce, and then how much is our allotment, because everybody else in the COVAX initiative will get a portion as well.”
Setting national priorities
The World Health Organization has issued guidance on the factors countries should consider when they decide on their priority groups for vaccination, but MacDonald pointed out that it’s not simply a question of who is the most vulnerable to serious infection. For example, if the vaccine that comes out first proves to be ineffective for the top priority group, say seniors, then we may have to give it to the third priority group first.
“We may pivot and instead protect everybody who makes contact with the elderly, such as long-term care workers and household contacts,” she said.
No matter what happens, it will be important for public health officials to be up front about how they are making decisions.
“In 2013, during H1N1, the Calgary Flames got vaccinated before some health-care workers, so now people’s antennae are on high alert,” she said. “This vaccine must be distributed in a fair and equitable way.”
That will mean an extensive effort to ensure people with less access to health care—whether in a remote community or an inner city—will also be offered the shot if they are eligible to receive it, MacDonald said.
Monitoring real-world safety
Before we start giving anyone a shot in the arm, MacDonald said it’s key to have a system in place to monitor the safety of the vaccine. One challenge to overcome is the fact that health care is a provincial responsibility in Canada, meaning each province tracks this data in a different way.
“The fact that we don’t have a national immunization registry has been the bane of our existence for decades because we can’t easily link data from different provinces to look for issues with safety or effectiveness,” said MacDonald.
Now, thanks to COVID-19, MacDonald will co-lead a team of researchers from the provinces through the Canadian Immunization Research Network.
“We are currently exploring ways to pool efforts and data to ensure a more unified approach to vaccine safety evaluation once COVID vaccines are released to the public,” MacDonald said. “It is a great opportunity to join forces to ensure optimal vaccine safety monitoring.”
Helping people understand why they should get the shot
MacDonald is also a member of the advisory committee for the Privy Council’s COVID-19 Snapshot Monitoring (COSMO Canada), which has been doing its own regular surveys of Canadians on COVID-related topics. Results from September show that just 65 per cent of Canadians would be willing to take a safe and effective vaccine, while the latest numbers from the Angus Reid Institute indicate only 39 per cent of us would be willing to roll up our sleeves as soon as a vaccine is available. MacDonald advises caution in interpreting these numbers.
“With questions about COVID vaccine intention, you’re asking about something that doesn’t even exist yet, so what are you really measuring?” she asked. “It’s more about media coverage than anything concrete.”
“I think that the proportion of people who are expressing a desire to get vaccinated with a rapidly developed vaccine shows a great deal of trust in the system that is producing and approving the vaccine,” she said. “I actually find that very encouraging.”
When a vaccine is introduced in Canada, MacDonald would like to see targeted information campaigns about the potential risks and rewards, rather than a mandatory program. And trusted primary health-care providers such as family doctors and registered nurses are often seen as the most credible sources of information.
“We know that people don’t like to be told what to do,” she said. “We will need tailored messaging, because some people want to know the exact risk profile and some just want to know whether you would give it to your own kid, yes or no.
“Public health’s job is not to sell a vaccine but rather to support people in making the decision to get vaccinated—really communicating that this is a dangerous disease that has put our lives on hold and if we want to get back to our everyday lives and protect the vulnerable in our population, it's the right thing to do.”