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Health experts point to logistical delays, public uncertainty and other factors, while continuing to stress that third doses are critical to stop severe illness and save lives

Health-care workers at Toronto's Humber River Hospital tend to a ventilated COVID-19 patient, who is also an unvaccinated nurse. With the contagious Omicron variant on the loose, officials stress that having two regular doses and one booster is a strong safeguard against severe illness.Nathan Denette/The Canadian Press


Canada’s COVID-19 booster drive is slowing despite mounting evidence that an additional vaccine dose is needed to maintain strong protection from severe illness caused by SARS-CoV-2, according to a Globe and Mail analysis of uptake across the country.

While the dominant Omicron variant has been shown to cause less severe disease than the Delta variant before it, its hyper-transmissibility has walloped Canada’s health care system, pushing the daily national patient count above 11,000 for the first time in January. Three large studies from the U.S. Centers for Disease Control and Prevention (CDC) underscore the importance of boosters in preventing severe illness from Omicron and future variants, but as of Monday, only 41 per cent of Canadians had received an additional dose.

At its peak in the second week of January, nearly 350,000 shots were administered daily across the country, on a seven-day rolling average. By the end of the month, that had dipped to fewer than 200,000. The uptake of boosters is also slower than that of the push for second doses, which peaked at about 487,000 shots administered daily, on a seven-day rolling average.

In B.C., about 721,000 adults who have been invited to book their boosters have not yet done so, including about 46,000 aged 70 and up. (British Columbians must register with a provincial system to receive invitations to book their COVID-19 vaccination appointments.) Alberta is trailing behind other provinces, with just 32.7 per cent of its population boosted as of Jan 31. And in Quebec, some health experts have blamed January’s high death toll on the province’s slow campaign to deliver boosters to seniors living in the community.

DAILY COVID-19 VACCINATION DOSES

ADMINISTERED, BY DOSE AND

BYPROVINCE

First doses

Second doses

Third doses (boosters)

British Columbia

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Alberta

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Ontario

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Quebec

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

THE GLOBE AND MAIL, SOURCE: PROVINCIAL

GOVERNMENTS

DAILY COVID-19 VACCINATION DOSES

ADMINISTERED, BY DOSE AND BY PROVINCE

First doses

Second doses

Third doses (boosters)

British Columbia

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Alberta

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Ontario

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Quebec

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

THE GLOBE AND MAIL, SOURCE: PROVINCIAL GOVERNMENTS

DAILY COVID-19 VACCINATION DOSES ADMINISTERED, BY DOSE AND BY PROVINCE

Third doses (boosters)

First doses

Second doses

British Columbia

Alberta

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Quebec

Ontario

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

Feb.

2021

Apr.

June

Aug.

Oct.

Dec.

Feb.

2022

THE GLOBE AND MAIL, SOURCE: PROVINCIAL GOVERNMENTS

The reasons for the delays are varied. Devon Greyson, an assistant professor in the School of Population and Public Health at the University of British Columbia, whose research has focused on vaccine confidence and uptake, said the slower pace of booster administration may be partially attributed to logistical issues. First and second doses are still being administered, as well as vaccines to children age 5 to 11, which could potentially be creating capacity issues, they cited as an example.

The uncertainty of the Omicron wave has also made personal decision-making more difficult, Dr. Greyson said. “It takes a while for us to learn scientifically, and that goes for every new variant: How is this variant going to work? How protective are our current vaccines against this variant? How long is the duration of immunity from a newer vaccine?” they said. “But also, this Omicron wave has really shaken people, and they’re struggling in general. For some people, the stress of this current wave feels as bad as the initial wave in the spring of 2020, and that makes decision-making harder.”

Vancouver resident David Laing was seven days into fighting COVID-19 when he awoke one morning in early January to an invitation to book his booster. The digital marketing specialist was still experiencing nagging symptoms, including severe headaches, lower back pain and a cough, so when he saw the automated text message, a flitter of excitement quickly became frustration.

He rolled over and typed out an expletive, along with the message: “I already got COVID.”

“I was just so frustrated that I texted them back hoping that some IT guy on the other end would be like, ‘Dang. That sucks, buddy,’” said Mr. Laing, 38.

But as his symptoms, and annoyance, subsided, he was left wondering when he should book his appointment for. Did his infection induce some immunity? Should he wait? He held off as he started looking for answers.

Lucie Fletcher, 5, looks toward her mother, Dr. Daniele Behn Smith, as registered nurse Erin Thorpe administers a Pfizer vaccine in Victoria last November.Chad Hipolito/The Canadian Press

When Vancouver resident Catherine Fenn was invited to get her first two doses of COVID-19 vaccine, she accepted acquiescently. She didn’t love the idea of vaccinations in general, but understood that they were one of the best tools to change the course of the pandemic.

After both shots, Ms. Fenn, 61, experienced a headache, fever and persisting joint pain in her knees, hips and elbows, which her doctor later explained could be a side effect of her vaccination. When she got her invitation to book her booster last month, she decided to wait.

“I think if Omicron was a horrible variant and people were dropping dead on the sidewalk, I’d say, ‘Okay, who cares about joint pain? I’m going to do it,’” Ms. Fenn said. “But I don’t feel the same urgency with Omicron that I did when I got those two shots earlier. So I’m just kind of waiting and seeing.”

Governments and public-health officials have urged Canadians to get their boosters but have so far stopped short of adding a third-dose requirement to existing vaccine certificates. It’s a move that some feel should be reconsidered.

“There’s a window of opportunity, which is [closing] relatively soon, to slow down a bit the spread of Omicron, increase consumer confidence and be able to further open the economy,” said Peter Juni, scientific director of Ontario’s COVID-19 Science Table.

With the province having reopened restaurants, gyms, concert halls and other venues with capacity limits this week, he said now would be an ideal time to begin education campaigns for a mid-February deadline to require boosters to enter these discretionary settings. “We have to do it relatively swiftly, or we don’t do it at all,” he said.

At the Humber River Hospital, a health-care worker walks past a thank you sign in the ICU.Nathan Denette/The Canadian Press

The U.S. CDC released three large studies in January that highlight the importance of boosters during the Omicron-driven surge. One study that looked at nearly 88,000 hospitalizations in 10 states during the Omicron wave found that a booster dose was 90-per-cent effective at preventing hospitalization, compared to 57 per cent for two doses, six months after the second dose.

The study also looked at nearly 223,000 emergency-department and urgent-care visits, finding that a booster was 82-per-cent effective at preventing these visits, compared to 38 per cent for two doses, six months out.

“These findings underscore the importance of receiving a third dose of mRNA COVID-19 vaccine to prevent both moderately severe and severe COVID-19, especially while the Omicron variant is the predominant circulating variant and when the effectiveness of two doses of mRNA vaccines is significantly reduced against this variant,” wrote lead author Mark G. Thompson. “All unvaccinated persons should get vaccinated as soon as possible.”

Emerging Canadian data also underscore the importance of boosters. From mid-December to mid-January, unvaccinated Ontarians aged 60 and older were 22.4 times more likely to be hospitalized than those who had received three doses, and 11.8 times more likely than those who had received two.

In Alberta, data from the past 120 days show that unvaccinated people aged 60 and older were 35 times more likely to be hospitalized than those who had three doses, and five times more likely than those who had received two.

In the U.S., some states, postsecondary institutions and employers have added boosters to existing vaccination certificates, and Hawaii is expected to announce this month that all visitors to the Aloha State must have a third dose to bypass a five-day quarantine requirement.

A sign in Montreal advertises Quebec's COVID-19 vaccine passport.Graham Hughes/The Canadian Press

Ontario’s Dr. Juni said it would be a logical next step to add a booster requirement given that two doses no longer protect against infection from Omicron. “The logic of the vaccine certificates is to protect people from serious outcomes; we don’t let them expose themselves in high-risk settings if they’re not vaccinated. That’s okay,” he said. “But the other part is to keep infections under control, and this part is not addressed any more with a vaccine certificate that is based on two doses.”

Nazeem Muhajarine, a professor in community health and epidemiology at the University of Saskatchewan, agreed with the rationale of adding a booster requirement to vaccine certificates.

“I think we have to do this sooner than later, and particularly with the incentivizing idea in mind,” said Dr. Muhajarine, who is also a member of the Coronavirus Variants Rapid Response Network, a national research group that responds to the potential threat of emerging SARS-CoV-2 variants.

“The sooner we have more people whose vaccines are up to date, the better we will be, in terms of serious outcomes of Omicron COVID and any other variants in the future. All of our health care workers have been stretched to the limit and we don’t have capacity to keep doing everything that we need to do.”

Isaac Bogoch, an infectious-diseases physician at Toronto’s University Health Network, said governments must determine what their goals are and build policy around them. Including boosters in vaccine certificates would create safer indoor spaces, but these requirements should not be considered “pandemic-altering policies” as much transmission still occurs outside of restaurants, gyms and other businesses, he said.

Further, such a requirement cannot be fairly rolled out until there have been meaningful efforts to boost people equitably, he said. Data up to Jan. 9 showed that less than 20 per cent of people in some of Toronto’s northwest neighbourhoods had received a third dose, for example, compared to 50 per cent for some more central neighbourhoods.

“When you look at who’s got a third dose, it’s high-income neighbourhoods, and there’s actually a huge disparity with the communities that are disproportionately impacted by the virus and by policies to curb the virus,” Dr. Bogoch said.

“So if you make that policy now, suddenly, you’ve excluded significant segments of your society from going to a restaurant, grabbing a drink at a bar, going to the movies. … It would be really unfair.”

Mr. Laing, the Vancouver resident who recently recovered from COVID-19, said he is certain he will get his booster. He is still deciding on exactly when, figuring he has some time on his side.

Ms. Fenn continues to mull getting hers. If it were required in order to see her elderly mother in long-term care, or to enter restaurants and other discretionary settings, she would concede and book her shot, she said. She also often imagines the consequences if she were to get COVID-19 and infect others.

“What if I gave it to somebody unknowingly, in that incubation period, who is a vulnerable person? Or gave it to anybody, and somewhere down the line a vulnerable person gets it?” Ms. Fenn said. “So that bothers me. I have thought about that, for sure.”

With a report from The Canadian Press


Don’t have a booster shot yet? Experts respond to Canadians’ common questions

Patients wait for vaccines at the University of Toronto's Mississauga campus.Tijana Martin/The Canadian Press

I’ve had my primary series of two COVID-19 vaccine doses and recently got COVID. When is the best time to get my booster?

The National Advisory Committee on Immunization (NACI) recommends that a person with a COVID-19 infection get a booster, at the earliest, when one has completed his or her self-isolation period and is no longer symptomatic. However, some physicians may recommend a longer interval to produce a more robust immune response.

Janine McCready, an infectious-diseases physician at Michael Garron Hospital in Toronto, recommends waiting one to two months after a natural infection to allow one’s immune system “to mount a response to the infection and then boost on top of that for additional protection.”

Earl Brown, emeritus professor of virology at the University of Ottawa, recommends an interval of two to four months after an active infection. “This is because responses mature with time, but also weaken with time, so there is always a tension between renewing your levels of partial immunity and waiting for a more responsive immune system, which increases with time after vaccination,” he said.

NACI cautioned that the risk of reinfection over time, as well as the protection offered by previous infection against new variants, is difficult to determine.

“Therefore, if a delay in administering vaccination following infection is being considered, risk factors for exposure (including local epidemiology and circulation of variants of concern) and risk of severe disease should also be taken into account,” a NACI statement read.

A Montreal boy shows his 'brave child diploma' after being vaccinated.Paul Chiasson/The Canadian Press

If I’ve had two doses and an infection, do I have enough natural immunity to skip a booster?

It is too early to know the exact impact of the Omicron variant on immune status and disease resistance. Pre-Omicron studies have shown that some protection from COVID-19 persists for several months after infection, however this can vary greatly depending on a number of factors including which variant it is as well as a person’s age and the overall strength of their immune system. A U.S. CDC study published last September of 76 people with lab-confirmed COVID-19 cases found that 36 per cent did not develop antibodies.

In population studies, postinfection immunity was much less protective against reinfection than vaccine-induced immunity, Dr. Brown said. Studies of people who were both infected and vaccinated showed they had much higher levels of immunity, but that immunity was not long-lasting and reinfections occurred.

“Omicron infection will boost the immunity of a double-vaccinated person to levels that are as high or higher than a third dose of mRNA vaccine,” Dr. Brown said. “This level of immunity is expected to be good against reinfection with Omicron and other variants, but this has not yet been seen. If you want to maximize your benefits of vaccination, you will obtain a third mRNA vaccine dose any time after eight weeks of your natural infection to maximize the vaccine-induced immune response.”

A health-care worker holds a vial of the Pfizer vaccine.Maya Alleruzzo/The Associated Press

Which brand of vaccine should I get? Is one better than the other?

Pfizer’s booster dose contains the same 30 micrograms (mcg) of mRNA as its first two doses, while Moderna’s primary series contains 100 mcg each and its booster, 50 mcg. The Pfizer and Moderna boosters are considered interchangeable for most people.

For young adults aged 18 to 29, NACI recommends Pfizer over Moderna because of lower reported rates of myocarditis and pericarditis, rare heart inflammation conditions, than compared to Moderna’s full-dose 100-mcg vaccine. Data specific to Moderna’s 50-mcg booster dose are limited.

As of Jan. 14, there was a total of 1,643 reports of myocarditis or pericarditis – made since the start of the pandemic – to the Public Health Agency of Canada. Of these, 1,045 followed a Pfizer vaccine, for a reporting rate of 2.1 per 100,000 administered doses. There were 563 following Moderna vaccination, for a reporting rate of 2.8 per 100,000 administered doses.

For people who are aged 70 and older, or for those who have weaker immune systems, a full 100-mcg Moderna dose may be preferred for a booster.

I’ve had two doses and don’t feel any urgency to get a third. Why should I?

While a primary series of two doses offers almost no protection from Omicron infection, it still roughly halves the likelihood of hospitalization and death, Dr. Brown said. Young, healthy people are generally at lower risk for serious disease; however, they can still contribute to increased disease and hospital burden by transmitting COVID-19 to others.

“As hospitals are now the weak link in our health care system, it is currently important that we decrease the level of infection to keep high-risk individuals from needing hospital care,” he said.

Jamie Scott, professor emerita at Simon Fraser University and a former Canada research chair in molecular immunity, said while men, people aged 60 and up, and those with pre-existing conditions, such as diabetes or high blood pressure, are at higher risk of severe illness from COVID-19, young people are not risk-free.

“I can tell you young people are getting sick and dying,” she said. “So you’re taking some dice and you’re rolling them. And so the question is, do you really want to get infected? Not only that, but you might give it to somebody else.”

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