Warming up to the hotspot strategy: Why targeting hard-hit areas for immunization is Canada’s best shot at reducing COVID-19 cases

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As soon as it was done, Sheila Channer picked up the phone and called the people she loved most to tell them the good news: She had been vaccinated against COVID-19.

“It was beautiful,” she said. “I called my sister, I called her husband. I said, ‘I got it, I got it, I got it!’ ”

Ms. Channer placed the calls in her nightgown, inside the fuchsia-painted apartment in northwest Toronto she rarely leaves because of her chronic health conditions. As an 83-year-old, she had been eligible for a shot since late February, but wasn’t able to get one until a vaccination team knocked on her door on Wednesday and offered to inoculate her on the spot.

Ms. Channer received her jab as part of an immunization blitz in Toronto’s coronavirus-battered Jane and Finch area, a predominantly Black neighbourhood that, as of the end of March, had the lowest per capita vaccination rate in the city.

In the span of five days this week, hospital-based vaccination squads and community organizations began to reverse that, immunizing more than 12,000 Jane and Finch residents in apartment towers and at pop-up clinics at an outdoor basketball court and the Driftwood Community Centre, where people lined up before dawn during a freak April snowstorm.

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The Jane and Finch campaign is part of a “hotspot” strategy that experts say is Canada’s best shot at reducing COVID-19 cases, hospital admissions and deaths in the third wave – not just for those living in communities with high infection rates, but for everyone.

With vaccine supplies increasing but still inadequate to cover all adults, the idea is to rush outbreak-dousing vaccines to neighbourhoods burning with COVID-19, rather than sprinkling the jabs evenly among places that are on fire and those that aren’t.

Percentage of people who have received

at least one dose of a COVID-19 vaccine

By area based on the first three digits

of a postal code

5

10

15

20

25

30

35%

MARCH 28

As of the end of March, the Jane and Finch and Thorncliffe Park neighbourhoods had some of the lowest vaccination rates in Toronto, despite having high COVID-19 burdens.

York

Durham

Toronto

Peel

M3N

(Jane and Finch):

5.5%

M4H

(Thorncliffe Park):

7.8%

APRIL 18

By the third week of April, vaccination rates in Jane and Finch and Thorncliffe Park had improved significantly, thanks in part to the hotspot strategy.

York

Durham

Toronto

Peel

M3N:

20.4%

M4H:

24.7%

MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE:

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

Percentage of people who have received at least

one dose of a COVID-19 vaccine

By area based on the first three digits of a postal code

5

10

15

20

25

30

35%

MARCH 28

As of the end of March, the Jane and Finch and Thorncliffe Park neighbourhoods had some of the lowest vaccination rates in Toronto, despite having high COVID-19 burdens.

York

Durham

Toronto

Peel

M3N

(Jane and Finch):

5.5%

M4H

(Thorncliffe Park):

7.8%

APRIL 18

By the third week of April, vaccination rates in Jane and Finch and Thorncliffe Park had improved significantly, thanks in part to the hotspot strategy.

York

Durham

Toronto

Peel

M4H:

24.7%

M3N:

20.4%

MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE:

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

Percentage of people who have received at least

one dose of a COVID-19 vaccine

By area based on the first three digits of a postal code

5

10

15

20

25

30

35%

MARCH 28

As of the end of March, the Jane and Finch and Thorncliffe Park neighbourhoods had some of the lowest vaccination rates in Toronto, despite having high COVID-19 burdens.

York

Durham

Toronto

Peel

M3N

(Jane and Finch):

5.5%

M4H

(Thorncliffe Park):

7.8%

Halton

APRIL 18

By the third week of April, vaccination rates in Jane and Finch and Thorncliffe Park had improved significantly, thanks in part to the hotspot strategy.

York

Durham

Toronto

Peel

M4H:

24.7%

M3N:

20.4%

Halton

MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE:

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

British Columbia and Ontario have warmed to the hotspot approach, and the City of Toronto has embraced it with gusto. Manitoba announced on Friday that it would offer vaccines to any adult living in three Winnipeg neighbourhoods with high infection rates, as well as people working certain essential jobs in those areas.

However, other parts of Canada are taking a broader approach. Those provinces, having already offered vaccines to nursing-home residents, the elderly, front-line health workers and Indigenous people, remain wedded to doling out their remaining shots primarily by age and severity of pre-existing health conditions.

That age-first approach made sense at the start of Canada’s vaccination campaign, when scientists didn’t know how effective the shots might be at reducing spread of the virus. But that understanding is evolving.

At the same time, it has become more obvious than ever that some communities are suffering more than others during the pandemic’s third wave. The hottest of Canada’s hot spots are overwhelmingly in poor and racialized neighbourhoods filled with essential workers who live in crowded housing, often with multiple generations of their families.

Weekly average vaccination rate in Ontario,

by community type and age group

Percentage of people who have received at least

one dose of a COVID-19 vaccine

Hotspot communities

Non-hotspot communities

All

ages

Ages

70 to 79

Ages 80

and older

Ages

50 to 59

Ages

60 to 69

100%

80

60

40

20

0

1

2

1

2

1

2

1

2

1

2

= April 18

= March 28

1

2

CHEN WANG / THE GLOBE AND MAIL, SOURCE:

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

Weekly average vaccination rate in Ontario,

by community type and age group

Percentage of people who have received at least

one dose of a COVID-19 vaccine

Non-hotspot communities

Hotspot communities

All

ages

Ages

70 to 79

Ages 80

and older

Ages

50 to 59

Ages

60 to 69

100%

80

60

40

20

0

March

28

April

18

March

28

April

18

March

28

April

18

March

28

April

18

March

28

April

18

CHEN WANG / THE GLOBE AND MAIL, SOURCE:

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

Weekly average vaccination rate in Ontario, by community type and age group

Percentage of people who have received at least one dose of a COVID-19 vaccine

Non-hotspot communities

Hotspot communities

All ages

Ages 70 to 79

Ages 80 and older

Ages 50 to 59

Ages 60 to 69

100%

80

60

40

20

0

March

28

April

18

March

28

April

18

March

28

April

18

March

28

April

18

March

28

April

18

CHEN WANG / THE GLOBE AND MAIL, SOURCE: INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

“There’s emerging science that the vaccine is having more of an effect than we thought it would on reducing transmission,” said Sophia Ikura, the executive director of the Health Commons Solutions Lab based at Toronto’s Mount Sinai hospital. “If we vaccinate in a very focused way in these hotspot communities and get to as many of the residents of these communities [as possible] they will not pass on the virus at the same rate. The story is changing.”

Ms. Ikura is one of the co-authors of a new paper from Ontario’s COVID-19 Science Advisory Table that lays out the advantages of going all-in on hotspots. If, over the next 25 days, 60 per cent of the province’s vaccine supply is sent to the 20 per cent of neighbourhoods with the highest COVID-19 burden, Ontario could cut overall hospital and intensive-care admissions by 14 per cent and deaths by 11 per cent compared with the existing plan.

Strict public-health restrictions would have to stay in place at the same time, but the accelerated hotspot strategy offers a faster way out of lockdown purgatory than continuing to allocate vaccines primarily by age and chronic health condition as most of Canada is doing today, the science advisers argue.

For an encouraging example of how a hotspot strategy works, look to Prince Rupert.

The city of 12,000 on British Columbia’s northwest coast had a relatively mild experience with COVID-19 until infections flared up in February and March, giving the city among the highest per-capita infection rates in the province. There were cases in the community’s long-term care facilities and exposure alerts in schools and homeless shelters.

Health officials responded with a plan to offer vaccines to all adults in Prince Rupert, regardless of age, health condition or occupation.

Before the vaccine program, Prince Rupert, which has a large Indigenous population and high poverty rates, was recording nearly 120 COVID-19 infections per week. About 85 per cent of the community received first doses of the Pfizer-BioNTech and Moderna vaccines in the span of eight days. Last week, Prince Rupert had just three new COVID-19 infections.

“I think we are proof of concept that if you’re able to vaccinate a hotspot, it will make a tangible and meaningful difference,” said Blair Mirau, a Prince Rupert city councillor who received his shot during the mass vaccination campaign.

Earlier this week, the B.C. government singled out 13 neighbourhoods for special attention in the vaccine rollout. Health officials have set up extra vaccine clinics in those areas, which are primarily in the Vancouver region and also include Dawson Creek, in the province’s north. Residents older than 40 in the hotspots have priority access to the AstraZeneca vaccine.

Most of the hotspots have racialized populations well above the provincial average, including parts of Surrey, where a large proportion of residents are South Asian.

Meanwhile, the health authority that covers northern B.C. has now identified dozens of communities for mass vaccination of everyone over 18, including on Haida Gwaii, while Island Health has also identified a number of remote and small communities, including on the Gulf Islands and Tofino, for whole-community vaccinations.

Quebec has stuck more closely than most to age criteria for vaccination, only moving to vaccinate essential workers and people with chronic conditions in the past week.

Montreal’s targeted neighbourhood campaigns have been aimed at rounding out vaccination in the 55-and-older crowd in hard-hit neighbourhoods with low uptake, rather than lowering the age threshold in some places. The effort has relied on community outreach, from public address systems mounted on vehicles to flyers, door-to-door knocking and religious leaders pitching vaccination at services.

“We have found when we go into a community and vaccinate leaders and elders, a lot of other people will follow,” said Martine Thériault, a local community organizer for Montreal’s south-central health region. “In recent weeks we’ve really been down to the people who were really hesitant, but they start talking to each other, and there’s a snowball effect.”

Saskatchewan put more resources for vaccine administration in Regina in response to high rates of infection in the city but did not adjust the eligibility requirements. While the province is currently offering vaccines to people aged 44 or older, that has been lowered to 40 for people in the northern region of the province, where more than half the population is Indigenous.

In Alberta, Chief Medical Officer of Health Deena Hinshaw said infection rates are so bad everywhere – the province’s rates are currently the highest in the country, a distinction it also held in the second wave – that it wouldn’t make sense to target specific neighbourhoods.

“What we’re doing right now is focusing on those of highest risk of severe outcomes and mitigating opportunities where the virus could sometimes spread very quickly,” Dr. Hinshaw said at a recent COVID-19 briefing.

There are, however, some areas with significantly higher rates than the provincial average. The far northeast corner of Calgary, for example, has the highest rates of active and new infections in the province’s two largest cities and is nearly twice the provincial average. More than 80 per cent of people living in the Calgary Upper Northeast health area identify as visible minorities, according to census data.

Declining to adopt a hotspot strategy is, “an ethical issue that we’re going to have to deal with in Alberta as we watch other provinces, like Ontario and B.C., pivot a lot faster than us,” said Gabriel Fabreau, a professor of medicine at the University of Calgary and a general internist at the Peter Lougheed Hospital in northeast Calgary.

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Although the Ontario government hasn’t gone as far as its science advisers would like, Premier Doug Ford committed on April 16 to sending 25 per cent of future vaccines to the 13 public-health units with the highest rates of COVID-19 deaths, hospital admissions and transmission.

The province had already agreed to make everyone over the age of 18 eligible for a vaccine in 114 high-risk neighbourhoods through mobile and pop-up clinics, an announcement that caused widespread confusion because the government failed to say how, exactly, younger adults in hotspots could sign up for shots. Frustration overflowed at pop-ups in Scarborough, another hard-hit community, this week, when people who took a day off work to get vaccinated discovered there weren’t enough doses for all who wanted them.

Large-scale communication of the hotspot program was a mess, conceded Isaac Bogoch, an infectious disease physician at Toronto’s University Health Network and a member of the province’s vaccine task force. But the program was never intended for a wide audience; it was supposed to be hyperlocal, with those most in need of vaccines notified of mobile clinics by their own neighbours, religious leaders and community health workers, he said.

“That is equity being baked into the system,” Dr. Bogoch said, “rather than having people who are at much lower risk, who still live in the exact same postal code, disproportionately coming out for the vaccine.”

In Toronto’s Jane and Finch neighbourhood, the hyperlocal approach paved the way for the vaccination of nearly 2,000 people over two days in a community theatre and three towers on San Romanoway, one of them home to Sheila Channer.

Co-ordinated by the Black Creek Community Health Centre, the San Romanoway Revitalization Association and Humber River Hospital, the blitz was led by “community ambassadors” – trusted locals who are proving to be the secret to vaccinating high-risk neighbourhoods where trust in the government and health care system is sometimes low.

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Patricia Baptiste, 64, has lived at 10 San Romanoway for 41 years. She handed out flyers, knocked on doors and answered her neighbours’ questions before vaccinators made their door-to-door rounds through the neighbourhood on Tuesday and Wednesday.

Ms. Baptiste, who received her own shot three weeks ago, is keenly aware of the toll of COVID-19. Two friends died of it recently, one a fellow resident of 10 San Romanoway. “She always used to be down here with us,” Ms. Baptiste said, gesturing to a common room on the main floor of the building. “So you can imagine, we miss her so much. It’s unbelievable that we’re not going to see her anymore. She’s my age, too.”

As the mobile clinic on San Romanoway reached its final hours Wednesday, volunteers roamed the hallways to ensure they hadn’t missed anyone, and called people on a “no-waste” list, urging them to come to an impromptu clinic set up on the first floor of the building. People flooded in, including employees of a nearby No Frills, where owner Danny Durante was directing traffic at the checkout so some of his workers could head across the street and get vaccinated.

Michelle Westin of the Black Creek Community Health Centre said the uptake on San Romanoway and at the two larger pop-up clinics this week demonstrated that the community’s lower vaccination rates in late March were less about hesitancy and more about access for people who may not have cars, health cards or the English-language and computer skills to navigate the mainstream booking system.

“We know the appetite and the need is there,” she said.

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With files from Chen Wang

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