On Monday, the National Advisory Council on Immunization changed its recommendation for use of the AstraZeneca vaccine … again: because of safety concerns, it will no longer be offered to people under the age of 55. I spoke with epidemiologist Isaac Bogoch to find out what the change means — and what can be done to assure the public that the vaccination program remains on track.
Matt Gurney: Let’s start with the most basic part of this: What was the substance of Monday’s announcement?
Isaac Bogoch: Essentially, the National Advisory Council on Immunization has said that, for those people under the age of 55, they don’t believe that the AstraZeneca vaccine should be used, and it should be temporarily suspended while we learn more about these blood clots that have been associated with the vaccine. However rare they may be, the data that exists to date demonstrates that it’s more likely in women and more likely in a younger age cohort. I think it’s still fair to say that this chapter has not been fully written. We don’t have all the answers, but that’s what the data appears to show to date. And I think the NACI recommendation is very reasonable.
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Gurney: I’m still trying to understand the rationale a bit. So these reports from outside of Canada suggest a very, very low incidence of clots, but that’s balanced against the very, very low risk of serious health problems for younger populations who contract COVID-19. Meanwhile, the blood clots aren’t being reported among older people, and their risk of serious illness or death from COVID-19 is high. So is the age-based guidance because of the risk of clots to the young, the risk of COVID-19 to the old, or both?
Bogoch: Yeah. It’s several factors, as you point out. So one is that in the data that’s available today, it appears that the risk of this particular type of blood clot is more common in people under the age of 50. In addition to that, we know that the risk of severe COVID-19 in those under the age of 50 is far, far lower, compared to, for example, those over the age of 60. And then we have to factor in the potential benefits and mitigating factors related to the vaccine — in particular, the AstraZeneca vaccine. And when you put all those three data points and questions together, it’s pretty reasonable to draw a line at the age of 55. You could argue it should be a few years higher or a few years lower, but I think they took a very reasonable data-driven approach based on the data that’s available today. And I think that’s a completely reasonable approach to take.
Gurney: All of this is against the backdrop of, here in Ontario, a third wave, and across Canada, a desperate scramble to get access to more vaccine. Supply is a big issue. I had previously asked one of your colleagues about the idea of designating certain vaccines as intended for certain segments of the population: older and other high-risk populations get Vaccine X, and younger and lower-risk populations get Vaccine Y. And I was told, sure, that’s possible. But it complicates the logistics of getting these shots into arms. We weren’t using AstraZeneca for anyone below 55 anyway, so in Ontario, will this have a big impact?
Bogoch: In Ontario, specifically, this doesn’t really change that much. As you point out, we’ve only been giving this vaccine to the 60-plus crowd, and we can continue to give it to the 60-plus crowd. What is a little bit unfortunate is that this is a great vaccine that can go into, for example, primary-care clinics. And, certainly, there will be a point in time — hopefully sooner rather than later — where we’ll be vaccinating multiple age groups and those with other underlying medical comorbidities. And this is a good vaccine that can be deployed in pharmacies or primary-care clinics.
This decision means that, for the time being at least, we have to reserve this for the over-60 crowd. Is it going to vastly alter our rollout in Ontario? Not vastly, but it certainly will have some impact. It probably will end up slowing things down, because once the over-60 population is vaccinated, there are still a lot of people left, and we will be more reliant on Moderna and Pfizer and, hopefully, Johnson & Johnson, when it comes in the door.
Gurney: What’s funny — not actually that funny — is that, a few weeks ago, when AstraZeneca was approved for all adults under age 65, there was a thought that we should reserve the mRNA vaccines — Pfizer and Moderna — for those most at risk: the elderly and those with comorbidities. And then the others could be reserved for mass use in the less vulnerable populations. But now we’ve flipped that! I’m a healthy 30-something, and now I’m only eligible for a Pfizer or Moderna. This is getting very hard to keep up with.
Bogoch: It sure is. All of the available vaccines ultimately do the same thing in the sense that they reduce your risk of getting the infection. And they of course significantly reduce your risk of getting sick, going into the hospital, and dying. Let’s think forward a bit, after the dust settles, when we reach the tail-end of the third wave and things are looking a little bit better. When case counts are down, the hospitals are decompressing — then I think it’s fair to say, okay, we’re all going to need a booster at some point; we’re all going to need an updated vaccine for the variants of concern. Then it’s reasonable to say, “Okay, this cohort is going to get this vaccine and that cohort’s going to get that vaccine” based on the data.
But right now, the house is on fire, and you’ve got to use every tool at your disposal to put the fire out. That includes all the vaccines. Now we’ve got to give this vaccine to people over the age of 55. This isn’t the first time we’ve done this. Think about the flu. There are flu shots that are dedicated just for people over the age of 65. We do that every single year; we can do this. It’s not a big deal. We can do it. This is slightly different, but not that much different.
Gurney: While we’re talking about the age groups, and this is a bit off track, we’re hearing reports that these new variants are hitting younger groups harder than what we saw in the first two waves. COVID-19 is changing, and we have to change with it. How does that play into the strategy around vaccination and cohorts?
Bogoch: At the end of the day, the biggest goal is to stop people from dying. There are a lot of people that need to be prioritized for vaccine. If you look at, for example, Ontario’s Phase 2 groups, people say, hey, we’re not being prioritized. Many people actually are; it’s just that there’s still a shortage of vaccines, so we can’t get to everyone yet.
At Phase 2, which is the prioritization above the general community, you’ve got essential workers in there, and that includes teachers. You’ve got everyone in congregate settings, you’ve got people with various medical comorbidities, and you’ve got different age cohorts for different communities. We have racialized people in low-income neighborhoods that are disproportionately impacted and need access to vaccines. You know, the risk of death, for example, of a 50-year-old in certain areas is the same as the risk of death as an 80-year-old in other areas. We have to vaccinate essential workers. No one’s denying that that’s extremely important. But you also have to vaccinate people who are going to die if they get infected with COVID-19.
The variants are posing problems. We are seeing younger cohorts in hospital and in the ICU. That’s real. We’re seeing a lot of essential workers there. That’s real. We certainly have to do things to protect essential workers, which does include vaccination. But we also have to create safer workspaces, and there has not been a lot of work done on that front. There’s a lot we can do to really help Ontarians with the vaccine rollout. The vulnerable and the higher-burden areas, for example, get priority access to vaccines compared to other areas. The public-health units certainly have flexibility to use their vaccines at their disposal. So they could theoretically target their warehouses and meatpacking plants and other occupational settings where there is greater transmission. They could do pop-up clinics there, if they desired.
But I certainly think that the number one goal is to alleviate death and suffering. Look at all the data in Canada, and over 90 per cent of the deaths are people over the age of 60. We have to protect our older populations. They’re dying. And they’re going to continue to die. We’ve done a decent job vaccinating long-term care, the 80-plus community, and front-line health-care providers. There’s still a lot of work to be done, but there’s been some progress on that front — significant progress on that front — and also with Indigenous communities, especially in remote communities. But we still have a ways to go with other priority groups, like those with underlying medical conditions or senior populations living in the community. And, of course, with essential workers.
Gurney: So just before I turned my recorder on, I noted that Monday’s announcement had a touch of the absurd about it — the announcement by NACI came just a few hours after Health Minister Christine Elliott had made a very public point of getting her first dose of AstraZeneca, specifically to improve public confidence! And combat vaccine hesitancy! And then this happens hours later. And I shouldn’t laugh, but I did.
The AstraZeneca vaccine seems to really, really work. It does the job. But there has been one issue after another with the public communication around the vaccine. The company screwed up their own information releases, and that was a fiasco. Here in Ontario, we started using this only for under-65s, then it was everyone, and now it’s no one under 55. I was joking with my editor — by next week, it’ll be approved only for right-handed Capricorns. This is going to be another setback for confidence in a vaccine that really does seem to work.
Bogoch: Yeah. Yeah. Look, it’s damaging. We’d be foolish to say otherwise and pretend it’s not. The communications needs to be handled on two fronts. There’s the science. And then there’s the public-health aspect of it as well, the public health and the communications. The science is the science, right? Like if there’s blood clots, there’s blood clots — we have to understand what that is. And we have to communicate that in a fair, transparent, and effective manner. But then there’s the other stuff, and that’s a little bit more preventable, you know — the back and forth: “We are going to give it to people under the age of 65. No, wait, now we’re going to give it to people over the age of 55. We’re going to change our policy.”
And, yeah, there’s the company as well that really botched the release of their new clinical-trial data with the data-safety monitoring board calling them out publicly. There’s been a lot of communication problems with this, and many of them were preventable. I think you’re going to need very, very skilled public-health communicators who sit in official positions to really discuss in an open, honest, and transparent manner what these decisions are, why these decisions are made, why we still think this is a very solid vaccine for people over the age of 55, and how you can access it. That just requires very skilled communication. But even with that, I think anytime there’s a headline or an update, I think we just continue to erode trust in this product. It’s going to be an uphill battle.
This interview has been condensed and edited for length and clarity.