In July, the province reported that 80 per cent of eligible Ontarians had received their first COVID-19 vaccination. The remaining benchmarks needed to move out of Step 3 include 75 per cent of eligible Ontarians with their second shot and no public-health unit reporting less than 70 per cent with both doses. Data shows that we are edging toward the former goal — but seven PHUs have not yet hit the latter.
“We’re doing well, but the job isn’t done,” says epidemiologist Isaac Bogoch, a member of the province’s vaccine task force.
There are multiple COVID-19 datasets in Ontario, and when it comes to vaccinations, not all of them agree. For example, the data compiled by the Ministry of Health doesn't align perfectly with similar data compiled by Public Health Ontario. The benefit of the second-dose vaccination data collected by the non-profit ICES — which covers all ages, not just those over 12 — is that it allows for more granular comparisons of vaccination rates by forward-sortation areas, or FSAs, which are defined by the first three letters of a postal code. It also provides insight into how many Ontarians overall remain vulnerable. Data released August 13 indicates that, provincewide, 79 per cent have received first doses and 70 per cent have received both — double-dose rates range from 38.85 per cent in southwestern Ontario’s N5H postal code to 77.45 per cent in N7W, also in the southwest.
ICES senior scientist Jeff Kwong cautions that looking just at the numbers, without taking context into account, is not enough to tell the whole story: for example, while First Nations communities have historically reported higher vaccination rates, that might not be reflected in the data, as Kwong could not confirm that those numbers are reported in the provincial COVaxON Vaccination Management System. Then there are residents who get vaccinated elsewhere but fail to inform their local public-health unit.
Nevertheless, the ICES data does provide an informed sense of which areas are making strides and which are lagging. With Theresa Tam, Canada’s chief public health officer, saying the country has now entered the fourth wave — and with the fall return to school growing closer — TVO.org looks at the most recent ICES data to examine where Ontarians aren’t getting their shots and what experts say needs to be done.
Greater Toronto Area
Thorncliffe Park is seeing the lowest double-vaccination rate in the GTA, according to the data. In the high-rise residential Toronto neighbourhood, which encompasses the M4H postal code, 51.9 per cent of the population has had a double dose.
Toronto Public Health says multiple factors have contributed to that rate. “Some residents are having difficulty finding time in the day to get vaccinated, especially if they are working at times outside of traditional work hours and would have to take unpaid time off work to get vaccinated,” reads an emailed statement. “Others, such as seniors, may be having trouble getting to places where vaccinations are taking place or face technical barriers to book an appointment.” TPH has also heard that language barriers have been a concern.
To address lagging vaccination rates in neighbourhoods including Thorncliffe Park, TPH says, it created vaccine-engagement teams, drawing on 150 community agencies and including 280 neighbourhood ambassadors. “These teams have been an effective, customized approach to connecting with people in their own community, in their language, in a culturally relevant manner, to help remove barriers that are keeping residents from being vaccinated, including vaccine hesitancy.”
Flemingdon Health Centre’s interim CEO, Shobha Oza, says that the neighbourhood’s demographics affect the total-population data and that 60.8 per cent of Thorncliffe’s 12-and-up population is fully vaccinated. “The percentage of very young kids in Thorncliffe is really high.”
Efforts similar to TPH’s community-engagement initiative appear to have been effective
elsewhere. As of July 25, L1H, which includes south-central Oshawa, had 47.91 per cent of its population double-vaccinated, placing it last in the GTA. But by August 8, that number had jumped to 54.68 per cent. Francis Garwe, CEO of Carea Community Health Centre, suggests outreach efforts may have helped.
“The word of mouth in these communities, whether low-income or newcomer, seems to be the biggest vehicle of how information is communicated,” he says. To counter misinformation and break language barriers in L1H, Carea this spring began working with six ambassadors from the South Asian and Black communities who counter misinformation on the ground and campaign door-to-door. It also hosted virtual town halls in such languages as Punjabi and Tamil.
Garwe says outreach efforts are ongoing. “We have four more events happening this month in those areas where food, music, and back to school supplies will be distributed to families for free and we plan to provide [a] vaccination clinic in partnership with Public Units as well,” he says in a follow-up email. (By Josh Sherman)
Hamilton has 334 cases per million people — one of the highest rates in Ontario — as well as one of the lowest vaccination rates.
On the shores of Lake Ontario and north of downtown Hamilton, L8L is the least vaccinated
in the catchment area for the city’s public-health unit: 48.09 per cent of people have gotten two shots. The FSA, which is home to about 35,000 residents, is one of the least vaccinated in Ontario and well below Hamilton’s total-population rate of 60.4 per cent.
All but one of the neighbouring FSAs — L8R, L8N, L8M and L8H — had coverage rates below 55 per cent, as of Friday’s data.
Those FSAs are all within the so-called lower city, named for its location below the mountain that divides Hamilton. Overall, it tends to be more racialized and less affluent. “Whether we’re talking about income, access to housing, or racialized groups, all of those things are playing out in the areas that have our lowest vaccine coverage,” explains Elizabeth Richardson, Hamilton’s medical officer of health.
These compounding factors, known as social determinants of health, create problems of access and confidence, Richardson says. Given histories of discrimination in the health-care system, marginalized people may feel uncomfortable in clinics run by people who aren’t from the same background; that’s why public health introduced a vaccine-ambassador program. “We’ve hired people deliberately from the backgrounds of people that are underrepresented in terms of our vaccine groups,” says Richardson. “And we’ve been working very closely with a whole range of providers, in terms of getting information out to folks.”
Clinics in the area have been inaccessible for some due to location or limited operating hours, some say. “I know for a number of working families, the availability of walk-in clinics in the evening is an essential game-changer,” says Nrinder Nann, councillor for Ward 3, which largely overlaps L8L. Pop-up and mobile clinics would help, too, she adds.
According to Richardson, “People really are saying they need [a clinic] to be as close to people as it can possibly be. We’re actually breaking down those geographies even further to see, where are the specific areas? Where are the specific pockets where people are still having lower vaccine-coverage rates? And what do we need to do on that very, very local basis to help them?”
Both Nann and Richardson say it’s important not to stigmatize neighbourhoods with low vaccination rates. “For these groups, it’s not about choice; it is about the circumstances they find themselves in,” says Richardson. “It’s absolutely essential that we understand those things and that we work to address them on the bigger-picture perspective.” (By Justin Chandler)
In some areas of the north, ICES data doesn’t allow for a definitive sense of uptake. That’s because a number of First Nations have chosen not to submit their data to the COVaxON database, says Kit Young Hoon, medical officer of health for the Northwestern Health Unit. As a result, there is a “significant amount of data missing” when it comes to FSAs with First Nations communities.
For example, the ICES data indicates that P0W — a large swath of land, known as rural Rainy
River, along the United States border, stretching from Quetico Provincial Park to the Manitoba border — has the lowest vaccination rate in northwestern Ontario, with only 46.49 per cent of the population fully immunized. However, according to NWHU estimates as of August 1, the rate was likely closer to 61 per cent, says Young Hoon.
(Likewise, a lack of First Nations data means that, while P0P, an FSA that includes Manitoulin Island and the north shore of Lake Huron, shows up in ICES as having only 40.39 per cent with both doses, Public Health Sudbury & Districts tells TVO.org that 75 per cent of people over the age of 12 on Manitoulin Islandnare fully vaccinated.)
“Some First Nations have chosen not to put their data in [the database], and they’re allowed to do so because of OCAP principles,” says Young Hoon. OCAP — which stands for ownership, control, access, and possession — is a framework developed in the late 1990s to address harmful research and data-collection practices conducted by outsiders in First Nations communities; it gives them control over their own information.
According to Young Hoon, the lowest vaccination rate in the NWHU’s catchment can be found in P0V, a large area that encompasses such communities as Dryden and Red Lake, as well as more than a dozen remote First Nations. There, only 50.99 per cent of people are fully vaccinated, according to ICES. Young Hoon says that, while she doesn’t “have a good answer” as to how accurate the estimates are, this particular FSA has “always been lower” throughout the vaccine rollout than other FSAs within NWHU’s catchment area.
Young Hoon notes that scheduling issues, forest-fire evacuations, and concerns about vaccine safety may be hindering immunization efforts in the northwest. The unit continues to run vaccine clinics, she says, and to focus on messaging about vaccine safety.
ICES data indicates that one of the FSAs facing the biggest uptake hurdles in the northeast is P3C, which is just west of Sudbury’s downtown core: 50.75 per cent of people there have gotten both shots. “Our early analyses identified that half of the lowest uptake areas in the urban core of Greater Sudbury were in the P3C area,” says Nastassia McNair, program manager for vaccines at PHSD.
The three main neighbourhoods in P3C are the Donovan, the Flour Mill, and the West End.
Data from the 2016 census shows that the population of the FSA, which is home to 16,249 people, skews younger and has lower levels of education and income than the city at large: the median age was 40.6, compared to a city-wide median age of 43.3; the median individual employment income was $25,929, compared to $35,738 across Greater Sudbury; and 45.63 per cent reported having no post-secondary education, compared to 38.23 per cent in Greater Sudbury.
McNair says that the health unit has found lower uptake in younger populations, most notably in the 12- to 14-year-old range, and that, while people likely have general health concerns about the vaccines, she’s also heard references to barriers created by transportation, scheduling, work, and child care.
PHSD is winding down its mass-immunization clinics, McNair says, and shifting its focus to mobile and pop-up clinics that target specific regions and demographics: “Last week, we were in a grocery-store parking lot, and we [administered] nearly 200 doses in a day,” McNair says, adding that pop-up clinics will be held in P3C at such local gathering places as Dynamic Earth, Percy Playground, and the Cambrian Heights Arena.
Earlier this year, the unit partnered with such groups as Black Lives Matter Sudbury and held clinics targeting the homeless population. It’s reaching out to community organizations and workplaces to book mobile clinics and is currently conducting a vaccine-hesitancy survey. (By Charnel Anderson and Nick Dunne)
Syd Gardiner, a Cornwall councillor and the chair of the Eastern Ontario Health Unit board, says that, while the city is in “good shape,” with a very low number of cases (there were 12 active as of Thursday), “the only problems we’ve been having — and I get mad about this — is the fact that some people are refusing to take the shots.” He attributes that lack of uptake in part to “confusion” created by the province’s booking system. Recently, he says, he told a caller who was struggling to book through the provincial phone line, “Do me a favour: go down to the grocery store … and tell them you want your second shot.” The next day, Gardiner says, “He had it.”
In K6H, which covers the eastern part of Cornwall, 48.77 per cent of people are fully vaccinated — the ninth-lowest rate of any of the 514 FSAs listed. In K6J, which also covers a large part of the city centre, 52.96 per cent of residents were fully vaccinated. (As of Friday, the full vaccination rate across the entire Eastern Ontario Health Unit, among those ages 12 and older, was 72.06 per cent.)
Addressing low vaccination rates in K6H and K6J in a press briefing on Monday, Paul Roumeliotis, the EOHU’s medical officer of health, said the health unit is seeing a similar pattern in Hawkesbury. “There are a multitude of reasons — there are social determinants of health reasons,” he says. “We continually have difficulty in those areas with delivery of other programs, so I’m not surprised. There may be people who don’t have access to the internet, maybe people who don’t want to go to clinics.” In 2015, the median household income in K6H was $46,646, nearly $30,000 lower than the provincial average. Household incomes in K6J and in Hawkesbury were also lower.
Andrew Keck, one of the managers of the vaccine rollout for the Renfrew County and
District Health Unit, says that, as the region is primarily rural, many of the health unit’s FSAs are large and contain numerous different communities. “You wouldn’t be able to apply a generalized trend for one community over another just based on that FSA data,” he says. “What’s happening in Deep River isn’t necessarily what’s going on Killaloe or Wilno or Whitney.” The unit consults with mayors, municipal councils, and health-care organizations to help decide where to bring its pop-up vaccination clinics next. It’s also taken to social media to ask residents for their input.
Originally, the health unit focused on setting up pop-up clinics in the most rural communities, but it’s now looking at other populations that might be underserved, Keck says — for example, by setting up a couple of pop-up clinics for homeless individuals at the Grind, a community-service hub and coffee shop in Pembroke. “It’s a lot of strategic thinking, so rural is one piece, but there are a lot of other pieces as well,” he says. “Everything is on the table.” (By Marsha McLeod)
As early as February, the Southwestern Public Health Unit suspected that vaccinating at least 75 per cent of its population would be a challenge. In the PHU’s vaccination plan, released earlier this year, the agency stated that “SWPH has the largest vaccine hesitancy rate in Ontario — as such, this target may not be achieved locally in some of our region.” SWPH is home to FSA code N5H, which has the lowest double-vaccination rate in the province, at 38.85 per cent.
The postal code encompasses the town of Aylmer and extends into the rural counties of
Malahide and Bayham, notes Joyce Lock, the medical officer of health. Since last year, the Aylmer Church of God has made headlines for flouting provincial COVID-19 restrictions. As a result, the church and, by extension, the town have become associated with vaccine hesitancy.
“Health beliefs, including beliefs about vaccines, are complex,” says Lock. “They are originating from a whole slew of social reasons, including your family background, your level of education, your faith group, your personal experience with vaccines and with the health system. All of these come into play.”
Douglas W. MacPherson is an infectious-disease specialist at St. Thomas General Hospital, located in the N5R postal code, where, according to ICES data, 60 per cent of residents are double-vaccinated. “It’s sometimes difficult to communicate complex technologies,” says MacPherson. “People are going to have concerns. What does [the vaccine] mean for me, what does that mean for my genetics, and what is that going to mean for my fertility and my children?”
Lock says the agency is working to position itself as a trusted source of information and a place free of stigma and judgment; its goal is to reach people where they are, in a way that works for them. That means adopting approaches that bring vaccines to the health unit’s rural and agri-business population through targeted pop-up clinics.
MacPherson says accessible communication that addresses concerns about the vaccine is necessary to get the message out to unvaccinated populations: “Getting the message right, listening to what the community concerns are and being able to address it in a dispassionate but honest way, so people believe you — and can, if they are hesitant, feel reassured and get access to vaccines.”
Chris Mackie, medical officer of health for the Middlesex-London Health Unit, says that the unit has yet to achieve optimal vaccination rates in certain neighbourhoods with significant economic and social barriers. “We haven’t reached the coverage that we’d like in neighbourhoods, or sub-populations, that have barriers to vaccination or are otherwise affected by social determinants of health,” says Mackie. In response, the health unit is taking a targeted approach, hiring a diversity outreach worker, reaching out to such groups as the Black London Network, and hosting events in mosques and Sikh temples. “We really value that outreach-based approach and try to partner with whatever community groups are in that neighbourhood,” says Mackie. (By Ashley Okwuosa)
Looking at the province as a whole, Isaac Bogoch highlights another piece of the vaccination puzzle: family doctors. “You have to address those individual needs and those individual concerns, and that’s where primary care is helpful, because they know their patients, they have a longstanding relationship with them, and they can spend the time to discuss the vaccine and how it impacts them on an individual level.”
As Ontario’s remaining unvaccinated population is spread out across the province and can’t be easily categorized, Bogoch says, we’ll need to keep devising new tools and approaches: “When we look at the unvaccinated, it’s not a homogeneous group. It’s a very heterogeneous group — and that’s why we need a multitude of strategies to reach those different pockets and to reach those different populations.”
With files from John Michael McGrath.
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