‘Difficult days ahead’: A medical officer of health on variants and vaccines

TVO.org speaks with Kieran Moore, Kingston’s medical officer of health, about the role of public-health units, family doctors and vaccination — and why April could be an important month
By Nathaniel Basen - Published on Feb 24, 2021
Kieran Moore is the medical officer of health for Kingston, Frontenac, and Lennox and Addington. (Courtesy of KFL&A Public Health)

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Ontario is set to begin the next phase of its vaccination plan, as record numbers of doses arrive in the province. But exact details are scarce, including who is eligible, how they will know when it’s their turn, and where they’ll get the shot.

The province announced that public-health units will manage local vaccination campaigns — which some saw as it shirking responsibility, leaving communities without a plan.

Kieran Moore is a new member of the province’s vaccine task force, and the medical officer of health for Kingston, Frontenac, and Lennox and Addington — a region that currently has no local spread of the virus. He’s also a professor of emergency and family medicine at Queen’s University. 

TVO.org speaks with Moore about the preparedness of public-health units, the role of family doctors in delivering the vaccine, and the next three months of Ontario’s pandemic.    

TVO.org: You’ve been on the vaccine task force now for a few weeks — in part because of your experience in family medicine and public health. What has that experience been like?

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Kieran Moore: Well, I'm honoured to be on the table and to contribute. It's a great group to be reviewing this whole strategy with. And, certainly, I'm happy now that someone that's grounded in primary care and public health is at the table as well — I think they've made great strides to ensure that public health is leading local implementation of the immunization strategy. That's our strength. And also that primary care is integrated as a very important partner in the rollout.

TVO.org: I’ve done interviews like this one in which experts have criticized the province for not integrating family doctors and the typical flu-shot infrastructure in the COVID-19-immunization effort. Is that criticism fair?

Moore: Since I've been involved, what I do is I meet with leadership of primary care, together with [U of T’s] Isaac Bogoch. So I've been meeting with the Association of Local Public Health Agencies, as well as the Association of Family Health Teams, Indigenous Primary Health Care Council, the section of general family physicians of the Ontario Medical Association, the Ontario College of Family Physicians — I've been meeting with them twice weekly, once with the OMA and then once with this group. And then I meet regularly with the task force and with my public-health colleagues, and we've just been trying to increase the communication, the collaboration, and the coordination.

So, at a high level, I think that messaging and communication collaboration is working. It's just, we don't have a lot of details to share yet with our primary-care colleagues, because, as you must know, Ontario’s COVaxON registration tool hasn't been finalized, nor have the eligibility criteria. All of that needs to get finalized before we can really effectively communicate with our primary-care colleagues. I am very confident, though, that my public-health colleagues have reached out at a local level and have integrated primary care into the local planning.

Primary care is so important to build confidence in the vaccine and would counsel on the benefits and be able to identify patients that have the highest need in terms of their medical conditions. For us locally, primary care is going to be an essential partner in administrating the vaccines. They're going to run one of our large mass-vaccine clinics, as well as run the distribution to our large family-health teams that support patients in the north part of our community. We could not do this work without them. We're also partnered with one of our community-health centres that will actually be offering immunizations at their facility. So integral partners from supporting the planning, to building confidence in the vaccine, as well as frankly just putting needles in arms. They're going to be essential partner for us. In KFLA, primary care provides around 60 per cent of all influenza immunization, and pharmacies do around 30, and then public health and other immunizers do around 10 per cent. We have absolutely committed to ensure that primary care would deliver the same quantity of vaccine as we move forward through our COVID response.

TVO.org: What is it about primary care, or family doctors, that makes it so well-suited to lead in this sort of program? Is it the relationships they have? The flu-shot experience?

Moore: It's all of the above. They understand their patients. They'll understand those that would have a higher priority — so if they had medical conditions that should be prioritized. They also have infrastructure: they have fridges for cold chain, and they have nurses and staff that are used to immunizing. They immunize all children in the whole children's schedule. So they do have expertise and competence to offer, as well as already existing infrastructure. And this is getting to be an expensive rollout, having to rent spaces for mass-immunization clinics. But they can, with the right product, actually immunize in their office in an organized way and distribute in an equitable way.

We need a flexible and adaptive strategy that meets the needs of patients and families, and having a family doctor that can immunize is just essential to our plan.

TVO.org: Earlier this week, the province said that individual health units will be able to create their own plan; some saw that as a sign it was downloading the responsibility. Was that the right choice?

Moore: I know. I heard that as well. And I don't want the public to be fearful that they're going to be drastically different — 34 different ways. We all followed a very similar game plan; we've just filled in the chapters of that game plan somewhat differently, which would meet the needs of our community and would highlight the geographic disparity in many of our areas, and the health system partners, which are different community to community.

I like that we're going to be locally responsive and meet the needs of our community and build on the strengths of the existing relationships with primary care. I like having that flexibility. And I honestly think it's going to work very well across Ontario. I've seen many plans of our sister health units from Windsor, to Ottawa, to North Bay, and they will all be harnessing the strength and partnership of primary care. But they’ll also aim to be flexible if we have to ramp up the availability of delivery, because we get a new vaccine like AstraZeneca or Johnson & Johnson, or if we have to deliver more in mass clinics because we just have Pfizer and limited Moderna.

TVO.org: I think you and I spoke last March about the importance of local public-health units, local expertise, and local flexibility. At the same time, this seems like a lot of work at a time when health units are already quite busy. Can they handle it?

Moore: Yeah, we'll have to be balanced and have to bring in partners. I think all health units are somewhat stretched right now just trying to do good case and contact management and keep up with our basic programming. But we do know this will be short-lived. This is six months where we're going to have to really concentrate on making sure the vaccine never stays long in any freezer and is rapidly delivered to those that need it. I think we can accomplish that mission, and we can still do good case and contact management knowing that as we get better population coverage with immunization, we'll have to do less outbreak management and less case and content management. So there's hope on both sides that we will eventually have a balance between our population coverage with immunization and our need to really respond to outbreaks. It should be inversely proportionate.

TVO.org: It strikes me that this is a pretty solid argument being made by the province for the importance of public-health units and what they have to offer. At the same time, this government has also wanted to amalgamate health units. Does this vaccine rollout say anything about the importance of the size of public-health units?

Moore: I think there are lessons learned already from the size of health units, in that many of the smaller health units have done relatively well in terms of being able to control the virus and have responded rapidly. There's probably the right size, whether that's 300,000 or 400,000 people, that one local public-health agency can be responsible for, where you can manage things appropriately if you're given the right resources.

But I do think that after any outbreak — and this has been after SARS and after the pandemic — we have to sit down, reflect on what worked and what didn't work, review the previous reports on public health, and discuss how to improve our response. And if that means amalgamation, that would mean amalgamation. But, clearly, we have to reflect and learn and improve. We’ll have more pandemics over time. This is public-health expertise, and we have to be prepared for the next one.

TVO.org: We’re trying to figure out how to get my 91-year-old grandmother vaccinated and have heard at various times that public health will call her, that her doctor will call her, that she should call someone, and that she should use an online tool. How are people going to know when it’s their turn?

Moore: Yes. I think there's going to be good central communication to all Ontarians when the COVaxON tool is available, so the first and easiest way is through electronic means. Certainly age-based criteria, over 80, will be in the first phase. If you can't access through a computer, we're hearing that there'll be what's called a concierge service, where you would phone, and that person on the phone would walk through your eligibility, put your data in, and be able to tell you where your appointment will be for immunization and when your follow-up appointment is. Also, potentially, send that in an email or send it in paper if required. Those details are critical to the success of our immunization strategy.

The government's been working day in, day out to have this available. I would think the first week of March is when the broad-based communication strategy will start and the tool will become available [the government has since announced that the tool is set to become available on March 15]. We're currently already using the tool to gather names of people in long-term-care facilities and uploading their data. So the tool exists;- it’s working. We're also using it for healthcare workers, the highest-risk health-care workers, from our hospital partners. The next phase is to make that public-facing and individualized and secure. But, also, if you don't have computer access, there will be a telephone service, and that telephone service may be coordinated at a local level as well.

TVO.org: That's very good to hear. I think in the absence of information, it can seem to us in the public that there isn’t really much of a plan.

Moore: Yeah, our communities have all been so patient. We're working diligently to make sure that, when the vaccine is available, the tools will be available to register.

TVO.org: There are really interesting conversations happening in the public realm about vaccinations — for example, is it better to do as many first doses as possible or to make sure that everyone who receives their first dose also gets their second? Is that a serious idea discussed among the members of the task force?

Moore: I do think it's a serious idea. It's being reviewed at the federal level, whether one dose could be sufficient or if we space out the dosing. Certainly, our priority in Ontario has been to follow the product monograph for those that are most susceptible to this virus — those in long-term-care facilities and those over 80 will adhere to the monograph to the fullest extent that we can. And for those that we're trying to maximize first doses to, we've been given permission for Pfizer to potentially spread the second dose out to 42 days. That’s as far as we’ve gone in Ontario, but we're seeking the guidance of the federal government on the effectiveness of one dose. The literature is very, very positive for one dose and the immunity that it brings. The more we can spread out that second dose, the more we can do first doses and get greater population coverage.

So there's good reason to try to maximize first doses at a population level — especially with variants circulating in some parts of Ontario, we would want to use the immunization strategy as best we can to limit their spread.

TVO.org: Earlier you mentioned the AstraZeneca and Johnson & Johnson vaccines. In both of your roles, the availability of those vaccines seems like a pretty big variable to have unknown. Is it frustrating to have this uncertainty over if and when they’ll be approved for use?

Moore: Yeah, I mean, it's frustrating, but I absolutely don't want to speed up or make any shortcuts in the scientific assessment of the safety and effectiveness of the vaccines. I'd much prefer the federal government and Health Canada take their time, get it right, ensure that their review of the scientific information provided to them is accurate and reliable, and that there are no shortcuts taken when it comes to the safety of vaccines. Their recommendations should be grounded in the best science. I'm not privy to their processes, but I don't mind it as long as safety and effectiveness for all Canadians is at the forefront of their decision making.

TVO.org: What do the next three months look like, with the virus generally and the vaccine rollout specifically?

Moore: The next three months are going to be difficult times. To be honest, we're in a bit of a race against the variants of concern. We really want to monitor how they're spreading in Ontario, because if the variants of concern start to take over, we may have to see even more strict public-health measures put back in place. These next few weeks are going to be really important for Ontarians to adhere to best practices, to stay home as much as you can, to stay local, stay within your household, wear your mask, and wash your hands. Be attentive to when you're going to be offered the vaccine. It really will be a difficult time, I would say, all the way through to the beginning of April. If we can, as a community, as all Ontarians, limit the spread of the variants, that will really give our vaccination strategy a hand — and it will help us keep our economy open and our schools open.

I would say the next month is going to be day-to-day watching the data, and I'm confident the premier will be making data-driven decisions and listening closely to the chief medical officer of health and the scientific table. But these will be difficult days ahead.

We're not out of the woods by any means, and we've done so well to get our case counts down. I don't want us to lose that good momentum. To see the number of people hospitalized going down is brilliant. But if we start seeing that do an uptick, and then the number of people in intensive-care settings goes up, then we're really going to have to be very, very careful. We really are going to have to watch the variants of concern: we know what happened in England and Ireland and other jurisdictions where these variants took off. It's going to be very difficult months ahead, as we try to balance case and contact-knowledge management, reopening the economy and schools, as well as rolling out a robust, population-based immunization strategy. It's going to be tense.

This interview has been condensed and edited for length and clarity.

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