Having grown up in a fiercely academic household, I have vivid memories of bringing home tests, proudly displaying my score of 80 per cent, and then hearing my parents ask, “What about the other 20 per cent?” While that was initially discouraging, it motivated me to understand what was missing.
Vaccinations in Canada have been largely a success story. As of the writing of this piece, we now have over 80 per cent of the eligible population vaccinated with a single dose and 60 per cent of the population fully vaccinated, making us a global leader. Yet with 20 per cent remaining and a more transmissible variant, we could still be facing a difficult fall and winter. While we decide how to provide more freedoms to the vaccinated, we should also be developing proactive approaches to reach the unvaccinated.
The work across all levels of government, health care, hospitals, public-health units, ambassadors, and media has led the country to today’s success. Breakthrough infections will occur, but it is unlikely that the fully vaccinated population will produce significant strain on the health-care system. In Ontario, only 10 fully vaccinated individuals have ended up in ICU due to COVID-19. However, the global situation suggests that unvaccinated individuals pose an issue for health-care systems — particularly with the emergency of the Delta variant. Vaccinations have dramatically cut deaths in the United Kingdom, but 63 per cent of hospital admissions are among the less than 20 per cent of the population who are unvaccinated.
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With 20 per cent unvaccinated, the ultimate rise of SARS-COV-2 transmission poses a danger to an exhausted health-care system. In some settings, such as acute and long-term care, the use of vaccine mandates for employees fulfils the principle of “do no harm” — a central tenet of medical ethics. Vaccination mandates for those who deal with vulnerable patients, many of whom cannot derive immunity from vaccinations due to underlying medical issues, ensure that as much protection as possible is offered for preventing transmission of the virus.
Vaccination passports create the opportunity to use vaccinations (or serial testing) to protect high-risk environments, such as restaurants, bars, and gyms, even in times of high health-care pressures. In countries such as France, passports for fully vaccinated individuals — or proof of recent negative tests — have been used not only to protect these environments, but also to increase vaccine uptake among individuals who want to enjoy these settings.
Such mandates and passports, however, have their limits, and we have to be conscious of secondary harms. While evidence suggests that the vaccination of 12- to 17-year-olds is effective in limiting transmission and morbidity, linking that to the ability to attend school, particularly after two years of disrupted education, may lead to downstream consequences. For many teenagers, parents are a primary source of influence and access to vaccination. Should we keep unvaccinated teenagers out of school — during some of the most formative years of career trajectory and growth — because their parents have counselled them to forgo the shot?
In Ontario, there are lower vaccine rates in 12- to 15-year-olds in refugee communities as compared to their peers, and the effects of school exclusion in this population must be taken into account. Using school as a forum for vaccine education, encouragement, and administration may be a more effective strategy than mandates.
We must also encourage vaccination among those COVID-19 has affected the most: essential workers, racialized communities, multigenerational households, and those facing poverty, not those going to bars, restaurants, and gyms. An effective vaccine response in Ontario requires strategies to reach these communities. In this province, vaccination rates in those 70 and older in the most COVID-19-affected neighbourhoods remain 10 per cent lower than in the least affected neighbourhoods. Refugees, immigrants, and recent OHIP registrants still have lower rates of immunization than the general population.
Messaging for this population should involve honest counselling about the concerns that remain, ones related to such issues as safety, fertility, and side effects. Outreach from primary care, cultural ambassadors, religious communities, educators, and people of trust is still important and should be funded and supported locally. Improving access to meet the demands of the unvaccinated population — through primary-care providers and walk-in, workplace, and overnight vaccination clinics — may help people get their dose. And it’s incredibly important to allow for work absences, transport, and child care in order to deal with the practicalities of immunization.
It’s also vital to acknowledge that individuals still have vaccine questions and concerns; instead of lumping them together as anti-vaxxers and “COVIDIOTS,” we must support honest and transparent conversations among those willing to listen. Much of the messaging on social media has involved shaming those who chose to be unvaccinated and then acquired the disease. As a clinician who has worked extensively in sexual health and HIV, I know that this approach does nothing more than continue to stigmatize an already ostracized population — and worsen their ability to access care. This should not be an us-versus-them situation but a partnership, one that allows us to reach as many individuals as possible and respects the ethical principles of those who opt against vaccination.
The gains that have been made in Canada are profound, and we truly are heading into a new era of the pandemic in which our ability to interact with others and society seems more stable. We should celebrate where we are as a nation, but if we’re going to have a sustainable post-pandemic strategy, we need to understand the needs and priorities of that remaining 20 per cent — and, through partnership, get more shots in arms.